Chapter 10

Medical Care:

Physical and Mental Illness

The Problem In Sociological Perspective

•Health care outranks taxes, terrorism, and crime as problems the government needs to address.•Not just biology

Social component• Industrialization and lifestyle

Greater affluence• Iatrogenesis

Illness caused by medical care staff If the number of Americans killed by medical errors– became an official classification of death, it would

rank as number 6 in the top 10 leading causes of death

• Changing ideas about health and illness The way pregnancy is handled by physicians

highlights social nature of health and illness (In and out as quickly as possible)

Definitions of “diseases” are not fixed either• Environment and disease on a global level

Medical researchers are investigating how environment affects human disease

Looking at how human activities reshape environment and profound effects on the diseases that humans experience

The Social Organization of Medicine as a Social Problem

•An explosion in medical costs Medical costs continue to soar• Reasons for the explosion in costs

Increase in the standard of living, people live longer Development of expensive technology Seek out health care after illness arises, rather than

investing time and energy in preventive care Accepted view that medical care is a commodity that

should be sold for profit

•Medicine for profit: a two-tier system of medical care Medicine for profit is also known as a fee-for-

servicesystem.

Two-tier system of medical care: one for those who can afford insurance, and another for those who cannot

•Women’s reproductive organs Doctors report a bias against women’s reproductive

organs. Most of the 600,000 hysterectomies performed

each year in the United States are unnecessary.

•Medicine for profit: cesarean delivery Some physicians driven by profit•Why have cesarean births increased?

Profit Convenience Technology• A Feminist Controversy

Central issue is the relative power of women Cesarean delivery takes power over childbirth away

from women and places it in the hands of doctors

Physical Illness as a Social Problem

• Life expectancy and infant mortality Researchers analyze life expectancy when determining

how healthy or ill a society is as a whole. Infant Mortality Rate (IMR)

• Number of babies who die before 1 year of age, per 1,000 live births

• Most accurate measures of a group’s health conditions

Countries with less poverty have better health

• Lifestyle Although poverty is important, lifestyle may be even

more significant. Lifestyle is the major cause of illness and death.• Heroic medicine

U.S. creates a need for specialists in the pursuit of profit.

Emphasis on specialists has led to a shortage of primary care doctors who treat routine problems.

Health Affairs estimates that the United States spends $1 billion on health care for illegal immigrants each year.

• Uneven distribution of medical services Some areas house an abundance of physicians,

while other regions have very few doctors

Mental Illness as a Social Problem

•Measuring mental illness Experts argue that the rates of mental illness have

increased because people are experiencing more stress while their social support systems are weaker

Attempts to measure rates of mental illness today are also inaccurate

Data are inadequate because experts rarely agree on definitions and classifications of mental illness

•The social nature of mental illness How we define mental illness is a matter of dispute Has a strong social influence

• A two-tier system of mental health delivery Made up of two parts: the illness and the medical

delivery system Deinstitutionalization

• The release of hospitalized mental patients into the community

• Plan was to support them with medication and community health services

• In reality, few of the planned community centers were ever built.

Symbolic Interactionism

•Determining the meaning of symptoms and behavior People from different backgrounds interpret symptoms

differently Use cultural symbols to determine what our symptoms

mean•The significance of definitions

Groups compete to get their view of health accepted Definitions are socially created, developing out of

social interaction

• Different referral networks Patient’s frame of reference lies within a lay referral network Physician’s frame of reference, in contrast, lies within a

professional referral network• Depersonalization

Consequence of the professional referral network is that some doctors treat patients not as people, but as objects

Defensive Medicine: cautious practice incorporating the use of any and all available tests to ensure that an identifiable illness is not overlooked

• Problems in communication Different backgrounds and expectations often make it difficult

for patients and physicians to communicate with one another.

Functionalism

• Does society benefit? Functionalists assume that customs or social institutions

persist only if they fulfill social needs.• Whose needs are met by a health care system that is

hospital-based and oriented toward acute illnesses?• Who benefits from allowing environmental diseases to

flourish?• What are the benefits of depersonalizing patients or of

making childbirth a rigorous medical procedure?

• Fee-for-service means profits Difficult for doctors to make money if people are not

sick. Profits, not health care, are the engine that drives the

U.S. health care system. The more services doctors sell at the highest price, the

more they earn. That system is functional for patients is indicated by

rising life expectancy and decreasing infant mortality rates.

• A self-correcting system Functionalists argue that system is self-correcting Functionalists view fee-for-service health care as a

system that responds to shifting needs of the nation• The global level

Functionalists also analyze functions and dysfunctions of medicine on a global level.

• Exporting modern Western medicine to the Least Industrialized Nations

• Also dysfunctional because they encourage populations of these nations to surge

• Outpace the nations’ food production, leading to mass starvation and political upheaval

Conflict Theory•Conflict theorists argue that the U.S. medical

system is not self-correcting.•View American patterns of illness and health

care as the outcome of clashes between interest groups controlled by the most powerful•Argue that the poor are more often sick

because they lack sufficient income and high-quality education, food, housing, jobs, and medical services

•Medicaid Viewing Medicaid as a first step to socialized medicine,

the AMA fought against its passage. Congress designed Medicaid to satisfy the public’s

criticism while still providing profit for doctors.• Colliding interests of doctors and patients

Emphasize that doctors and patients form two sorts of classes

Those who control medicine and those who receive treatment.

In a capitalist system of production for profit, alienation of patient and physician is like that of owner and worker.

An Overview of Physical Health Problems

•Historical changes in health problems 6 of the 10 leading causes of death have remained

the same according to Figure 10-9. Symbolic interactionists would point out that these

labels are arbitrary. Several of the top killers in both centuries are

caused primarily by lifestyle and environmental pollution.

Leading causes of death reinforce the point made earlier about how health and illness are related to lifestyle and the environment.

•Infectious diseases Two reasons for the decline in infectious

diseases:• Prescription drugs and vaccinations have

wiped out many diseases• Clean running water

The resurgence of infectious diseases• Develop new strains that are resistant• Most feared infectious disease today is

HIV/AIDS

How Disease Is Related to Behavior and Environment: the Case of HIV/Aids

•Background Example of the relationship between behavior, environment,

and disease The disease no longer discriminates

•A global epidemic 25 million people have died 40 million people around the world are infected now 5 million more people are being infected each year Common in Sub-Saharan Africa because lack of sex education

and protection 15 million children have been orphaned as a result of AIDS

• HIV/Aids in the United States• Antiretroviral drugs (ARVs)

• Halt the progression of AIDS• Not equally available to all• Not readily available in some Least Industrialized Countries• Combination of ARVs and education caused AIDS deaths in

the U.S. to decrease• They do not prevent people from infecting others with HIV.

• Some groups have higher rates of HIV/AIDS because of social factors.• Sharing needles• Sex with multiple partners• Unprotected sex

• Ominous changes• HIV virus mutates rapidly• Some individuals have contracted strains of HIV that are resistant.

Social Inequalities in Physical Illness

• Poverty and health• Economic factors largely determine who will be healthy and

who will be sick Social inequality is essential factor that underlies patterns of

disease and death• Occupational health hazards

Stem from lower-class working environments Occupational disease

• Results from long-term exposure to specific substances or from continuous or repetitive physical acts

• Paying the bill• Looking at who pays medical bills helps expose

social inequalities of health care

• Unanticipated consequences of Medicaid and Medicare• Undermining of public hospitals• Because Medicaid’s rates were low, doctors and

private hospitals refused to accept Medicaid patients

• Medical insurance• Lack of medical insurance highlights racial–ethnic

inequalities

Social Inequalities in Mental Illness

•Social class and mental illnessSociologists found that people’s emotional

well-being declines with decreases in social class.

More likely to be depressed, anxious, nervous, and phobic

• The delivery of mental health services• Individual psychotherapy• Psychoanalysis• Short-term directive therapy• Group therapy• Drug therapy• Electroconvulsive therapy (ECT)

• Consequences of ability to pay• Type of therapy does not depend on

person’s problems, but on person’s ability to pay

Social Policy• Fee-for-service system encourages physicians to sell

specialized services to get patients to come back for visits.• Focusing on acute problems creates depersonalization.•Malpractice insurance is expensive, and drives up the cost of

medical care.• Concentrating on heroic intervention is more expensive and

less effective than long-term prevention.• Being paid to stay healthy

Some employers give their workers a rebate for staying healthy.

Prepaid Medical Care: The Example of Managed Care

•Managed Care Often purchased as a contractual package by

employers Health Maintenance Organization (HMO)•The positive side

Because doctors make more money when patients stay well, they encourage preventive care.

• Profits and a conflict of interest• Ethical dilemma: profits or patient care• Physicians argument against HMOs

• Loss of autonomy and reduced quality of care

• Limiting medical treatment in order to increase profits has led to severe problems

Physician Assistants

•Strategy for controlling costs•Use of physician assistants has led to in-house

rivalry•Must work under the supervision of physicians•“If they want to do more, they can go to

medical school.”

Training Physicians

•Medical schools graduate about 16,000 physicians a year. Same today as 25 years ago• In 2010 women will make up more than half of the nation’s

medical school graduates. Unsure if change in gender will have significant effect on

how medicine is practiced Female doctors are:

• As likely as male doctors to be generous or greedy.• Patient or profit-oriented.• In favor of heroic medicine or preventive medicine.

• Social policy that might reduce costs and help give care to the poor would be to train more physicians.

• Suggest students be allowed to go to college and medical school free in return for spending specified amount of time in areas where there are doctor shortages.

• Would increase physician presence in poorer areas and increase competition among physicians.• Outcry of physicians to such a proposal would be

loud, for their income would drop as prices for their services fell.

Domiciliary Care

• Home health care, or domiciliary care– Treatment given within a patient’s

home– Less expensive and often more

humane– May involve profiteering– Another approach: create domiciliary

programs for mentally ill

• Eating ourselves to death• 2 of every 3 Americans are overweight• More likely to have strokes, to suffer heart attacks,

and to come down with diabetes• Our culture encourages people to visit a doctor

when health problems arise, rather than to exercise and eat healthier

• The problems with preventive medicine• Quiet and unassuming• Often obscured by the drama of heroic medicine

Humanizing Health Care

• Depersonalization: being treated as an inanimate object• Process has to begin in medical school or in pre-med training•Medical training needs to stress the inherent worth of

patients• Need to incorporate a holistic approach•May require changing how fees are collected• Self-care groups

Aim of policies is to move health care away from hospital into the home

Offer inexpensive alternatives to highly technological and costly medical care