Chapter 13

Health and Medicine

Social Issues in the News

“Children’s Quality of Life Declining,” the headline said. A study from the Foundation for Child

Development said that more than 21% of American children would be living in poverty in 2010,

up 5% from 2006 and the highest rate in two decades. Child experts warned that the increasing

poverty could impair children’s health. The sociologist who led the study worried that child

obesity could increase as families were forced to move away from more expensive health food to

processed and fast food. A child psychology professor said that people who grow up in poverty

have higher rates of cancer, liver and respiratory disease, and other conditions. The president of

the American Academy of Pediatrics agreed that family poverty is a health risk for children, who

are more likely to be born prematurely and/or with low birth weight and to develop asthma and

other health problems as they grow. She added that all of these problems can have lifelong

effects: “The consequences of poverty build on themselves, so that the outcomes can be felt for

years to come.” (Landau, 2010; Szabo, 2010) [1]

This news story reminds us that social class is linked to health and illness, and it illustrates just one of
the

many ways in which health and medicine are an important part of the social fabric. Accordingly, this

chapter examines the social aspects of health and medicine. It does not discuss the medical causes of

various diseases and illnesses, and neither does it tell you how to become and stay healthy, as these are

not, strictly speaking, sociological topics. But it will discuss the social bases for health and illnesses and

some of today’s most important issues and problems in health care.

[1] Landau, E. (2010, June 8). Children’s quality of life declining, says report. CNN. Retrieved

from [Link] Szabo, L. (2010, June 8). More than

1 in 5 kids

live in poverty. USA Today. Retrieved from[Link]

1Achild08_ST_N.htm

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13.1 Understanding Health, Medicine, and Society

LEARNING OBJECTIVES

1. Understand the basic views of the sociological approach to health and medicine.

2. List the assumptions of the functionalist, conflict, and symbolic interactionist perspectives on health

and medicine.

Health refers to the extent of a person’s physical, mental, and social well-being. This definition, taken

from the World Health Organization’s treatment of health, emphasizes that health is a complex

concept that involves not just the soundness of a person’s body but also the state of a person’s mind

and the quality of the social environment in which she or he lives. The quality of the social

environment in turn can affect a person’s physical and mental health, underscoring the importance

of social factors for these twin aspects of our overall well-being.

Medicine is the social institution that seeks both to prevent, diagnose, and treat illness and to

promote health as just defined. Dissatisfaction with the medical establishment has been growing.

Part of this dissatisfaction stems from soaring health-care costs and what many perceive as

insensitive stinginess by the health insurance industry, as the 2009 battle over health-care reform

illustrated. Some of the dissatisfaction also reflects a growing view that the social and even spiritual

realms of human existence play a key role in health and illness. This view has fueled renewed interest

in alternative medicine. We return later to these many issues for the social institution of medicine.

The Sociological Approach to Health and Medicine

We usually think of health, illness, and medicine in individual terms. When a person becomes ill, we
view

the illness as a medical problem with biological causes, and a physician treats the individual accordingly.
A sociological approach takes a different view. Unlike physicians, sociologists and other public health

scholars do not try to understand why any one person becomes ill. Instead, they typically examine rates
of

illness to explain why people from certain social backgrounds are more likely than those from others to

become sick. Here, as we will see, our social location in society—our social class, race and ethnicity, and

gender—makes a critical difference.

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The fact that our social backgrounds affect our health may be difficult for many of us to accept. We all

know someone, and often someone we love, who has died from a serious illness or currently suffers
from

one. There is always a “medical” cause of this person’s illness, and physicians do their best to try to cure
it

and prevent it from recurring. Sometimes they succeed; sometimes they fail. Whether someone suffers
a

serious illness is often simply a matter of bad luck or bad genes: we can do everything right and still

become ill. In saying that our social backgrounds affect our health, sociologists do not deny any of these

possibilities. They simply remind us that our social backgrounds also play an important role (Cockerham,

2009). [1]

A sociological approach also emphasizes that a society’s culture shapes its understanding of health and

illness and practice of medicine. In particular, culture shapes a society’s perceptions of what it means to

be healthy or ill, the reasons to which it attributes illness, and the ways in which it tries to keep its

members healthy and to cure those who are sick (Hahn & Inborn, 2009). [2] Knowing about a society’s

culture, then, helps us to understand how it perceives health and healing. By the same token, knowing

about a society’s health and medicine helps us to understand important aspects of its culture.
An interesting example of culture in this regard is seen in Japan’s aversion to organ transplants, which
are

much less common in that nation than in other wealthy nations. Japanese families dislike disfiguring the

bodies of the dead, even for autopsies, which are also much less common in Japan than other nations.

This cultural view often prompts them to refuse permission for organ transplants when a family member

dies, and it leads many Japanese to refuse to designate themselves as potential organ donors (Sehata &

Kimura, 2009; Shinzo, 2004). [3]

As culture changes over time, it is also true that perceptions of health and medicine may also change.

Recall from Chapter 1 "Sociology and the Sociological Perspective" that physicians in top medical schools

a century ago advised women not to go to college because the stress of higher education would disrupt

their menstrual cycles (Ehrenreich & English, 2005). [4] This nonsensical advice reflected the sexism of
the

times, and we no longer accept it now, but it also shows that what it means to be healthy or ill can
change

as a society’s culture changes.

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A society’s culture matters in these various ways, but so does its social structure, in particular its level of

economic development and extent of government involvement in health-care delivery. As we will see,
poor

societies have much worse health than richer societies. At the same time, richer societies have certain

health risks and health problems, such as pollution and liver disease (brought on by high alcohol use),

that poor societies avoid. The degree of government involvement in health-care delivery also matters: as

we will also see, the United States lags behind many Western European nations in several health

indicators, in part because the latter nations provide much more national health care than does the

United States. Although illness is often a matter of bad luck or bad genes, then, the society we live in can
nonetheless affect our chances of becoming and staying ill.

Sociological Perspectives on Health and Medicine

The major sociological perspectives on health and medicine all recognize these points but offer different

ways of understanding health and medicine that fall into the functional, conflict, and symbolic

interactionist approaches. Together they provide us with a more comprehensive understanding of

health,

medicine, and society than any one approach can do by itself (Cockerham, 2009). [5]Table 13.1 "Theory

Snapshot" summarizes what they say.

Table 13.1 Theory Snapshot

Theoretical

perspective

Functionalism

Major assumptions

Good health and effective medical care are essential for the smooth functioning of society.

Patients must perform the “sick role” in order to be perceived as legitimately ill and to be

exempt from their normal obligations. The physician-patient relationship is hierarchical:

the physician provides instructions, and the patient needs to follow them.

Conflict theory

Social inequality characterizes the quality of health and the quality of health care. People

from disadvantaged social backgrounds are more likely to become ill and to receive

inadequate health care. Partly to increase their incomes, physicians have tried to control

the practice of medicine and to define social problems as medical problems.

Symbolic

interactionism

Health and illness are social constructions: Physical and mental conditions have little or no

objective reality but instead are considered healthy or ill conditions only if they are defined
as such by a society. Physicians “manage the situation” to display their authority and

medical knowledge.

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The Functionalist Approach

As conceived by Talcott Parsons (1951), [6] the functionalist perspective on health and medicine

emphasizes that good health and effective medical care are essential for a society’s ability to function. Ill

health obviously impairs our ability to perform our roles in society, and if too many people are
unhealthy,

society’s functioning and stability suffer. This was especially true for premature death, said Parsons,

because it prevents individuals from fully carrying out all their social roles and thus represents a “poor

return” to society for the various costs of pregnancy, birth, child care, and socialization of the individual

who ends up dying early. Poor medical care is likewise dysfunctional for society, as people who are ill
face

greater difficulty in becoming healthy and people who are healthy are more likely to become ill.

For a person to be considered legitimately sick, said Parsons, several expectations must be met. He

referred to these expectations as the sick role. First, sick people should not be perceived as having
caused

their own health problem. If we eat high-fat food, become obese, and have a heart attack, we evoke less

sympathy than if we had practiced good nutrition and maintained a proper weight. If someone is driving

drunk and smashes into a tree, there is much less sympathy than if the driver had been sober and
skidded

off the road in icy weather.

Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as

faking their illness or malingering after becoming healthier, they are no longer considered legitimately ill

by the people who know them or, more generally, by society itself.
Third, sick people are expected to have their illness confirmed by a physician or other health-care

professional and to follow the professional’s advice and instructions in order to become well. If a sick

person fails to do so, she or he again loses the right to perform the sick role.

If all of these expectations are met, said Parsons, sick people are treated as sick by their family, their

friends, and other people they know, and they become exempt from their normal obligations to all of
these

people. Sometimes they are even told to stay in bed when they want to remain active.

Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the

person’s illness, decide how to treat it, and help the person become well. To do so, they need the

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cooperation of the patient, who must answer the physician’s questions accurately and follow the

physician’s instructions. Parsons thus viewed the physician-patient relationship as hierarchical: the

physician gives the orders (or, more accurately, provides advice and instructions), and the patient
follows

them.

Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s
health,

but his perspective has been criticized for several reasons. First, his idea of the sick role applies more to

acute (short-term) illness than to chronic (long-term) illness. Although much of his discussion implies a

person temporarily enters a sick role and leaves it soon after following adequate medical care, people
with

chronic illnesses can be locked into a sick role for a very long time or even permanently. Second,
Parsons’s

discussion ignores the fact, mentioned earlier, that our social location in society in the form of social
class,

race and ethnicity, and gender affects both the likelihood of becoming ill and the quality of medical care
we receive. Third, Parsons wrote approvingly of the hierarchy implicit in the physician-patient

relationship. Many experts say today that patients need to reduce this hierarchy by asking more
questions

of their physicians and by taking a more active role in maintaining their health. To the extent that

physicians do not always provide the best medical care, the hierarchy that Parsons favored is at least

partly to blame.

The Conflict Approach

The conflict approach emphasizes inequality in the quality of health and of health-care delivery (Conrad,

2009). [7] As noted earlier, the quality of health and health care differ greatly around the world and
within

the United States. Society’s inequities along social class, race and ethnicity, and gender lines are

reproduced in our health and health care. People from disadvantaged social backgrounds are more likely

to become ill, and once they do become ill, inadequate health care makes it more difficult for them to

become well. As we will see, the evidence of inequities in health and health care is vast and dramatic.

The conflict approach also critiques the degree to which physicians over the decades have tried to
control

the practice of medicine and to define various social problems as medical ones. Their motivation for
doing

so has been both good and bad. On the good side, they have believed that they are the most qualified

professionals to diagnose problems and treat people who have these problems. On the negative side,
they

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have also recognized that their financial status will improve if they succeed in characterizing social

problems as medical problems and in monopolizing the treatment of these problems. Once these

problems become “medicalized,” their possible social roots and thus potential solutions are neglected.
Several examples illustrate conflict theory’s criticism. Alternative medicine is becoming increasingly

popular (see the discussion later in the chapter), but so has criticism of it by the medical establishment.

Physicians may honestly feel that medical alternatives are inadequate, ineffective, or even dangerous,
but

they also recognize that the use of these alternatives is financially harmful to their own practices. Eating

disorders also illustrate conflict theory’s criticism. Many of the women and girls who have eating

disorders receive help from a physician, a psychiatrist, a psychologist, or another health-care

professional.

Although this care is often very helpful, the definition of eating disorders as a medical problem

nonetheless provides a good source of income for the professionals who treat it and obscures its
cultural

roots in society’s standard of beauty for women (Whitehead & Kurz, 2008). [8]

Obstetrical care provides another example. In most of human history, midwives or their equivalent were

the people who helped pregnant women deliver their babies. In the 19th century, physicians claimed
they

were better trained than midwives and won legislation giving them authority to deliver babies. They
may

have honestly felt that midwives were inadequately trained, but they also fully recognized that
obstetrical

care would be quite lucrative (Ehrenreich & English, 2005). [9] In a final example, many hyperactive

children are now diagnosed with ADHD, or attention-deficit/hyperactivity disorder. A generation or

more

ago, they would have been considered merely as overly active. After Ritalin, a drug that reduces

hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD

diagnosis was increasingly applied, and tens of thousands of children went to physicians’ offices and
were

given Ritalin or similar drugs. The definition of their behavior as a medical problem was very lucrative for

physicians and for the company that developed Ritalin, and it also obscured the possible roots of their

behavior in inadequate parenting, stultifying schools, or even gender socialization, as most hyperactive
kids are boys (Conrad, 2008). [10]

Critics of the conflict approach say that its assessment of health and medicine is overly harsh and its

criticism of physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of

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people in the industrial world; even in the poorer nations, moreover, health has improved from a
century

ago, however inadequate it remains today. Although physicians are certainly motivated, as many people

are, by economic considerations, their efforts to extend their scope into previously nonmedical areas
also

stem from honest beliefs that people’s health and lives will improve if these efforts succeed. Certainly

there is some truth in this criticism of the conflict approach, but the evidence of inequality in health and

medicine and of the negative aspects of the medical establishment’s motivation for extending its reach

remains compelling.

The Interactionist Approach

The interactionist approach emphasizes that health and illness are social constructions. This means that

various physical and mental conditions have little or no objective reality but instead are considered

healthy or ill conditions only if they are defined as such by a society and its members (Buckser, 2009;

Lorber & Moore, 2002). [11] The ADHD example just discussed also illustrates interactionist theory’s

concerns, as a behavior that was not previously considered an illness came to be defined as one after
the

development of Ritalin. In another example, in the late 1800s opium use was quite common in the
United

States, as opium derivatives were included in all sorts of over-the-counter products. Opium use was

considered neither a major health nor legal problem. That changed by the end of the century, as
prejudice
against Chinese Americans led to the banning of the opium dens (similar to today’s bars) they
frequented,

and calls for the banning of opium led to federal legislation early in the 20th century that banned most

opium products except by prescription (Musto, 2002). [12]

In a more current example, an attempt to redefine obesity is now under way in the United States.
Obesity

is a known health risk, but a “fat pride” movement composed mainly of heavy individuals is arguing that

obesity’s health risks are exaggerated and calling attention to society’s discrimination against
overweight

people. Although such discrimination is certainly unfortunate, critics say the movement is going too far
in

trying to minimize obesity’s risks (Saulny, 2009).[13]

The symbolic interactionist approach has also provided important studies of the interaction between

patients and health-care professionals. Consciously or not, physicians “manage the situation” to display

their authority and medical knowledge. Patients usually have to wait a long time for the physician to
show

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up, and the physician is often in a white lab coat; the physician is also often addressed as “Doctor,” while

patients are often called by their first name. Physicians typically use complex medical terms to describe
a

patient’s illness instead of the more simple terms used by laypeople and the patients themselves.

Management of the situation is perhaps especially important during a gynecological exam. When the

physician is a man, this situation is fraught with potential embarrassment and uneasiness because a man

is examining and touching a woman’s genital area. Under these circumstances, the physician must act in
a

purely professional manner. He must indicate no personal interest in the woman’s body and must
instead
treat the exam no differently from any other type of exam. To further “desex” the situation and reduce
any

potential uneasiness, a female nurse is often present during the exam (Cullum-Swan, 1992). [14]

Critics fault the symbolic interactionist approach for implying that no illnesses have objective reality.

Many serious health conditions do exist and put people at risk for their health regardless of what they or

their society thinks. Critics also say the approach neglects the effects of social inequality for health and

illness. Despite these possible faults, the symbolic interactionist approach reminds us that health and

illness do have a subjective as well as an objective reality.

KEY TAKEAWAYS

• A sociological understanding emphasizes the influence of people’s social backgrounds on the quality of

their health and health care. A society’s culture and social structure also affect health and health care.

• The functionalist approach emphasizes that good health and effective health care are essential for a

society’s ability to function. The conflict approach emphasizes inequality in the quality of health and in

the quality of health care.

• The interactionist approach emphasizes that health and illness are social constructions; physical and

mental conditions have little or no objective reality but instead are considered healthy or ill conditions

only if they are defined as such by a society and its members.

FOR YOUR REVIEW

1. Which approach—functionalist, conflict, or symbolic interactionist—do you most favor regarding how
you

understand health and health care? Explain your answer.

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2. Think of the last time you visited a physician or another health-care professional. In what ways did
this

person come across as an authority figure possessing medical knowledge? In formulating your answer,
think about the person’s clothing, body position and body language, and other aspects of nonverbal

communication.

[1] Cockerham, W. C. (2009). Medical sociology (11th ed.). Upper Saddle River, NJ: Prentice Hall.

[2] Hahn, R. A., & Inborn, M. (Eds.). (2009). Anthropology and public health: Bridging differences in
culture and

society (2nd ed.). New York, NY: Oxford University Press.

[3] Sehata, G., & Kimura, T. (2009, February 28). A decade on, organ transplant law falls short. The Daily

Yomiuri [Tokyo], p. 3; Shinzo, K. (2004). Organ transplants and brain-dead donors: A Japanese doctor’s

perspective. Mortality, 9(1), 13–26.

[4] Ehrenreich, B., & English, D. (2005). For her own good: Two centuries of the experts’ advice to
women (2nd ed.).

New York, NY: Anchor Books.

[5] Cockerham, W. C. (2009). Medical sociology (11th ed.). Upper Saddle River, NJ: Prentice Hall.

[6] Parsons, T. (1951). The social system. New York, NY: Free Press.

[7] Conrad, P. (Ed.). (2009). Sociology of health and illness: Critical perspectives (8th ed.). New York, NY:
Worth.

[8] Whitehead, K., & Kurz, T. (2008). Saints, sinners and standards of femininity: Discursive constructions
of

anorexia nervosa and obesity in women’s magazines. Journal of Gender Studies, 17, 345–358.

[9] Ehrenreich, B., & English, D. (2005). For her own good: Two centuries of the experts’ advice to
women (2nd ed.).

New York, NY: Anchor Books.

[10] Conrad, P. (2008). The medicalization of society: On the transformation of human conditions into
treatable

disorders. Baltimore, MD: Johns Hopkins University Press.

[11] Buckser, A. (2009). Institutions, agency, and illness in the making of Tourette syndrome. Human
Organization,

68(3), 293–306; Lorber, J., & Moore, L. J. (2002). Gender and the social construction of illness (2nd ed.).
Lanham,
MD: Rowman & Littlefield.

[12] Musto, D. F. (Ed.). (2002). Drugs in America: A documentary history. New York, NY: New York
University Press.

[13] Saulny, S. (2009, November 7). Heavier Americans push back on health debate. The New York
Times, p. A23.

[14] Cullum-Swan, B. (1992). Behavior in public places: A frame analysis of gynecological exams. Paper
presented

at the American Sociological Association, Pittsburgh, PA.

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13.2 Health and Medicine in International Perspective

LEARNING OBJECTIVES

1. Describe how the nations of the world differ in important indicators of health and illness.

2. Explain the health-care model found in industrial nations other than the United States.

As with many topics in sociology, understanding what happens in other societies and cultures helps

us to understand what happens in our own society. This section’s discussion of health and health

care across the globe, then, helps shed some light on what is good and bad about U.S. health and

medicine.

International Disparities in Health and Illness

Figure 13.4

Two-thirds of the 33 million people worldwide who have HIV/AIDS live in sub-Saharan Africa. This
terrible fact

illustrates just one of the many health problems that people in poor nations suffer.

Source: Photo courtesy of khym54, [Link]

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The nations of the world differ dramatically in the quality of their health and health care. The poorest

nations suffer terribly. Their people suffer from poor nutrition, unsafe water, inadequate sanitation, a

plethora of diseases, and inadequate health care. One disease they suffer from is AIDS. Some 33 million

people worldwide have HIV/AIDS, and two-thirds of these live in sub-Saharan Africa. Two million people,

most of them from this region, died in 2008 from HIV/AIDS (World Health Organization, 2010). [1] All of

these problems produce high rates of infant mortality and maternal mortality and high death rates. For
all

of these reasons, people in the poorest nations have shorter life spans than those in the richest nations.

A few health indicators should indicate the depth of the problem. Figure 13.5 "Infant Mortality for Low

Income, Lower Middle Income, Higher Middle Income, and High Income Nations, 2008" compares an

important indicator, infant mortality (number of deaths before age 1 per 1,000 live births) for nations

grouped into four income categories. The striking contrast between the two groups provides dramatic

evidence of the health problems poor nations face. When, as Figure 13.5 "Infant Mortality for Low

Income, Lower Middle Income, Higher Middle Income, and High Income Nations, 2008" indicates, 80

children in the poorest nations die before their first birthday for every 1,000 live births (equivalent to 8

out of 100), the poor nations have serious problems indeed. Figure 13.6 "Percentage of Population With

Access to Adequate Sanitation Facilities, 2008" shows how the world differs in access to adequate

sanitation facilities (i.e., the removal of human waste from the physical environment, as by toilets).

Whereas this percentage is at least 98% in the wealthy nations of North America, Western Europe, and

Australia and New Zealand, it is less than 33% in many poor nations in Africa and Asia.

Figure 13.5 Infant Mortality for Low Income, Lower Middle Income, Higher Middle Income, and

High Income Nations, 2008

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Source: Data from World Bank. (2010). Health nutrition and population statistics. Retrieved

from [Link]

Figure 13.6 Percentage of Population With Access to Adequate Sanitation Facilities, 2008

Source: Adapted from World Bank. (2010). Improved sanitation facilities (% of population with

access). Retrieved from [Link]

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[Link]/ext/ddpreports/ViewSharedReport?&CF=&REPORT_ID=5558&REQUEST_TY

PE=VIEWADVANCEDMAP.

Chapter 9 "Aging and the Elderly" presented an international map on life expectancy. That map was

certainly relevant for understanding aging around the globe but is also relevant for understanding

worldwide disparities in health and health care. We reproduce this map here (see Figure 13.7 "Average

Life Expectancy Across the Globe"). Not surprisingly, the global differences in this map are similar to

those for adequate sanitation in the map depicted in Figure 13.6 "Percentage of Population With Access
to

Adequate Sanitation Facilities, 2008". North America, Western Europe, and Australia and New Zealand

have much longer life expectancies (75 years and higher) than Africa and Asia, where some nations have

expectancies below 50 years. The society we live in can affect our life span by more than a quarter of a

century.

Figure 13.7 Average Life Expectancy Across the Globe

Source: Adapted from Global Education Project. (2004). Human conditions: World life expectancy

map. Retrieved from [Link]

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Health Care in Industrial Nations

Industrial nations throughout the world, with the notable exception of the United States, provide their

citizens with some form of national health care and national health insurance (Reid, 2009). [2] Although

their health-care systems differ in several respects, their governments pay all or most of the costs for

health care, drugs, and other health needs. In Denmark, for example, the government provides free

medical care and hospitalization for the entire population and pays for some medications and some
dental

care. In France, the government pays for some of the medical, hospitalization, and medication costs for

most people and all of these expenses for the poor, unemployed, and children under the age of 10. In

Great Britain, the National Health Service pays most medical costs for the population, including medical

care, hospitalization, prescriptions, dental care, and eyeglasses. In Canada, the National Health
Insurance

system also pays for most medical costs. Patients do not even receive bills from their physicians, who

instead are paid by the government.

Although these national health insurance programs are not perfect—for example, people sometimes
must

wait for elective surgery and some other procedures—they are commonly credited with reducing infant

mortality, extending life expectancy, and more generally for enabling their citizenries to have relatively

good health. In all of these respects, these systems offer several advantages over the health-care model

found in the United States (Hacker, 2008) [3] (see the “Learning From Other Societies” box).

Learning From Other Societies

National Health Care in Wealthy Nations

As the text discusses, industrial nations other than the United States provide free or low-cost health care

to their citizens in what is known as national (or universal) health insurance and national health care.

Although the United States spends more per capita than these nations on health care, it generally ranks

much lower than they do on important health indicators. Of 23 wealthy nations from North America,

Western Europe, and certain other parts of the world (Australia, Japan, New Zealand; the exact number
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of nations varies slightly by indicator), the United States has the lowest life expectancy and the highest

infant mortality and rate of diabetes. It ranks only 21st in mortality from heart disease and stroke and

only 15th in dental health among children. The United States also ranks lowest for annual doctor

consultations per capita and among the highest for hospital admissions for various conditions, such as

congestive heart failure, that are avoidable with adequate primary and outpatient care (Organisation for

Economic Co-operation and Development, 2009). [4] The conclusion from these international

comparisons is inescapable:

Although the United States spends more on health care than other countries with similar per

capita income and populations, it has worse health outcomes, on average.…Compared to the

United States, other countries are more committed to the health and well-being of their citizens

through more-universal coverage and more-comprehensive health care systems. (Mishel,

Bernstein, & Shierholz, 2009, pp. 349, 353) [5]

Because of Canada’s proximity, many studies compare health and health-care indicators between the

United States and Canada. A recent review summarized the evidence: “Although studies’ findings go in

both directions, the bulk of the research finds higher quality of care in Canada” (Docteur & Berenson,

2009, p. 7). [6]

Surveys of random samples of citizens in several nations provide additional evidence of the advantages
of

the type of health care found outside the United States and the disadvantages of the U.S. system. In

surveys in 2007 of U.S. residents and those of six other nations (Australia, Canada, Germany, the

Netherlands, New Zealand, and the United Kingdom), Americans ranked highest in the percentage
uninsured (16% in the United States compared to 0–2% elsewhere), highest in the percentage that did
not

receive needed medical care during the last year because of costs, and highest by far in the percentage
that

had “serious problems” in paying medical bills in the past year (Schoen et al., 2007). [7]

A fair conclusion from all the evidence is that U.S. health lags behind that found in other wealthy nations

because the latter provide free or low-cost national health care to their citizens and the United States
does

not. If so, the United States has much to learn from their example. Because the health-care reform

achieved in the United States in 2009 and 2010 did not include a national health-care model, it is likely

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that the United States will continue to lag behind other democracies in the quality of health and health

care. Even so, the cost of health care will almost certainly continue to be much higher in the United
States

than in other Western nations, in part because the United States uses a fee-for-service model in which

physicians are paid for every procedure they do rather than the set salary that some other nations
feature.

KEY TAKEAWAYS

• The world’s nations differ dramatically in the quality of their health and health care. People in poor

nations suffer from many health problems, and poor nations have very high rates of infant mortality and

maternal mortality.

• Except for the United States, industrial nations have national health-care systems and national health

insurance. Their health-care models help their citizens to have relatively good health at affordable
levels.

FOR YOUR REVIEW

1. What do you think should be done to help improve the health of poor nations? What role should the

United States play in any efforts in this regard?

2. Do you think the United States should move toward the national health insurance model found in
other

Western nations? Why or why not?

[1] World Health Organization. (2010). WHO and HIV/AIDS. Retrieved

from[Link]

[2] Reid, T. R. (2009). The healing of America: A global quest for better, cheaper, and fairer health care.
New York,

NY: Penguin Press.

[3] Hacker, J. S. (Ed.). (2008). Health at risk: America’s ailing health system—and how to heal it. New
York, NY:

Columbia Univeristy Press.

[4] Organisation for Economic Co-operation and Development. (2009). Health at a glance 2009: OECD
indicators.

Paris, France: OECD Publishing.

[5] Mishel, L., Bernstein, J., & Shierholz, H. (2009). The state of working America 2008/2009. Ithaca, NY:
ILR Press

[An imprint of Cornell University Press].

[6] Docteur, E., & Berenson, R. A. (2009). How does the quality of U.S. health care compare

internationally? Washington, DC: Urban Institute.

[7] Schoen, C., Osborn, R., Doty, M. M., Bishop, M., Peugh, J., & Murukutla, N. (2007). Toward higher-
performance

health systems: Adults’ health care experiences in seven countries, 2007. Health Affairs 26(6), w717–
w734.

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13.3 Health and Illness in the United States

LEARNING OBJECTIVES

1. Describe how and why social class, race and ethnicity, and gender affect health and health care in the

United States.

2. Summarize how health and illness in the United States vary by sociodemographic characteristics.

When we examine health and illness in the United States, there is both good news and bad news. The

good news is considerable. Health has improved steadily over the last century, thanks in large part to

better public sanitation and the discovery of antibiotics. Illnesses and diseases such as pneumonia

and polio that used to kill or debilitate people are either unknown today or treatable by modern

drugs. Other medical discoveries and advances have also reduced the extent and seriousness of

major illnesses, including many types of cancer, and have prolonged our lives. The mortality rate

from heart disease is down 50% from the early 1980s, and the mortality rate from strokes is down

about 51% (Centers for Disease Control and Prevention, 2010). [1]

As a result of all of these factors, the U.S. average life expectancy climbed from about 47 years in

1900 to about 78 years in 2010 (recall Figure 9.6 "Changes in U.S. Life Expectancy at Birth, 1900

2010"). Similarly, infant mortality dropped dramatically in the last half-century from 29.2 infant

deaths per 1,000 live births in 1950 to only 6.7 in 2006 (see Figure 13.8 "Infant Deaths per 1,000

Live Births, United States, 1950–2006"). Public health campaigns have increased awareness of the

sources and seriousness of some health problems and led to behavioral changes and, for some

problems, legislation that has reduced these problems. For example, cigarette smoking declined from

51% for males and 34% for females in 1965 to 22% and 17.5%, respectively, in 2007 (National Center

for Health Statistics, 2009). [2] In another area, various policies during the past three decades have

dramatically reduced levels of lead in young children’s blood; 88% had unsafe levels in the mid

1970s, compared to less than 2% today (Centers for Disease Control and Prevention, 2007). [3]

Figure 13.8 Infant Deaths per 1,000 Live Births, United States, 1950–2006
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Source: Data from National Center for Health Statistics. (2009). Health, United States, 2009.

Hyattsville, MD: Centers for Disease Control and Prevention.

Unfortunately, the bad news is also considerable. While the United States has improved its health in

many ways, it nonetheless lags behind most other wealthy nations in several health indicators, as we

have seen, even though it is the wealthiest nation in the world. Moreover, about 15% of U.S.

households and more than 32 million persons are “food-insecure” (lacking sufficient money for

adequate food and nutrition) at least part of the year; more than one-fifth of all children live in such

households (Nord, Andrews, & Carlson, 2009). [4] More than 8% of all infants are born at low birth

weight (under 5.5 pounds), putting them at risk for long-term health problems; this figure has risen

steadily for a number of years and is higher than the 1970 rate (National Center for Health Statistics,

2009). [5] In other areas, childhood rates of obesity, asthma, and some other chronic conditions are

on the rise, with about one-third of children considered obese or overweight (Van Cleave,

Gortmaker, & Perrin, 2010). [6] Clearly the United States still has a long way to go in improving the

nation’s health.

There is also bad news in the social distribution of health. Health problems in the United States are

more often found among the poor, among people from certain racial and ethnic backgrounds, and,

depending on the problem, among women or men. Social epidemiology refers to the study of how

health and illness vary by sociodemographic characteristics. When we examine social epidemiology

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in the United States, we see that the distribution of health and illness depends heavily on our social
location in society. In this way, health and illness both reflect and reinforce society’s social

inequalities. The next section discusses some of the key findings on U.S. social epidemiology and the

reasons for disparities they illustrate. We start with physical health and then discuss mental health.

The Social Epidemiology of Physical Health

Social Class

Not only do the poor have less money, but they also have much worse health. There is growing
recognition

in the government and in medical and academic communities that social class makes a huge difference

when it comes to health and illness. A recent summary of the evidence concluded that social class

inequalities in health are “pervasive” in the United States and other nations across the world (Elo, 2009,

p. 553). [7]

Many types of health indicators illustrate the social class–health link in the United States. In an annual

survey conducted by the government, people are asked to indicate the quality of their health. As Figure

13.10 "Family Income and Self-Reported Health (Percentage of People 18 or Over Saying Health Is Only

Fair or Poor)" shows, poor people are much more likely than those with higher incomes to say their
health

is only fair or poor. These self-reports of health are subjective indicators, and it is possible that not

everyone interprets “fair” or “poor” health in the same way. But objective indicators of actual health
also

indicate a strong social class–health link, with some of the most unsettling evidence involving children.
As

a recent report concluded,

The data illustrate a consistent and striking pattern of incremental improvements in health with

increasing levels of family income and educational attainment: As family income and levels of

education rise, health improves. In almost every state, shortfalls in health are greatest among

children in the poorest or least educated households, but even middle-class children are less

healthy than children with greater advantages. (Robert Wood Johnson Foundation, 2008, p. 2) [8]
For example, infant mortality is 86% higher among infants born to mothers without a high school degree

than those with a college degree, and low birth weight is 29% higher. According to their parents, one-
third

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of children in poor families are in less than very good health, compared to only 7% of children in wealthy

families (at least four times the poverty level). In many other health indicators, as the news story that

began this chapter indicated, children in low-income families are more likely than children in wealthier

families to have various kinds of health problems, many of which endure into adolescence and
adulthood.

Figure 13.10 Family Income and Self-Reported Health (Percentage of People 18 or Over Saying

Health Is Only Fair or Poor)

Source: Data from National Center for Health Statistics. (2009). Health, United States, 2009.

Hyattsville, MD: Centers for Disease Control and Prevention.

Poor adults are also at much greater risk for many health problems, including heart disease, diabetes,

arthritis, and some types of cancer (National Center for Health Statistics, 2009). [9] Rates of high blood

pressure, serious heart conditions, and diabetes are at least twice as high for middle-aged adults with

family incomes below the poverty level than for those with incomes at least twice the poverty level. All
of

these social class differences in health contribute to a striking difference in life expectancy, with the

wealthiest Americans expected to live four and a half years longer on average than the poorest
Americans

(Pear, 2008). [10]

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Several reasons account for the social class–health link (Elo, 2009; Pampel, Krueger, & Denney,

2010). [11] One reason is stress, which is higher for people with low incomes because of unemployment,

problems in paying for the necessities of life, and a sense of little control over what happens to them.

Stress in turn damages health because it impairs the immune system and other bodily processes (Lantz,

House, Mero, & Williams, 2005). [12] A second reason is that poor people live in conditions, including

crowded, dilapidated housing with poor sanitation, that are bad for their health and especially that of

their children (Stewart & Rhoden, 2006). [13] Although these conditions have improved markedly in the

United States over the last few decades, they continue for many of the poor.

Another reason is the lack of access to adequate health care. As is well known, many poor people lack

medical insurance and in other respects have inadequate health care. These problems make it more
likely

they will become ill in the first place and more difficult for them to become well because they cannot

afford to visit a physician or to receive other health care. Still, social class disparities in health exist even

in countries that provide free national health care, a fact that underscores the importance of the other

reasons discussed here for the social class–health link (Elo, 2009). [14]

A fourth reason is a lack of education, which, in ways not yet well understood, leads poor people to be

unaware of risk factors for health and to have a fatalistic attitude that promotes unhealthy behaviors
and

reluctance to heed medical advice (Elo, 2009). [15] In one study of whether smokers quit smoking after a

heart attack, only 10% of heart attack patients without a high school degree quit smoking, compared to

almost 90% of those with a college degree (Wray, Herzog, Willis, & Wallace, 1998). [16]

A final and related reason for the poor health of poor people is unhealthy lifestyles, as just implied.

Although it might sound like a stereotype, poor people are more likely to smoke, to eat high-fat food, to

avoid exercise, to be overweight, and, more generally, not to do what they need to do (or to do what
they

should not be doing) to be healthy (Pampel, Krueger, & Denney, 2010; Cubbins & Buchanan,
2009). [17] Scholars continue to debate whether unhealthy lifestyles are more important in explaining
poor

people’s poor health than factors such as lack of access to health care, stress, and other negative
aspects of

the social and physical environments in which poor people live. Regardless of the proper mix of reasons,

the fact remains that the poor have worse health.

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In assessing the social class–health link, we have been assuming that poverty leads to poor health. Yet it
is

also possible that poor health leads to poverty or near-poverty because of high health-care expenses
and

decreased work hours. Recent evidence supports this causal linkage, as serious health problems in

adulthood often do force people to reduce their work hours or even to retire altogether (J. P. Smith,

2005). [18] Although this linkage accounts for some of the social class–health relationship that is so

noticeable, evidence of the large impact of low income on poor health remains compelling.

Race and Ethnicity

Health differences also exist when we examine the effects of race and ethnicity (Barr, 2008), [19] and
they

are literally a matter of life and death. We can see this when we compare life expectancies for whites
and

African Americans born in 2006 (Table 13.2 "U.S. Life Expectancy at Birth for People Born in 2006").

When we do not take gender into account, African Americans can expect to live 5 fewer years than
whites.

Among men, they can expect to live 6 fewer years, and among women, 4.1 fewer years.

Table 13.2 U.S. Life Expectancy at Birth for People Born in 2006

Both sexes 73.2

Men 69.7

African American

Women 76.5

Both sexes 78.2

Men 75.7

White

Women 80.6

Source: Data from National Center for Health Statistics. (2009). Health, United States, 2009. Hyattsville,

MD: Centers for Disease Control and Prevention.

At the beginning of the life course, infant mortality also varies by race and ethnicity (Table 13.3
"Mother’s

Race and Ethnicity and U.S. Infant Mortality, 2003–2005 (Average Annual Number of Infant Deaths per

1,000 Live Births)"), with African American infants more than twice as likely as white infants to die
before

their first birthday. Infant mortality among Native Americans is almost 1.5 times the white rate, while
that

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for Latinos is about the same (although the Puerto Rican rate is also higher, at 8.1), and Asians a bit
lower.

In a related indicator, maternal mortality (from complications of pregnancy or childbirth) stands at 8.0

maternal deaths for every 100,000 live births for non-Latina white women, 8.8 for Latina women, and a

troubling 28.7 for African American women. Maternal mortality for African American women is thus 3.5

times greater than that for non-Latina white women. In other indicators, African Americans are more

likely than whites to die from heart disease, although the white rate of such deaths is higher than the
rates
of Asians, Latinos, and Native Americans. African Americans are also more likely than whites to be

overweight and to suffer from asthma, diabetes, high blood pressure, and several types of cancer.
Latinos

and Native Americans have higher rates than whites of several illnesses and conditions, including

diabetes.

Table 13.3 Mother’s Race and Ethnicity and U.S. Infant Mortality, 2003–2005 (Average Annual Number

of Infant Deaths per 1,000 Live Births)

African American

13.3

Asian

4.8

Latina

5.6

Central and South American 4.8

Cuban

4.5

Mexican

5.5

Puerto Rican

8.1

Native American

8.4

White

5.7

Source: Data from National Center for Health Statistics. (2009). Health, United States, 2009. Hyattsville,

MD: Centers for Disease Control and Prevention.

Commenting on all of these disparities in health, a former head of the U.S. Department of Health and

Human Services said a decade ago, “We have been—and remain—two nations: one majority, one

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minority—separated by the quality of our health” (Penn et al., 2000, p. 102). [20] The examples just

discussed certainly indicate that her statement is still true today.

Why do such large racial and ethnic disparities in health exist? To a large degree, they reflect the high

poverty rates for African Americans, Latinos, and Native Americans compared to those for whites

(Cubbins & Buchanan, 2009).[21] In addition, inadequate medical care is perhaps a special problem for

people of color, thanks to unconscious racial bias among health-care professionals that affects the
quality

of care that people of color receive (see discussion later in this chapter).

An additional reason for racial disparities in health is diet. Many of the foods that have long been part of

African American culture are high in fat. Partly as a result, African Americans are much more likely than

whites to have heart disease and high blood pressure and to die from these conditions (Lewis-Moss,

Paschal, Redmond, Green, & Carmack, 2008).[22] In contrast, first-generation Latinos tend to have diets

consisting of beans, grains, and other low-fat foods, preventing health problems stemming from their

poverty from being even worse. But as the years go by and they adopt the typical American’s eating
habits,

their diets tend to worsen, and their health worsens as well (Pérez-Escamilla, 2009). [23]

In a significant finding, African Americans have worse health than whites even among those with the

same incomes. This racial gap is thought to stem from several reasons. One is the extra stress that
African

Americans of all incomes face because they live in a society that is still racially prejudiced and

discriminatory (Williams, Neighbors, & Jackson, 2008). [24] In this regard, a growing amount of research

finds that African Americans and Latinos who have experienced the most racial discrimination in their
daily lives tend to have worse physical health (Lee & Ferraro, 2009; Gee & Walsemann, 2009). [25]
Some

middle-class African Americans may also have grown up in poor families and incurred health problems in

childhood that still affect them. As a former U.S. surgeon general once explained, “You’re never dealing

with a person just today. You’re dealing with everything they’ve been exposed to throughout their lives.

Does it ever end? Our hypothesis is that it never ends” (Meckler, 1998, p. 4A). [26]

To some degree, racial differences in health may also have a biological basis. For example, African

American men appear to have higher levels of a certain growth protein that may promote prostate
cancer;

African American smokers may absorb more nicotine than white smokers; and differences in the ways

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African Americans’ blood vessels react may render them more susceptible to hypertension and heart

disease (Meckler, 1998). [27] Because alleged biological differences have been used as the basis for
racism,

and because race is best thought of as a social construction rather than a biological concept (see
Chapter 7

"Race and Ethnicity"), we have to be very careful in acknowledging such differences (Frank,

2007). [28] However, if they do indeed exist, they may help explain at least some of the racial gap in
health.

A final factor contributing to racial differences in health is physical location: poor people of color tend to

live in areas that are unhealthy places because of air and water pollution, hazardous waste, and other

environmental problems. This problem is termed environmental racism (King & McCarthy, 2009).
[29]One

example of this problem is found in the so-called Cancer Alley on a long stretch of the Mississippi River
in

Louisiana populated mostly by African Americans; 80% of these residents live within 3 miles of a
polluting industrial facility.

Gender

The evidence on gender and health is both complex and fascinating. Women outlive men by more than
6

years, and, as Table 13.2 "U.S. Life Expectancy at Birth for People Born in 2006" showed, the gender

difference in longevity persists across racial categories. At the same time, women have worse health
than

men in many areas. For example, they are much more likely to suffer from migraine headaches,

osteoporosis, and immune diseases such as lupus and rheumatoid arthritis. Women thus have more

health problems than men even though they outlive men, a situation commonly known as the morbidity

paradox (Gorman & Read, 2006). [30] Why, then, do women outlive men? Conversely, why do men die

earlier than women? The obvious answer is that men have more life-threatening diseases, such as heart

disease and emphysema, than women, but that raises the question of why this is so.

Several reasons explain the gender gap in longevity. One might be biological, as women’s estrogen and

other sex-linked biological differences may make them less susceptible to heart disease and other life

threatening illnesses, even as they render them more vulnerable to some of the problems already listed

(Kuller, 2010). [31] A second reason is that men lead more unhealthy lifestyles than women because of

differences in gender socialization. For example, men are more likely than women to smoke, to drink

heavily, and to drive recklessly. All such behaviors make men more vulnerable than women to life

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threatening illnesses and injuries (Gorman & Read, 2006). [32] Men are also more likely than women to

hold jobs in workplaces filled with environmental hazards and other problems that are thought to kill

thousands of people—most of them men—annually (Simon, 2008). [33]

A final reason is men’s reluctance to discuss medical problems they have and to seek help for them,
owing
to their masculine socialization into being “strong, silent types.” Just as men do not like to ask for

directions, as the common wisdom goes, so do they not like to ask for medical help. As one physician
put

it, “I’ve often said men don’t come in for checkups because they have a big Stattooed on their chests;
they

think they’re Superman” (Guttman, 1999, p. 10).[34] Studies find that men are less likely than women to
tell

anyone when they have a health problem and to seek help from a health-care professional (Emmers

Sommer et al., 2009). [35] When both sexes do visit a physician, men ask fewer questions than women
do.

In one study, the average man asked no more than two questions, while the average woman asked at
least

six. Because patients who ask more questions get more information and recover their health more
quickly,

men’s silence in the exam room may contribute to their shorter longevity (Foreman,

1999). [36] Interestingly, the development of erectile dysfunction drugs like Viagra may have helped

improve men’s health, as men have had to visit physician’s offices to obtain prescriptions for these drugs

when otherwise they would not have made an appointment (Guttman, 1999). [37]

We have just discussed why men die sooner than women, which is one of the two gender differences
that

constitute the morbidity paradox. The other gender difference concerns why women have more
nonfatal

health problems than men. Several reasons seem to account for this difference (Read & Gorman,

2010). [38]

One reason arises from the fact that women outlive men. Because women are thus more likely than
men

to be in their senior years, they are also more likely to develop the many health problems associated
with

old age. This suggests that studies that control for age (by comparing older women with older men,
middle-age women with middle-age men, and so forth) should report fewer gender differences in health

than those that do not control for age, and this is indeed true.

However, women still tend to have worse health than men even when age is taken into account.
Medical

sociologists attribute this gender difference to the gender inequality in the larger society thatChapter 8

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"Gender and Gender Inequality" discussed (see the “Sociology Making a Difference” box). For example,

women are poorer overall than men, as they are more likely to work only part-time and in low-paying
jobs

even if they work full-time. As discussed earlier in this chapter, poverty is a risk factor for health

problems. Women’s worse health, then, is partly due to their greater likelihood of living in poverty or

near-poverty. Because of their gender, women also are more likely than men to experience stressful
events

in their everyday lives, such as caring for a child or an aging parent, and their increased stress is an

important cause of their greater likelihood of depression and the various physical health problems

(weakened immune systems, higher blood pressure, lack of exercise) that depression often causes.
Finally,

women experience discrimination in their everyday lives because of our society’s sexism, and (as is also

true for people of color) this discrimination is thought to produce stress and thus poorer physical health

(Landry & Mercurio, 2009). [39]

Sociology Making a Difference

Gender Inequality and Women’s Health

Research during the past two decades has established that women are more likely than men to have
health

problems that are not life threatening. The text discusses that a major reason for this gender difference
is

gender inequality in the larger society and, in particular, the low incomes that many women have. As

sociologists Bridget K. Gorman and Jen’nan Ghazal Read (Gorman & Read, 2006, p. 96) [40] explain,

“Women are more likely than men to work part time, participate in unwaged labor, and receive lower

wages, all of which drives down their chances for good health.”

According to Gorman and Read, research on gender differences in health has failed to consider whether

the size of this difference might vary by age. This research has also neglected measures of health beyond

self-rated health, a common measure in many studies.

Gorman and Read addressed these research gaps with data on about 152,000 individuals from several

years of the National Health Interview Survey, conducted annually by the federal government. Among

other findings, women were much more likely than men overall to suffer from functional limitations
(e.g.,

inability to walk steadily or to grasp small objects). When Gorman and Read controlled for age, this

gender difference was greater for people in their middle and senior years than for those at younger
ages.

They also found that socioeconomic status was not related to functional limitations at younger ages but

did predict these limitations at older ages (with poorer people more likely to have limitations). In an

additional finding, socioeconomic status was strongly related to self-reported health at all ages.

The two sociologists drew a pair of policy conclusions from this set of findings. The first is the “need to

understand and respond to women’s greater burden of functional limitations at every age of adulthood,

particularly in middle and late life” (p. 108). The second is the need for public policy to “continue to

address the causes and consequences of women’s disadvantaged social position relative to men,” as
their

finding on the importance of socioeconomic status “highlights the health gains for women that would
accompany improvement in their socioeconomic standing” (p. 108). In calling attention to the need for

public policy on women’s health to address women’s functional limitations and lower economic
resources,

Gorman and Read’s research was a fine example of sociology again making a difference.

Mental Health and Mental Illness

Health consists of mental well-being as well as physical well-being, and people can suffer mental health

problems in addition to physical health problems. Scholars disagree over whether mental illness is real
or,

instead, a social construction. The predominant view in psychiatry, of course, is that people do have
actual

problems in their mental and emotional functioning and that these problems are best characterized as

mental illnesses or mental disorders and should be treated by medical professionals (Kring & Sloan,

2010). [41] But other scholars, adopting a labeling approach (see Chapter 5 "Deviance, Crime, and Social

Control"), say that mental illness is a social construction or a “myth” (Szasz, 2008). [42] In their view, all

kinds of people sometimes act oddly, but only a few are labeled as mentally ill. If someone says she or
he

hears the voice of an angel, we attribute their perceptions to their religious views and consider them

religious, not mentally ill. But if someone instead insists that men from Mars have been in touch, we are

more apt to think there is something mentally wrong with that person. Mental illness thus is not real but

rather is the reaction of others to problems they perceive in someone’s behavior.

This intellectual debate notwithstanding, many people do suffer serious mental and emotional
problems,

such as severe mood swings and depression, that interfere with their everyday functioning and social

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interaction. Sociologists and other researchers have investigated the social epidemiology of these
problems. Several generalizations seem warranted from their research (Cockerham, 2011). [43]

First, social class affects the incidence of mental illness. To be more specific, poor people exhibit more

mental health problems than richer people: they are more likely to suffer from schizophrenia, serious

depression, and other problems (Mossakowski, 2008). [44] A major reason for this link is the stress of

living in poverty and the many living conditions associated with it. One interesting causal question here,

analogous to that discussed earlier in assessing the social class–physical health link, is whether poverty

leads to mental illness or mental illness leads to poverty. Although there is evidence of both causal
paths,

most scholars believe that poverty contributes to mental illness more than the reverse (Warren, 2009).
[45]

Second, there is no clear connection between race and ethnicity and mental illness, as evidence on this

issue is mixed: although many studies find higher rates of mental disorder among people of color, some

studies find similar rates to whites’ rates (Mossakowski, 2008). [46] These mixed results are somewhat

surprising because several racial/ethnic groups are poorer than whites and more likely to experience

everyday discrimination, and for these reasons should exhibit more frequent symptoms of mental and

emotional problems. Despite the mixed results, a fair conclusion from the most recent research is that

African Americans and Latinos are more likely than whites to exhibit signs of mental distress

(Mossakowski, 2008; Jang, Chiriboga, Kim, & Phillips, 2008; Araujo & Borrell, 2006). [47]

Third, gender is related to mental illness but in complex ways, as the nature of this relationship depends

on the type of mental disorder. Women have higher rates of manic-depressive disorders than men and
are

more likely to be seriously depressed, but men have higher rates of antisocial personality disorders that

lead them to be a threat to others (Kort-Butler, 2009; Mirowsky & Ross, 1995). [48] Although some
medical

researchers trace these differences to sex-linked biological differences, sociologists attribute them to

differences in gender socialization that lead women to keep problems inside themselves while

encouraging men to express their problems outwardly, as through violence. To the extent that women
have higher levels of depression and other mental health problems, the factors that account for their

poorer physical health, including their higher rates of poverty and stress and rates of everyday

discrimination, are thought to also account for their poorer mental health (Read & Gorman, 2010). [49]

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KEY TAKEAWAYS

• Social class, race and ethnicity, and gender all influence the quality of health in the United States.
Health

problems are more common among people from low-income backgrounds and among people of color.

Women are more likely than men to have health problems that are not life threatening.

• Although debate continues over whether mental illness is a social construction, many people do suffer

mental health problems. The social epidemiology for mental health and illness resembles that for
physical

health and illness, with social class, race and ethnicity, and gender disparities existing.

FOR YOUR REVIEW

1. In thinking about the health problems of individuals from low-income backgrounds, some people
blame

lack of access to adequate health care for these problems, while other people blame unhealthy lifestyles

practiced by low-income individuals. Where do you stand on this debate? Explain your answer.

2. Write a brief essay in which you present a sociological explanation of the higher rate of depression
found

among women than among men.

[1] Centers for Disease Control and Prevention. (2010). Mortality by underlying and multiple cause, ages
18+: US,

1981–2006. Retrieved from[Link]

[2] National Center for Health Statistics. (2009). Health, United States, 2009. Hyattsville, MD: Centers for
Disease
Control and Prevention.

[3] Centers for Disease Control and Prevention. (2007). Interpreting and managing blood lead levels <10
μg/dL in

children and reducing childhood exposures to lead: Recommendations of CDC’s advisory committee on
childhood

lead poisoning [Link] (Morbidity and Mortality Weekly Report), 56(RR-8), 1–16.

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[16] Wray, L. A., Herzog, A. R., Willis, R. J., & Wallace, R. B. (1998). The impact of education and heart
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[18] Smith, J. P. (2005). Unraveling the SES-health connection [Supplemental material].Population and

Development Review, 30, 108–132.

[19] Barr, D. A. (2008). Health disparities in the United States: Social class, race, and health. Baltimore,
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[22] Lewis-Moss, R. K., Paschal, A., Redmond, M., Green, B. L., & Carmack, C. (2008). Health attitudes
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behaviors of African American adolescents. Journal of Community Health, 33(5), 351–356.

[23] Pérez-Escamilla, R. (2009). Dietary quality among Latinos: Is acculturation making us sick? Journal of
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American Dietetic Association, 109(6), 988–991.

[24] Williams, D. R., Neighbors, H. W., & James S. Jackson, P. (2008). Racial/ethnic discrimination and
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[33] Simon, D. R. (2008). Elite deviance (9th ed.). Boston, MA: Allyn & Bacon.
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beliefs, and perceptions of communication inappropriateness. Sex Roles: A Journal of Research, 60, 9–
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13.4 Medicine and Health Care in the United States

LEARNING OBJECTIVES

1. Summarize the major developments in the rise of scientific medicine.

2. Discuss several problems with the U.S. health-care model involving direct fees and private health

insurance.

3. Describe any two issues in U.S. health care other than the lack of health insurance.

As the health-care debate in 2009 and 2010 illustrates, the practice of medicine in the United States

raises many important issues about its cost and quality. Before we discuss some of these issues, a

brief discussion of the history of medicine will sketch how we have reached our present situation

(Louden, 1997; Porter, 2006). [1]

The Rise of Scientific Medicine

The practice of medicine today in the United States and much of the rest of the globe follows a scientific

approach. But scientific medicine is a relatively recent development in the history of the world.
Prehistoric

societies attributed illness to angry gods or to evil spirits that took over someone’s body. The
development

of scientific medicine since then illustrates one of the sociological insights discussed at the beginning of

this chapter: the type of society influences its beliefs about health and ways of healing.

Figure 13.14

Modern medicine began during the 17th century with the discovery by

English physician William Harvey of how blood circulates through the

body.

Source:

[Link]

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The roots of today’s scientific medicine go back to the ancient civilizations in the Middle East, Asia, and

Greece and Rome, which began to view health and illness somewhat more scientifically. In ancient
Egypt,

for example, physicians developed some medications, such as laxatives, that are still used, and they also

made advances in the treating of wounds and other injuries. The ancient Chinese developed several
drugs,

including arsenic, sulfur, and opium, that are also still used. Ancient India developed anesthesia,

antidotes for poisonous snakebites, and several surgical techniques including amputation and the

draining of abscesses (Porter, 2006). [2] Ancient Greece built medical schools in which dissection of

animals was used to help understand human anatomy. Later, a Greek physician named Galen, who lived

in Rome during the 100s A.D., wrote influential treatises on inflammation, infectious disease, and the

muscular and spinal cord systems. Medical advances continued in the Middle Ages and the Renaissance,

as various physicians wrote about smallpox, measles, and other diseases, and several medical schools
and

hospitals were established. Leonardo da Vinci and other scientists performed many dissections and

produced hundreds of drawings of human anatomy. Other major advances, including the development
of

surgical techniques and the treatment of burns, were also made during this period.

What is now called modern medicine began in the 1600s, as scientists learned how blood circulates

through the body and used microscopes to discover various germs, including bacteria. By the end of the

1800s, the germ theory of disease had become widely accepted, thanks largely to the work of Louis

Pasteur and other scientists. Other key developments during this time included the discovery of ether
gas

as an effective anesthesia and the realization that surgery needed to be carried out under the strictest

standards of cleanliness (Porter, 2006). [3] During the 1800s, the American Medical Association and
other
professional associations of physicians were founded to advance medical knowledge and standards and
to

help give physicians a monopoly over the practice of medicine (Starr, 1982). [4] In the early 1900s,

scientists learned about the importance of vitamins, and penicillin was developed as the first antibiotic.

Developments in immunology, physiology, and many other areas of medicine have obviously advanced
far

beyond what we knew a century ago and remain too numerous and complex to discuss here.

Scientific medicine has saved countless lives: life spans used to average no more than the age of 40 or
so,

as we have seen, but in industrial nations now average well into the 70s. Still, as we have also seen, huge

disparities remain across the world today in life spans and the quality of health. Disparities also exist in

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the quality of health care across the world. In the United States, questions about the cost and
effectiveness

of health care have dominated the news. We now turn to some of these issues.

U.S. Health Care and the Industrial World

Medicine in the United States is big business. Expenditures for health care, health research, and other

health items and services have risen sharply in recent years, having increased tenfold since 1980, and
now

costs the nation more than $2.6 trillion annually (see Figure 13.15 "U.S. Health Care Expenditure, 1980

2010 (in Billions of Dollars)"). This translates to the largest figure per capita in the industrial world.

Despite this expenditure, the United States lags behind many other industrial nations in several
important

health indicators, as we have already seen. Why is this so?

Figure 13.15 U.S. Health Care Expenditure, 1980–2010 (in Billions of Dollars)

Source: Data from U.S. Census Bureau. (2010). Statistical abstract of the United States: 2010.
Washington, DC: U.S. Government Printing Office. Retrieved

from [Link]

The U.S. Health-Care Model

As discussed earlier, other Western nations have national systems of health care and health insurance.
In

stark contrast to these nations, the United States relies on a direct-fee system, in which patients are

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expected to pay for medical costs themselves, aided by private health insurance, usually through one’s

employer. Table 13.4 "Health Insurance Coverage in the United States, 2008" shows the percentages of

Americans who have health insurance from different sources or who are not insured at all. (All figures
are

from the period before the major health-care reform package was passed by the federal government in

early 2010.) Adding together the top two figures in the table, 57% of Americans have private insurance,

either through their employers or from their own resources. Almost 28% have some form of public

insurance (Medicaid, Medicare, other public), and 15.4% are uninsured. This final percentage amounts
to

about 46 million Americans, including 8 million children, who lack health insurance. Their lack of health

insurance has deadly consequences because they are less likely to receive preventive health care and
care

for various conditions and illnesses. It is estimated that 45,000 people die each year because they do not

have health insurance (Wilper et al., 2009). [5]

Table 13.4 Health Insurance Coverage in the United States, 2008

Employer

52.3%

Individual
4.7%

Medicaid

14.1%

Medicare

12.4%

Other public 1.2%

Uninsured

15.4%

Source: Data from Kaiser Family Foundation. (2010). Kaiser state health facts. Retrieved

from [Link]

Although almost 28% of Americans do have public insurance, this percentage and the coverage provided

by this insurance do not begin to match the coverage enjoyed by the rest of the industrial world.
Although

Medicare pays some medical costs for the elderly, we saw in Chapter 9 "Aging and the Elderly"that its

coverage is hardly adequate, as many people must pay hundreds or even thousands of dollars in

premiums, deductibles, coinsurance, and copayments. The other government program, Medicaid, pays

some health-care costs for the poor, but many low-income families are not poor enough to receive

Medicaid. Eligibility standards for Medicaid vary from one state to another, and a family poor enough in

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one state to receive Medicaid might not be considered poor enough in another state. The State
Children’s

Health Insurance Program (SCHIP), begun in 1997 for children from low-income families, has helped

somewhat, but it, too, fails to cover many low-income children. Largely for these reasons, about two

thirds of uninsured Americans come from low-income families.

Not surprisingly, the 15.4% uninsured rate varies by race and ethnicity (seeFigure 13.16 "Race, Ethnicity,

and Lack of Health Insurance, 2008 (Percentage With No Insurance)"). Among people under 65 and thus

not eligible for Medicare, the uninsured rate rises to almost 21% of the African American population and

32% of the Latino population. Moreover, 45.3% of adults under 65 who live in official poverty lack health

insurance, compared to only about 6% of high-income adults (those with incomes higher than four times

the poverty level). Almost one-fifth of poor children have no health insurance, compared to only 3.5% of

children in higher-income families (Kaiser Family Foundation, 2010). [6] As discussed earlier, the lack of

health insurance among the poor and people of color is a significant reason for their poorer health.

Figure 13.16 Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage With No Insurance)

Source: Data from [Link]. (2010). Uninsured rates for the nonelderly by race and

ethnicity, states (2007–2008), U.S. (2008). Retrieved

from [Link]

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Issues in U.S. Health Care

The lack of insurance of so many Americans is an important health-care issue, but other issues about

health care also seem to make the news almost every day. We examine a few of these here.

Managed Care and HMOs

To many critics, a disturbing development in the U.S. health-care system has been the establishment

of health maintenance organizations, or HMOs, which typically enroll their subscribers through their

workplaces. HMOs are prepaid health plans with designated providers, meaning that patients must visit
a

physician employed by the HMO or included on the HMO’s approved list of physicians. If their physician

is not approved by the HMO, they either have to see an approved physician or see their own without

insurance coverage. Popular with employers because they are less expensive than traditional private
insurance, HMOs have grown rapidly in the last three decades and now enroll more than 70 million

Americans (see Figure 13.17 "Growth of Health Maintenance Organizations (HMOs), 1980–2007

(Millions of Enrollees)").

Figure 13.17 Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of

Enrollees)

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Source: Data from U.S. Census Bureau. (2010). Statistical abstract of the United States: 2010.

Washington, DC: U.S. Government Printing Office. Retrieved

from [Link]

Although HMOs have become popular, their managed care is also very controversial for at least two

reasons (Kronick, 2009). [7] The first is the HMOs’ restrictions just noted on the choice of physicians and

other health-care providers. Families who have long seen a family physician but whose employer now

enrolls them in an HMO sometimes find they have to see another physician or risk going without

coverage. In some HMOs, patients have no guarantee that they can see the same physician at every
visit.

Instead, they see whichever physician is assigned to them at each visit. Critics of HMOs argue that this

practice prevents physicians and patients from getting to know each other, reduces patients’ trust in
their

physician, and may for these reasons impair patient health.

The second reason for the managed-care controversy is perhaps more important. HMOs often restrict
the

types of medical exams and procedures patients may undergo, a problem calleddenial of care, and limit

their choice of prescription drugs to those approved by the HMO, even if their physicians think that

another, typically more expensive drug would be more effective. HMOs claim that these restrictions are

necessary to keep medical costs down and do not harm patients.

Several examples of the impact of managed care’s denials of coverage and/or care exist. In one case, a

woman with a bone spur on her hip had successful arthroscopic surgery instead of open hip surgery, the

more common and far more expensive procedure for this condition. When her insurance company
denied

coverage for her arthroscopic surgery, the patient had to pay doctor and hospital fees of more than

$21,000. After a lengthy appeal process, the insurance company finally agreed to pay for her procedure

(Konrad, 2010). [8] In a more serious case a decade ago, a 22-year-old woman died after going to a

physician several times in the preceding week with chest pain and shortness of breath. She was
diagnosed

with a respiratory infection and “panic attacks” but in fact had pneumonia and a blood clot in her left

lung. Her physician wanted her to have lab tests that would have diagnosed these problems, but her

HMO’s restrictions prevented her from getting the tests. A columnist who wrote about this case said
that

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“an unconscionable obsession with the bottom line has resulted in widespread abuses in the managed

care industry. Simply stated, there is big money to be made by denying care” (Herbert, 1999, p. A25). [9]

Racial and Gender Bias in Health Care

Another problem in the U.S. medical practice is apparent racial and gender bias in health care. Racial
bias

seems fairly common; as Chapter 7 "Race and Ethnicity" discussed, African Americans are less likely than

whites with the same health problems to receive various medical procedures (Smedley, Stith, & Nelson,

2003). [10] Gender bias also appears to affect the quality of health care (Read & Gorman,

2010). [11] Research that examines either actual cases or hypothetical cases posed to physicians finds
that

women are less likely than men with similar health problems to be recommended for various
procedures,
medications, and diagnostic tests, including cardiac catheterization, lipid-lowering medication, kidney

dialysis or transplant, and knee replacement for osteoarthritis (Borkhoff et al., 2008). [12]

Other Problems in the Quality of Care

Other problems in the quality of medical care also put patients unnecessarily at risk. These include:

• Sleep deprivation among health-care professionals. As you might know, many physicians

get very little sleep. Studies have found that the performance of surgeons and medical residents

who go without sleep is seriously impaired (Institute of Medicine, 2008). [13] One study found that

surgeons who go without sleep for 24 hours have their performance impaired as much as a drunk

driver. Surgeons who stayed awake all night made 20% more errors in simulated surgery than

those who slept normally and took 14% longer to complete the surgery (Wen, 1998). [14]

• Shortage of physicians and nurses. Another problem is a shortage of physicians and nurses

(Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010; Fuhrmans, 2009). [15] This is a general

problem around the country, but even more of a problem for two different settings. The first such

setting is hospital emergency rooms, Because emergency room work is difficult and relatively low

paying, many specialist physicians do not volunteer for it. Many emergency rooms thus lack an

adequate number of specialists, resulting in potentially inadequate emergency care for many

patients.

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Rural areas are the second setting in which a shortage of physicians and nurses is a severe

problem. The National Rural Health Association (2010)[16] points out that although one-fourth of

the U.S. population is rural, only one-tenth of physicians practice in rural areas. Compounding

this shortage is the long distances that patients and emergency medical vehicles must travel and

the general lack of high-quality care and equipment at small rural hospitals. Partly for these
reasons, rural residents are more at risk than urban residents for health problems, including

mortality. For example, only one-third of all motor vehicle accidents happen in rural areas, but

two-thirds of all deaths from such accidents occur in rural areas. Rural areas are also much more

likely than urban areas to lack mental health services.

• Mistakes by hospitals. Partly because of sleep deprivation and the shortage of health-care

professionals, hundreds of thousands of hospital patients each year suffer from mistakes made by

hospital personnel. They receive the wrong diagnosis, are given the wrong drug, have a procedure

done on them that was really intended for someone else, or incur a bacterial infection. These and

other mistakes are thought to kill almost 200,000 patients per year, or almost 2 million every

decade (Crowley & Nalder, 2009). [17]

Complementary and Alternative Medicine (CAM)

As the medical establishment grew in the 19th and 20th centuries, it helped to formulate many
standards

for medical care and training, including licensing restrictions that prevent anyone without a degree from
a

recognized medical school from practicing medicine. As noted earlier, some of its effort stemmed from

well-intentioned beliefs in the soundness of a scientific approach to medical care, but some of it also

stemmed from physicians’ desire to “corner the market” on health care, and thus raise their profits, by

keeping other health practitioners such as midwives out of the market.

There is increased recognition today that physical health depends at least partly on psychological well

being. As the old saying goes, your mind can play tricks on you, and a growing amount of evidence

suggests the importance of a sound mind for a sound body. Many studies have found that stress
reduction

can improve many kinds of physical conditions and that high levels of stress can contribute to health

problems (B. W. Smith et al., 2010). [18]

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Evidence of a mind-body connection has fueled the growing interest in complementary and alternative

medicine (CAM) that takes into account a person’s emotional health and can often involve alternative

treatments such as acupuncture and hypnosis. In the last two decades, several major medical centers at

the nation’s top universities established alternative medicine clinics. Despite the growing popularity of

alternative medicine, much of the medical establishment remains skeptical of its effectiveness. Even so,

about 40% of Americans use an alternative medicine product or service each year, and they spend about

$34 billion per year on the various kinds of products and services that constitute alternative medicine

(Wilson, 2009) [19](see Figure 13.20 "Use of Selected Forms of Complementary and Alternative
Medicine

(CAM), 2007 (Percentage of U.S. Adults Using Each Form During Past Year)").

Figure 13.20 Use of Selected Forms of Complementary and Alternative Medicine (CAM), 2007

(Percentage of U.S. Adults Using Each Form During Past Year)

Source: Data from U.S. Census Bureau. (2010). Statistical abstract of the United States: 2010.

Washington, DC: U.S. Government Printing Office. Retrieved

from [Link]

Medical Ethics and Medical Fraud

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A final set of issues in U.S. medicine concerns questions of medical ethics and outright medical fraud.

Many types of health-care providers, including physicians, dentists, medical equipment companies, and

nursing homes, engage in many types of health-care fraud. In a common type of fraud, they sometimes

bill Medicare, Medicaid, and private insurance companies for exams or tests that were never done and

even make up “ghost patients” who never existed or bill for patients who were dead by the time they
were
allegedly treated. In just one example, a group of New York physicians billed their state’s Medicaid

program for over $1.3 million for 50,000 psychotherapy sessions that never occurred. All types of health

care fraud combined are estimated to cost about $100 billion per year (Kavilanz, 2010). [20]

Other practices are legal but ethically questionable. Sometimes physicians refer their patents for tests to
a

laboratory that they own or in which they have invested. They are more likely to refer patients for tests

when they have a financial interest in the lab to which the patients are sent. This practice, calledself

referral, is legal but does raise questions of whether the tests are in the patient’s best interests or
instead

in the physician’s best interests (Romano, 2009). [21]

In another practice, physicians are asking hundreds of thousands of their patients to take part in drug

trials. The physicians may receive more than $1,000 for each patient they sign up, but the patients are
not

told about these payments. Characterizing these trials, two reporters said that “patients have become

commodities, bought and traded by testing companies and physicians” and said that it “injects the

interests of a giant industry into the delicate physician-patient relationship, usually without the patient

realizing it” (Galewitz, 2009; Eichenwald and Kolata, 1999). [22] These trials raise obvious conflicts of

interest for the physicians, who may recommend their patients do something that might not be good for

them but would be good for the physicians’ finances.

KEY TAKEAWAYS

• Scientific medicine is a relatively recent development in the history of the world. For much of human

history, religious and spiritual beliefs, not scientific ones, shaped the understanding of health and the

practice of medicine

• The U.S. health-care model relies on a direct-fee system and private health insurance. This model has

been criticized for contributing to high health-care costs, high rates of uninsured individuals, and high

rates of health problems in comparison to the situation in other Western nations.

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• Other problems in U.S. health care include the restrictive practices associated with managed care,

racial/ethnic and gender bias in health-care delivery, and medical fraud.

FOR YOUR REVIEW

1. Do you know anyone, including yourself or anyone in your family, who lacks health insurance? If so,
do

you think the lack of health insurance has contributed to any health problems? Write a brief essay in

which you discuss the evidence for your conclusion.

2. Critics of managed care say that it overly restricts important tests and procedures that patients need
to

have, while proponents of managed care say that these restrictions are necessary to keep health-care

costs in check. What is your view of managed care?

Improving Health and Health Care: What Sociology Suggests

A sociological perspective on health and health care emphasizes the profound role played by social class,

race and ethnicity, and gender. As we have seen throughout this chapter, all three dimensions of social

inequality in the larger society affect both the quality of health and the quality of health care. People
from

low-income backgrounds have higher rates of physical and mental illness because of the stress and
other

factors associated with living with little money and also because of their lack of access to adequate
health

care. Partly because they tend to be poorer and partly because of the discrimination they experience in
their daily lives and in the health-care system, people of color also have higher rates of physical and

mental illness. Findings on gender are more complex, but women have higher rates than men of
nonfatal

physical illness and of depression and other mental illness, and they experience lower quality of health

care for certain conditions.

To improve health and health care in the United States, the importance of social class, race and
ethnicity,

and gender must be addressed. Efforts, as outlined in earlier chapters, that reduce poverty and

racial/ethnic and gender inequality should also improve the physical and mental health of those
currently

at risk because of their low incomes, race or ethnicity, and/or gender. At the same time, special efforts

must be made to ensure that these millions of individuals receive the best health care possible within
the

existing system of social inequality. In this regard, the national health-care and health insurance systems

of Canada, the United Kingdom, and many other Western nations provide models for the United States.

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As discussed in this chapter, these nations provide better health care in many ways to their citizens at a

lower cost than that incurred under the U.S. model of private insurance. Their models are not perfect,
but

a government-funded and government-run single-payer system—or “Medicare for all,” as it has been

called—shows great promise for improving the health and health care of all Americans, especially for

those now disadvantaged by their social class, race and ethnicity, and/or gender. The U.S. health-care

system, despite the recent health-care reform legislation and medical advances that just a short time
ago

were only a dream, still has a long way to go before affordable and high-quality health care is available
to

all. With the health of so many people at stake, the United States needs to make every effort to achieve
this essential goal.

This effort should certainly include an expansion of measures that fall broadly into what the field of
public

health calls preventive care. This approach recognizes that the best approach to health and health care
is

to prevent illness and disease before they begin. One facet of this approach focuses on the unhealthy

behaviors and lifestyles, including lack of exercise, obesity, and smoking, characteristic of millions of

Americans. Although the United States has public education campaigns and other initiatives on these
risk

factors, more could still be done. Another facet of this approach focuses on early childhood in general
but

especially on early childhood among low-income families. As this chapter has emphasized beginning
with

the “Social Issues in the News” story, many health problems begin very early in childhood and even in
the

womb. Home visitation and nutrition assistance programs must be expanded across the country to

address these problems.

What can be done to improve world health? Because the poorest nations have the poorest health, it is

essential that the wealthy nations provide them the money, equipment, and other resources they need
to

improve their health and health care. The residents of these nations also need to be given the resources

they need to undertake proper sanitation and other good health practices. In this regard, organizations

like the World Health Organization have been instrumental in documenting the dire status of health in

the poor nations and in promoting efforts to help them, and groups like Doctors Without Borders have

been instrumental in bringing health-care professionals and medical care to poor nations. Ultimately,

however, these nations’ poor health is just one of the consequences of the global stratification
examined

in Chapter 6 "Social Stratification". Until these nations’ economic circumstances and high rates of

illiteracy improve dramatically, their health status will remain a serious problem.
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Porter, R.

(Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge University Press.

[2] Porter, R. (Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge
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Press.

[3] Porter, R. (Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge
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Press.

[4] Starr, P. (1982). The social transformation of American medicine. New York, NY: Basic Books.

[5] Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009).
Health

insurance and mortality in US adults. American Journal of Public Health, 99(12), 1–7.

[6] Kaiser Family Foundation. (2010). Kaiser state health facts. Retrieved
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[7] Kronick, R. (2009). Medicare and HMOs—the search for accountability. New England Journal of
Medicine, pp.

2048–2050. Retrieved

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[8] Konrad, W. (2010, February 5). Fighting denied claims requires perseverance. The New York Times, p.
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[9] Herbert, B. (1999, July 15). Money vs. reform. The New York Times, p. A25.

[10] Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and
ethnic

disparities in health care. Washington, DC: National Academies Press.

[11] Read, J. G., & Gorman, B. K. (2010, June). Gender and health inequality. Annual Review of Sociology,
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[12] Borkhoff, C. M., Hawker, G. A., Kreder, H. J., Glazier, R. H., Mahomed, N. N., & Wright, J. G. (2008).
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of patients’ sex on physicians’ recommendations for total knee arthroplasty. Canadian Medical
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178(6), 681–687.

[13] Institute of Medicine. (2008). Resident duty hours: Enhancing sleep, supervision, and safety.
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National Academies Press.

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[14] Wen, P. (1998, February 9). Tired surgeons perform as if drunk, study says. The Boston Globe, p. A9.

[15] Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010).
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manager stress and work complexity: Factors that make a difference. The Journal of Nursing
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82–91; Fuhrmans, V. (2009, January 13). Surgeon shortage pushes hospitals to hire temps. The Wall
Street Journal,

p. A1.

[16] National Rural Health Association. (2010). What’s different about rural health care? Retrieved

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[17] Crowley, C. F., & Nalder, E. (2009, August 9). Secrecy shields medical mishaps from public view. San
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Chronicle, p. A1.

[18] Smith, B. W., Papp, Z. Z., Tooley, E. M., Montague, E. Q., Robinson, A. E., & Cosper, C. J. (2010).
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[19] Wilson, P. (2009). Americans spend $33.9 billion a year on alternative [Link] Reports
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[21] Romano, D. H. (2009). Self-referral of imaging and increased utilization: Some practical perspectives
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13.5 End-of-Chapter Material

Summary

1. A sociological approach emphasizes the relationship between health, medicine, and society. Our
social
backgrounds influence our health and access to health care, while the culture and social structure of a

society influences its perceptions of health and illness and ways of healing.

2. Sociological perspectives on health and illness fall into the functional, conflict, and interactionist

approaches encountered in previous chapters. The functional view emphasizes the importance of

health for a society’s stability and the roles that people play when they are sick. The conflict view

stresses inequality in the quality of health and health-care delivery and efforts by physicians to

monopolize the practice of medicine to increase their profits. According to the interactionist view,

health and illness are social constructions subject to people’s and society’s interpretations. The

interactionist view also studies how medical professionals and patients interact and the way

professionals manage understandings of such interaction.

3. Health and the quality of health care differ widely around the world and reflect global stratification.

The earth’s poorest nations have extremely high rates of infant mortality and life-threatening diseases

such as AIDS and very low life expectancy. Despite efforts of organizations like the World Health

Organization, the poor health of the poor nations’ residents remains a serious problem.

4. The United States ranks ahead of most of the world’s nations in most health indicators, and health in

the United States has greatly improved in the last century. At the same time, the United States lags

behind most other industrial nations in important health indicators such as infant mortality and life

expectancy. Moreover, serious disparities exist within the United States in the social distribution of

health, as evidenced by the study of social epidemiology.

5. Social class, race and ethnicity, and gender all affect the quality of health. Poor people lack health

insurance and access to health, face high amounts of stress, live in unhealthy social and physical
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environments, and are more apt to engage in unhealthy lifestyles. For all of these reasons, their health

is worse than that of the nonpoor. African Americans, Hispanics, and Native Americans all fare worse

than whites on many health indicators, in large part because of their poverty and history of

discrimination. Women fare worse than men on several heath indicators, but men have lower life

expectancies because of their higher rates of certain life-threatening illnesses. These rates are thought

to be due to men’s biology, unhealthy lifestyles brought on by their masculine socialization, and

unwillingness to seek medical treatment.

6. Social factors also help explain different rates of mental illness. The poor have higher rates of mental

disorders than the nonpoor because of the stress of poverty and other negative life conditions. Women

are more likely than men to be depressed and to suffer from some other disorders, but men are more

likely to have antisocial personality disorders with symptoms that make them a threat to others. Clear

racial and ethnic differences in mental disorders have not been found, perhaps because the strong

family bonds and religious faith of many minorities help protect them from disorders that would

otherwise be expected from their poverty and discrimination. In looking at Mexican-Americans,

there’s some evidence that living in American society raises the risks of mental disorders.

7. The history of medicine reflects a move from religious and spiritual approaches to healing to scientific

approaches. In prehistoric societies priests tried to appease the angry gods or chase away the evil

spirits who were thought to cause physical and mental illness. Ancient civilizations made great

advances in our understanding of health and illness, and the rise of scientific medicine beginning in

the 1600s helped pave the path for today’s scientific approach.
8. Despite these medical advances, health care in the United States today faces several problems. The

United States is alone in not offering universal national health insurance; its absence is thought to

help account for the country’s low ranking in the industrial world on major health indicators, as

significant numbers of our poor and minorities lack health insurance. Managed care has also come

under criticism for restricting coverage of important medical procedures and prescription medicines.

Racial and gender bias in health care is another problem that has adverse effects on the nation’s

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health. Other quality-of-care problems include tired physicians, a lack of emergency-room physicians,

and numerous mistakes made in hospitals. Disagreement over alternative medicine reflects the

historic battle between the medical establishment and other healers, while self-referral and other

issues raise important questions for medical ethics. Meanwhile, health-care fraud costs the nation

some $100 billion annually and remains an important problem for the nation to address.

USING SOCIOLOGY

You have always had an interest in health care and 2 months ago received your license to work as a

physician’s assistant after taking 2 years of courses beyond your BA. Having had a course in medical
sociology,

you learned about health-care disparities related to social class. Within a few weeks of receiving your
license,

you started working at a health-care clinic in a low-income neighborhood of a medium-sized city. Since
then

you have enjoyed your work because you’ve enjoyed helping the patients and think you are making a

difference, however small, to improve their health.

At the same time, you have become troubled by comments from two of the physicians on staff, who
have
scorned their patients for having so many health problems and for waiting too long to come in for
medical

help. You realize that you could jeopardize your job if you criticize the doctors’ views to anyone in the
office,

but you also feel the need to say something. What, if anything, do you do? Explain your answer.
questions

1. Which approach—functionalist, conflict, or symbolic interactionist—do you most favor

regarding how you understand health and health care? Explain your answer.
2. Think of the last time you visited a physician or another health-care professional. In what ways
did this person come across as an authority figure possessing medical knowledge? In
formulating your answer, think about the person’s clothing, body position and body language,
and other aspects of nonverbal communication.
3. What do you think should be done to help improve the health of poor nations? What role
should the United States play in any efforts in this regard?
4. Do you think the United States should move toward the national health insurance model found
in other Western nations? Why or why not?
5. In thinking about the health problems of individuals from low-income backgrounds, some
people blame lack of access to adequate health care for these problems, while other people
blame unhealthy lifestyles practiced by low-income individuals. Where do you stand on this
debate? Explain your answer.
6. Write a brief essay in which you present a sociological explanation of the higher rate of
depression found among women than among men.
7. Do you know anyone, including yourself or anyone in your family, who lacks health insurance? If
so, do you think the lack of health insurance has contributed to any health problems? Write a
brief essay in which you discuss the evidence for your conclusion.
8. Critics of managed care say that it overly restricts important tests and procedures that patients
need to have, while proponents of managed care say that these restrictions are necessary to
keep health-care costs in check. What is your view of managed care?
9. USING SOCIOLOGY You have always had an interest in health care and 2 months ago received
your license to work as a physician’s assistant after taking 2 years of courses beyond your BA.
Having had a course in medical sociology, you learned about health-care disparities related to
social class. Within a few weeks of receiving your license, you started working at a health-care
clinic in a low-income neighborhood of a medium-sized city. Since then you have enjoyed your
work because you’ve enjoyed helping the patients and think you are making a difference,
however small, to improve their health. At the same time, you have become troubled by
comments from two of the physicians on staff, who have scorned their patients for having so
many health problems and for waiting too long to come in for medical help. You realize that you
could jeopardize your job if you criticize the doctors’ views to anyone in the office, but you also
feel the need to say something. What, if anything, do you do? Explain your answer.