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CHAPTER COMMENTARY

The body may at first seem a fixed physical pre-given in social life, but this chapter

demonstrates that it is profoundly subject to social processes and conditions: the impact of

a changing world upon human physicality and the social technologies we adopt in making

choices about our bodies.

The example of anorexia and other eating disorders is located as a product of modernity,

and a stark visual comparison is drawn between the anorectic starvation among plenty of a

young Western woman and the starvation among famine within global plenty of a young

African woman. This comparison shows that there are clear commonalities between

scholars of health and those working on the sociology of the body. The complexity and

fluidity of social life demands constant choices and the body has become part of the

socialization of nature wherein what was once seen as ‘natural’ is now a social project on

which individuals must work.

The rise to dominance of the biomedical model of health is described, with its focus on

bodies and disease entities rather than people in the round. The biomedical model

developed medical practice as a tool for the rationalization and surveillance of the

population. The main assumptions of the model are: the germ theory of disease; the

separation of mind and body, rendering the patient as a sick body; that treatment lies in the

hands of trained specialists capable of viewing the patient through the medical gaze and not

with lay practitioners. The dominance of the biomedical model is linked with the

transformation to modernity and the triumph of science and rationalization. The emergence

of nation-states brings the idea of a population to be managed as an economic and military

resource. Foucault has been influential in viewing modern medicine as part of a process of

regulating and disciplining both individual bodies and the social body. The idea of ‘public

health’ took shape as a way of eradicating pathologies from the social body. A whole range

of institutions including hospitals, asylums prisons, schools and workhouses, developed as a

means of regulating and controlling the population.

Criticisms discussed include: the real causes of improved mortality and morbidity rates are

environmental not medical; the patient as a person is negated by becoming a sick body;

unscientific may not necessarily mean ‘bad’, and non-scientific approaches may have a

contribution to make to health; the medical profession has spread its influence through the

medicalization of normal experiences such as pregnancy, sadness and tiredness – this is

further discussed through the example of the use of Ritalin to control hyperactivity in

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children; the model has been open to gross political manipulation particularly in the area of

‘population policies’ the most extreme of which is eugenics. The rapid development of

genetic medicine brings these issues to the forefront in contemporary life.

It has also been suggested that biomedicine cannot cope with chronic and stress conditions.

Hierarchical medical organization has created long waiting lists and complex referral

procedures; concern over the harmful effects of medication and invasive surgery; the

asymmetrical power relationship between patient and doctor; and, a religious or

philosophical rejection of being treated as a body rather than holistically. Similarly, the

expansion of both alternative medicine and complementary medicine is located as a

manifestation of the processes of modernization which have promoted the notion of the

individual in control as an informed consumer and the conditions which create but cannot

cure the illnesses of modernity: insomnia, anxiety, stress and depression.

In the West everyone is on a diet in so far as we constantly make choices about what to eat

against a background of globalized food production, medical advice and social pressures to

look young and be attractive. The example of diet is a useful one, as nearly all students will

be willing to express an opinion and have stories to tell of weight reduction, ‘allergies’,

medical or politically motivated diets.

The emergence of HIV/AIDS in the 1980s is included as a counter to the general trend away

from acute towards chronic conditions. The rapid transmission of HIV and enormous death

toll of AIDS – some 25 million deaths worldwide – demonstrates that the modern

assumption that most fatal diseases had been brought under control does not allow for the

creation of new ones. The AIDS pandemic has certainly shaken people’s confidence in

modern medical science to prevent disease. Health inequalities are also thrown into sharp

relief by the distribution of HIV/AIDS cases, with developing countries suffering the most

severe consequences.

Next, the chapter turns to sociological perspectives on understanding health and illness. The

normal functioning of the body is a taken-for-granted aspect of social life. Illness disrupts

normal social life both for those who are ill and for people around them. Two sociological

approaches to the experience of illness are identified: the functionalist work of Parsons on

the sick role (a Classic Study) and interactionist approaches to the social meanings of illness.

Three pillars of the sick role are identified. The sick person: (1) is not personally responsible

for being sick; (2) is entitled to certain rights and privileges including a withdrawal from

normal responsibilities; and (3) must work to regain health by consulting medical experts

and agreeing to become a ‘patient’. Freidson argues that the sick role is modified in three

ways depending upon the perceived legitimacy of the illness, the special privileges normally

accorded to the ill being withheld from those with stigmatized illnesses. Goffman’s notion

of stigma acting to disqualify stigmatized individuals from full social acceptance is useful in

considering the reaction of medical professionals to members of stigmatized groups. Recent

debates about the treatment of smokers, heavy drinkers and the obese could be considered

here. The sick role models are criticized for failing to capture the lived complexity of illness.

It is this complexity which interactionist studies of the management of the self through

chronic illness have approached. Chronic illness involves daily processes of ‘illness work’,

‘everyday work’ and ‘biographical work’. Sociologists have studied how illness in such cases

becomes incorporated into an individual’s personal biography as ‘lived experience’.

Turning to the social basis of health, a range of data is presented demonstrating that the

benefits of improved healthcare have not been evenly distributed throughout the

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population; there are still considerable health inequalities. Social epidemiology studies the

distribution of diseases. Figures are presented to support the conclusion that there is a clear

class gradient to health. Materialist approaches are contrasted with cultural and

behavioural explanations in the formation of policy. For example, the UK’s Black Report of

1980 offered a materialist analysis and called for a strong anti-poverty strategy as the key to

improving health. Through the 1980s and most of the 1990s, government policy focused on

highly individualized cultural and behavioural explanations. Our Healthier Nation, 1999,

draws upon both material and cultural explanations, suggesting a series of joined-up

initiatives to tackle different dimensions in the healthcare puzzle.

Clear gender patterns in health are also noted: women live longer than men but are sicker

and suffer more disability; men suffer more from violence and accidents and are more

prone to substance dependency, while women are more likely to suffer from poverty. Doyal

argues that women’s experience of health and illness is shaped by material disadvantage

but also by their multiple roles in domestic work, employment, sexual reproduction,

childbearing, mothering and regulating fertility. It is therefore necessary to consider the

interaction between social, psychological and biological factors. Graham’s work on working-

class women suggests that many health problems are also related to their lack of social

support mechanisms. Oakley’s work also stresses the need for social support to act as a

buffer against the health consequences of the stress experienced by women.

When looking at patterns concerning the relationship between ethnicity and health, it is

more difficult to reach conclusions because, lacking any standard categories, it is hard to

compare findings between studies, many of which fail to collect information on the

probably significant factors of gender and class. Some illnesses are experienced more by

individuals from African Caribbean and Asian backgrounds, only a limited proportion of

which can be accounted for by inherited factors. Like explanations of class inequalities.

some turn to cultural explanations such as diet and consanguinity to explain these patterns.

Alternatively, social structural explanations include the over-concentration of members of

ethnic minority groups in poor housing and hazardous and poorly paid work. The effects of

both individual and institutional racism upon an individual’s health and patterns of

healthcare for minority groups are also significant.

In turning to health and social cohesion, the controversial argument that it is not the

healthiest countries that are necessarily the richest, but those without extreme social

inequalities and with high levels of social integration, is introduced and provides a link back

to the thought of Durkheim. The work of Wilkinson has been influential in linking ill health

to social inequalities and good health to better community cohesion.

The conventional understanding of ‘disability’ has been challenged within the new field of

disability studies. The language in which ‘disability’ is framed has provided a key site of

political struggle. The individual model presents disability as a property of the individual

who is presented as an ‘invalid’, suffering a personal tragedy, and who typically accepts the

medical model of disability. In contrast, the social model of disability distinguishes between

impairments and the disabling practices of society which prevent people with impairments

from fully participating in social life. Shakespeare and Watson question the extent to which

the social model can make invisible the experiences of impairment, which is to ignore a

large part of people’s lives. Research has shown that many people with ‘impairments’ prefer

to be identified as ‘ill’ rather than ‘disabled’. This is perhaps not surprising, as ‘disabled’ is a

stigmatized identity. The example of Cherubism is presented as an example of the

relationship between stigma and disability.

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Whilst the impairment/disability distinction has been politically useful for disability rights

campaigners, medical sociologists criticize the distinction, as both are social constructs;

maintaining the distinction implicitly accepts the biomedical model. The UK Disability

Discrimination Act (1995) and the 2010 Equality Act aim to protect disabled individuals

against discrimination. The Acts defines a disabled person as ‘anyone with a physical or

mental impairment, which has a substantial and long-term adverse effect upon their ability

to carry out normal day-to-day activities’. Globally, it is estimated that there are over 1

billion disabled people in the world. Many disabilities in the developing world are caused by

poverty. Poor sanitation and diet and a lack of medical care directly cause illness and

disability: infections, injuries and dietary deficiencies left untreated can become chronic and

disabling.

TEACHING TOPICS

The sociology of health and illness is a core theme in sociology teaching, at all levels. The

material in this chapter will also be of particular interest to students following vocational

courses in either health or social care and tutors will draw selectively upon it to support

projects and topics within those vocational frameworks.

1. Health inequalities

Inequalities in health exist between societies and within societies. This topic aims to explore

the dimensions of these inequalities drawing on ‘The social basis of health’ and ‘The

sociology of disability’, and aims to consider major conceptual frameworks within which

health inequalities have been analysed.

2. Biomedicine and medical power

The growth of biomedicine and the power of the medical profession are discussed

throughout the chapter, and especially in the sections on ‘Sociological perspectives on

medicine’ and ‘Sociological perspectives on health and illness’. This topic can also be linked

to the example of the pelvic examination used in chapter 8.

3. Disability

This is a very broad topic which focuses on the distinction between the individual and social

models of disability, and encourages students to consider in very practical terms the ways in

which society can be disabling.

ACTIVITIES

Activity 1: Health inequalities

Numerous studies have detailed a strong and enduring relationship between social class

and the prevalence of ill health. This statistical relationship is generally accepted as true,

although some would argue the statistics are a product of the ways in which they are

compiled and thus tell us little about health and a lot about how health professionals label

both people and illnesses. Even among the majority who accept that the statistical

relationship does tell us something real about the social distribution of ill health, there is no

explanation of this pattern, which is universally accepted. Understanding the nature of this

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relationship has very real political implications, as it is directly relevant to the formation of

healthcare strategies and the allocation of healthcare resources. This then is an area where

sociological interpretation and political preference become very difficult to disentangle.

Materialist or environmental explanations and cultural and behavioural explanations are

outlined on pages 457-60 of Sociology. A detailed analysis of these issues is offered by Sarah

Nettleton in her book The Sociology of Health and Illness. She first considers the arguments

about health statistics and then goes on to look at the other major types of explanation of

inequalities in health:

2. Health selection explanations. This perspective argues that health status can

influence social position. It is suggested that those who are healthy are more likely

to be upwardly mobile, and those who are unhealthy more likely to ‘drift’ into

lower social classes. … This account of social class differences has a social Darwinist

– survival of the fittest – ring to it. But this is not an inherent feature of the

approach. … [T]hose people who suffer ill health may well be discriminated against.

…

3. Cultural or behavioural explanations. … [S]ocial class differences cause variations

in health status, rather than vice versa. … Ways of living are presumed to vary

between different social positions; in particular people in lower social classes

indulge in more unhealthy behaviours, such as smoking, drinking alcohol, eating

more fat and sugar, and taking less exercise. At one extreme, these lifestyle factors

are seen to be in the control of the individual, and so it is up to the individual to

alter his or her behaviour and nurture more healthy attitudes. At the other

extreme, such behaviours are treated as being rooted in people’s social

circumstances, but nevertheless remain, from this perspective, the main cause of

social inequalities in health. …

4. Materialist explanations. This alternative social causation approach emphasizes

the effects of social structure on health. In general this approach focuses on the

impact of factors such as poverty, the distribution of income, unemployment,

housing conditions, pollution and working conditions in both public and domestic

spheres. … For example, when smoking and employment history are held constant,

there still appears to be a relationship between poor housing and the presence of

respiratory symptoms and heart disease. …

Some argue that the cultural and material explanations can be conflated, pointing

to the interaction between behavioural and structural factors, and suggest that it is

more fruitful to try to find the right balance between them. Others … [argue that

this]

is unhelpful because although it intends to emphasize the social rootedness

of lifestyles, such theorizing tends to discount any influence of the social

and material environment that is not mediated through behavioural

patterns. Thus intervention becomes reduced to developing culturally

sensitive methods for encouraging changes in lifestyle and neglects the

possibility of change in the environment. (Davy-Smith et al., 1990: 376)

Indeed, this comment in many ways anticipates New Labour’s response to

improving health, which emphasizes the importance of healthy lifestyles, albeit

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acknowledging the context of social inequalities.

(Sarah Nettleton, Sociology of Health and Illness (2nd edn), Cambridge: Polity,

2006, pp. 182–3)

1. What is the difference between a ‘social Darwinist’ and a ‘discrimination’ version of the

health selection explanations?

2. The cultural or behavioural explanations are currently most popular among government

policy-makers. What are the implications of these explanations for health policies?

3. If the materialist explanations are correct, what policies would be needed to tackle the

structural factors they identify?

4. What information would you like to be able to decide between these competing

explanations?

Activity 2: Biomedicine and medical power

A. Read the sections from Sociology on ‘Sociological perspectives on medicine’ and

‘Sociological perspectives on health and illness’.

1. What are the central assumptions of the biomedical model?

2. Which groups gain power through the biomedical model?

3. Who decides if a person can legitimately adopt the sick role?

The French theorist Michel Foucault is discussed on pages 439 and 441-2. He has been very

influential in recent studies of medicine and the body. His language is often quite florid and

difficult to understand, but try thinking about this short quote:

The body is directly involved in a political field; power relations have an immediate

hold upon it; they invest it, mark it, train it, torture it, force it to carry out tasks, to

perform ceremonies, to emit signs.

(Discipline and Punish, p. 25)

B. Read the ‘Using Your Sociological Imagination’ Box 11.1 on page 445, which tells the story

of Jan Mason. Also read the section ‘Illness as lived experience’ on pages 453-6.

1. In what ways does the turn to alternative medicine reflect a shift in the power relations

of the body?

2. How are those with chronic fatigue viewed by the medical gaze?

3. Why might someone with chronic fatigue syndrome prefer the identity ‘ill’ to ‘disabled’?

Activity 3: Disability

Read the section ‘The sociology of disability’.

The Disability Discrimination Act, Part 4, places duties on educational institutions to ‘make

reasonable adjustments’ to ensure that students are not disadvantaged because of

disability. ‘Reasonable’ is defined as: consistent with academic standards, affordable,

practical, not adversely affecting other students and consistent with health and safety

legislation. Since September 2005, all buildings and facilities must be physically accessible to

disabled students.

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In principle, although institutions will need to react to the particular needs of individual

students, adjustments should be made proactively to create enabling rather than disabling

environments for all students.

While you read the following description of a college, think about the kinds of ‘reasonable

adjustments’ the institution can make:

The students who use County College are generally happy there. It’s quite a small

college (1,500 students) and is seen as friendly and supportive place to work and

study. The college buildings are a mixture of: Victorian red-brick, neo-gothic, with a

grand central staircase and smaller back stairs which lead to staff offices on the upper

floors; some early 1970s blocks of teaching rooms and formal lecture halls with fixed

seating and writing ledges; and ‘the huts’, temporary classrooms located across the

car park and grassed areas. All of these buildings have their own particular problems.

The Victorian building fronts onto a busy road and in the summer there is a trade-off

between stifling heat and the traffic noise which comes in when the windows are

open. The 1970s block was designed at a time when seminar groups were quite small

and large lectures were very formally delivered from the front of the lecture hall with

only chalk-boards as visual aids. As a result, the classrooms tend to be overcrowded

on the rare occasions when all of the students turn up and attempts at involving

students in discussion in the lectures difficult. The ‘huts’ also suffer from heat and

noise fluctuations and are notorious for their broken, missing and sticking blinds

which make some rooms very bright on summer days and others very gloomy in the

winter. The timetable is a source of complaint as people have to get from one side of

the campus to the other in literally no time at all and are sometimes timetabled for

three hours without a break.

The staff use an interesting mix of teaching styles. Lectures are generally supported

with OHPs or Powerpoint presentations and quite a few staff make use of video clips.

All of the courses have course handbooks which outline the lecture and seminar

programmes and provide reading lists that include books, journal articles and

relevant website addresses. A lot of seminars include small group work and role play.

There is a Virtual Learning Environment where handbooks, lecture notes and other

backup resources are located and through which students can take part in on-line

conferences and submit their coursework electronically. The library and learning

resource area is wifi enabled.

1. How might this campus disable students with mobility impairments?

2. What difficulties might this campus present for students with different levels of sight and

hearing impairment?

3. What reasonable adjustments might the college make to enable students with diabetes

or chronic breathing difficulties?

4. What reasonable adjustments will lecturers need to consider in order that their lectures,

seminars and resources are equally accessible to all students?

5. In what ways does the Disability Discrimination Act utilize a social model of disability?

REFLECTION & DISCUSSION QUESTIONS

Health inequalities

Should health be the responsibility of the individual or of society as a whole?

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What would be the results if unhealthy foods were to be taxed?

How could access to healthcare for disadvantaged groups be improved?

As the demand for healthcare is infinite, it is a scarce resource which has to be rationed

– but on what basis?

Biomedicine and medical power

Do alternative and complementary medical practitioners use the medical gaze?

Are patient/doctor power relationships dismantled in alternative medical approaches?

Why are social phenomena medicalized?

What does it mean to say that medical treatment is a social technology?

Disability

Is the language we use to talk about disability really important?

How do you draw a line between illness, disability and impairment?

What are the limits of ‘reasonable adjustments’ in educational settings?

Should people with facial disfigurement undergo surgery to ‘fit in’ more easily?

ESSAY QUESTIONS

1. ‘The way to tackle ill health is to first tackle poverty’. Explain and discuss this view.

2. Why are people in the West rejecting biomedicine?

3. Is disability a feature of society or the individual?

MAKING CONNECTIONS

Health inequalities

There are links to issues of inequality across the whole book. Chapter 12 on stratification

and Chapter 13 on poverty both link strongly to this topic, and a global dimension can be

found in Chapter 14. Inequalities in terms of gender (Chapter 15) and ethnicity (Chapter 16)

are also relevant.

Biomedicine and medical power

This links directly to the management of self-identity and self-presentation discussed in

Chapter 8 and to Durkheim on social solidarity in Chapter 1 and Foucault in Chapter 3.

Disability

This topic is a useful comparator in the exploration of other forms of discrimination and

inequality. The discussion of prejudice and discrimination in Chapter 16 can be applied in

this context. The constructionist emphasis on the language of disability can also be linked to

ideas of ageing in Chapter 8.

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SAMPLE SESSION

Health inequalities

Aims

To introduce and illustrate a range of accounts of inequalities in health.

To link sociological research to current debates in health policy.

Outcome: By the end of this session students will be able to:

1. Describe two broad types of explanation for inequalities in health.

2. Identify an electronic source for government information on health.

3. Apply explanations of health inequalities to the analysis of an aspect of current health

policy.

Preparatory tasks

1. Read and make notes on the section ‘The social basis of health’

2. Locate and read the summary of Choosing Health (2004) on the Department of Health

website: www.dh.gov.uk

3. From the same site identify a recent press release which announces a new policy

initiative, print off a copy and bring it to class.

Classroom activities

1. Tutor-led whole group session reviewing the explanations identified in the section, ‘the

social basis of health’ and the key recommendations of Choosing Health. (10 minutes)

2. Tutor-led feedback from group on the recent policy initiatives they have identified. (10

minutes)

3. Split group into two. Each group to be given two or three of the recent press releases.

Group A to analyse them from a cultural and behavioural position and Group B from a

materialist position. (25 minutes)

4. Brief feedback from the groups. (10 minutes)

Assessment task

In groups of 3 or 4, prepare press releases for two new health policies: one which would be

supported by a cultural and behavioural analysis of health inequality and one by a

materialist analysis. Write a brief (300 word) statement saying which is which and why.