Health Care

The Structure of Health Care in the United States

Generally, U.S. citizens are quite healthy compared to the rest of the world.
Significant disparities exist in:
- Longevity.
- General health.
- Access to health care.
- Most disadvantaged groups: minorities, lower classes, and, for some ailments, women.
Deaths from diseases like smallpox and cholera have been virtually eliminated.

Debunking Society's Myths

Myth: Illness is strictly a physical thing.
Sociological Perspective: Culture heavily influences the definition of illness, even physical illness.
- Definition of physical illness can vary across cultures.
- Social conditions and factors influence the presence of illness.

Modern Medicine

Colonial Times:
- American physicians trained in western Europe.
- Competitors: alchemists, herbalists, ministers, faith healers, and barbers.
- Treatments: folk wisdom, superstition, regimens, and sometimes quackery.
- Infected scratch could lead to limb loss or death.
- "The fever" was a common cause of death.
- Etiologies: "bilious humors" to demonic possession.
- Practitioners did not sterilize instruments.
- "Bleeding" of patients (drawing "bad blood") and poking hole in the skull.
Mentally Ill and "Witches":
- Often thought to be possessed or witches.
- Labeling led to horrendous consequences (burnings or drownings).
- Most labelled witches were women, generally older, unmarried, childless, and of little use to the community (Erikson 1966).
- Eradication from society through labeling.
- Labeling theory applies to the study of witchcraft.
Nineteenth Century:
- Advances in biology and chemistry.
- Germ theory: illnesses caused by microscopic organisms (germs).
  - Initially debated, later established as a foundation of medicine.
- Isolating infected people and sealing infected wells could stop the spread of illness by stopping the spread of germs.
- Medicine transformed into a science.
- Social prestige of medicine greatly increased.
American Medical Association (AMA):
- Founded in 1847.
- Swept away rivals in the healing arts.
- Alternative therapies delegitimized or outlawed.
- Emerged as the most powerful organization in U.S. health care.
Late 1800s:
- Image of medicine as an upper-class profession took hold.
- Medical education was expensive.
- Medical schools drew upon White, male, urban populations.
- Physicians were entitled to take their place in the upper social strata.
- Herbalists and faith healers were raised in the rural lower class and generally remained there.
- African Americans and Hispanics became proportionately more affiliated with older folk practices and midwifery.

Gender and Modern Medicine

Male-dominated medical profession opposed gender equality.
Differences between genders labeled natural and unchangeable.
Men: rational and scientific; women: dominated by emotions and incapable of rigorous scientific thought (Smith-Rosenberg and Rosenberg 1984).
Beliefs persist in the medical profession today.
Women were expected to devote time/energy to childbearing instead of professions like science/medicine.
Physician in 1890 said God had "in creating the female sex … taken the uterus and built up a woman around it" (Smith-Rosenberg and Rosenberg 1984: 13).
Beliefs kept women out of medical school, physicians warned that too much thinking tended to interfere with a woman's ability to have children.
Physicians in the 1800s had strong opinions about female sexuality.
Women were supposed to have no interest in sex beyond the reproductive function.
Female orgasm was regarded as a disorder.
Male orgasm was considered natural, and regular sexual relations were necessary for men.
View promoted by the American Medical Association well into the 1920s.
Contraception and abortion were opposed, believed they would encourage increased sexual activity among women, thus endangering their health.

Specialization in Medicine

Since World War II, tremendous growth in the medical establishment.
Increased specialization: specialists (about 70 percent) outnumber general practitioners (about 30 percent).
Specialists (surgery, radiology, obstetrics/gynecology) enjoy high incomes (Weitz 2001).
Children taken to pediatricians (middle/upper class).
Mothers see gynecologists.
Allergists treat allergies.
Psychiatrists tend to moods.
Podiatrists minister to ravaged feet.
Family dentist sends to endodontist for root canal.

Medicare and Medicaid

U.S. government sought widespread guaranteed health service for veterans, the poor, and the elderly.
Medicare program (1965, President Lyndon B. Johnson): medical insurance covering hospital costs for individuals age sixty-five or older.
Does not cover physician costs outside the hospital, but programs are available (patient must pay a portion of the cost).
Medicaid: governmental program that provides medical care in the form of health insurance for people of any age who are poor, on welfare, or disabled.
Funded through tax revenues costs covered varies from state to state.
Medicare and Medicaid programs are as close as the United States has come to the ideal of universal health insurance.
Attempts at universal coverage (Bill Clinton's administration in the early 1990s) have not been successful (Weitz 2001; Starr 1995).

Theoretical Perspectives on Health Care

A deeper understanding of the nation's health care system and its problems can be extracted by applying the three major theoretical paradigms of sociology: functionalism, conflict theory, and symbolic interaction theory.

The Functionalist View of Health Care

Sick role: a pattern of expectations that society applies to one who is ill, has been coined by functionalist theory.
Functionalism argues that any institution, group, or organization can be interpreted by looking at its positive and negative functions in society.
Positive functions contribute to the harmony and stability of society.
Positive functions of the health care system are the prevention and treatment of disease.
Ideally, this would mean the delivery of health care to the entire population without regard to race-ethnicity, social class, gender, age, or any other characteristic.
Negative functions contribute to disharmony and instability.

Problem Areas in the U.S. Health Care System

Unequal distribution of health care by race-ethnicity, social class, or gender.
- Health care is more readily available to White or middle-class individuals in urban and suburban areas than to minorities and the poor.
- Particularly serious is the lack of health care delivery to Native American populations.
- On average, women tend to receive a lesser quality of health care than men.
Unequal distribution of health care by region.
- People in the United States die because they live too far from a doctor, hospital, or emergency room.
- Medical offices and hospitals are concentrated in cities and suburbs, less likely to be located in isolated rural areas.
- Rural people may travel a hundred miles or more to get to the doctor or an emergency room.
Inadequate health education of inner-city and rural parents.
- Parents do not understand the importance of immunizing their children against smallpox, tuberculosis, and other illnesses, and they are often suspicious of immunization programs.
- This hesitancy is reinforced by the depersonalized and inadequate care inner-city and rural residents often encounter when care is available at all.

The Conflict Theory View

Conflict theory stresses the importance of social structural inequality in society.
From the conflict perspective, the inequality of available resources inherent in our society is responsible for the unequal access to medical care.
Minorities, the lower classes, and the elderly, particularly elderly women, have less access to the health care system in the United States than Whites, the middle and upper classes, and the middle aged.
Functional theory would argue that relatively more access of the middle and upper classes to medical care is good for society because the upper classes are more beneficial ("functional") to society.
For a conflict theorist, this unequal access to medical care is bad for society because it is likely to result in disproportionately greater illness and death for people who are less privileged.
Restricted access is further exacerbated by the high costs of medical care, stemming from high fees and the abuses of the fee-for-service and third-party-payment systems.
The exceptionally high incomes of medical professionals amplify the social chasm between medical practitioners and an increasingly resentful public.
Excessive bureaucratization is another affliction of the health care system that adds to the alienation of patients.
The health system in the United States is burdened by endless forms for both physician and patient to authorize procedures, dispense medicines, monitor progress, to enter individuals into the system, and process payments.
Long waits for medical attention are normal, even in the emergency room, which can only increase the alienation of patients.

Symbolic Interactionism and the Role of Perceptions

Symbolic interactionists hold that illness is, in part, socially constructed.
The definitions of illness and wellness are culturally relative when sickness in one culture may be considered wellness in another culture.
A physical condition considered optimal in one era may be defined as sickness at another time in the same culture.
At the turn of the twentieth century, a healthy woman was supposed to be plump, a thin woman would be suspect of being unhealthy.
The health care system itself has a socially constructed aspect.
The ways we behave toward the ill, toward doctors, and toward innovative ventures such as health maintenance organizations (HMOs) are all social creations.
The symbolic interaction perspective highlights a number of socially constructed problems in the health care system.
Medical practitioners frequently subject patients to infantilization by treating them like children, even adult patients, and talking to them with "baby talk".
The patient is assigned a role that is heavily dependent on the physician and the health care system, much as an infant is dependent on its parents.
Doctors and nurses may begin patronizing the patient from the initial greeting, a condescending "How are we today?"
Physicians will commonly address women patient by their first names more often than men patients, yet all patients virtually always address physicians as "Doctor."
The patronizing and infantilizing of patients is common in emergency rooms, where minority patients are infantilized even more often than others (Weitz 2001; González 1996).
According to the symbolic interactionist analysis, one solution to the problems of condescension toward patients is to give health care professionals training about such matters in medical school.
This is just starting to happen in a few U.S. medical schools.
For example, one social issue addressed in some medical school courses on gynecology is how to manage the interaction when a male gynecologist treats his female patient.
Women feel uncomfortably vulnerable when they lie partially naked on an examination table with their heels in elevated stirrups and their legs open.
Strongly fixed social norms say that when a man touches a woman's genitals, it is an act of intimacy, yet the gynecological examination is supposed to be completely impersonal.
Male gynecologists are notorious for their failure to appreciate the discomfort of their female patients (Scully 1994; Emerson 1970).

Understanding Diversity: The Americans with Disabilities Act

The Americans with Disabilities Act (ADA), passed by Congress in 1990, prohibits discrimination against disabled persons.
In 1999, the U.S. Supreme Court restricted the definition of disability to exclude disabilities that can be corrected with devices such as eyeglasses or with medication.
Writing for the majority, Sandra Day O'Connor argued that the law requires people to be assessed based on each individual's condition, not as members of groups affected in a particular way.
The disability rights movement would argue that disabled people are a minority group with certain civil rights.
Symbolic interactionists would note the role of socially constructed meanings in legal negotiations.

Health and Sickness in the United States: A Picture of Diversity

Definitions of sick and well varied greatly over time.
Early 1900s until mid-1940s: thinness associated with poverty and hunger.
Late 1950s through the present: positive value on being thin.
Millions of young women have attempted to copy the slender, high fashion look, and an increased incidence of anorexia nervosa has been one result.
Anorexia nervosa: eating disorder characterized by compulsive dieting.
- Victims starve themselves, sometimes to death.
- They do not typically define themselves as ill because they tend to see themselves as overweight, even though they are dangerously thin.
Bulimia: eating disorder characterized by alternating between binge eating and then purging (induced vomiting) to avoid gaining weight.
Like many other diseases, anorexia and bulimia have social as well as biological causes.
A majority of people suffering from the disease are young, White women, from well-to-do families, most often two-parent families.
Anorexics have generally been pressured excessively by their parents to be high achievers.
A link between anorexia and the socially constructed ideals of beauty in our society, in which slenderness is displayed as the ideal of femininity.
Images of bodily "perfection" are emblazoned across television, magazines, and billboards.
These social values, which encourage compulsive dieting, are comparable to the footbinding once practiced in China and other forms of female mutilation found in some foreign cultures.
Anorexia is less likely to afflict African American women, Latinas, and lesbians.
Men have also been affected by social values for physical appearance.
Since the 1940s and especially from the mid-1970s on, a persistent male physical ideal has been the rippling physique of the body builder or weight lifter.
Young men have been urged by the media and their peers to "pump iron" for the perfect body, thus presumably to gain for themselves pride, muscle mass, and the adoration of women.
Many athletes have been goaded by the competition for physical size to use anabolic steroids.
Steroids will build muscle as advertised, but they can also shrivel the testicles and cause impotence, hair loss, heart arrhythmia, liver damage, strokes, and very possibly some forms of cancer.

Race and Health Care

Epidemiology: the study of all the factors-biological, social, economic, and cultural-associated with disease in society.
Social epidemiology: the study of the effects of social, cultural, temporal, and regional factors in disease and health.
Among the more important social factors that affect disease and health in the United States are race-ethnicity, social class, gender, and age.
Health can be affected by personal factors, such as dietary and hygienic habits, and by institutional factors, such as the structure of the health care system and the economic health of less advantaged groups.
Most factors that affect health detrimentally at either the personal or institutional level are likely to have a worse effect on the health of minorities.
Reflected in the dramatic differences in life expectancies for White Americans compared with other groups and in differences in life expectancy between men and women.
- White men can now expect to live to 74.6 years of age, whereas African American men have a life expectancy of only 67.8 years.
- Hispanic men have a life expectancy somewhat higher than African American men, at 70.1 years, as do Native American men, at 69.3 years, but still significantly lower than White men.
- White women can expect to live longer than White men, 80.0 years.
- African American women can expect to live more than seven years longer than African American men, 74.7 years, which is the same life expectancy as White men, but noticeably less than White women.
- Hispanic women live to 77.4 years, which is longer than White men, but still less than White women.
- Native American women commonly live to 77.0 years of age.
Among women, African Americans are more likely than Whites to fall victim to diseases such as cancer, heart disease, stroke, and diabetes.
Death of the mother during childbirth is three times higher among African American women than among White women.
In the forty-five to sixty-four age group, African American women die at twice the rate of White women.
The occurrence of breast cancer is lower among African American women than White women, yet the mortality rate for breast cancer for African American women is considerably greater than for White women.
African American women also develop cervical cancer at twice the rate of White women.
Twenty-five percent of all African American women suffer from hypertension (high blood pressure), which afflicts only 11 percent of White women.
The mortality rates for Native Americans are one and a half times greater than the mortality rates for the general population.
Among Native Americans under the age of forty-five, the death rate is three times that of American Whites.
Native American babies are almost twice as likely as White babies to die before they are one year old.
Hispanics, like African Americans, Native Americans, and other minorities, are significantly less healthy than Whites.
For example, Hispanics contract tuberculosis at a rate four times that of Whites.
Hispanics are less likely than Whites to have a regular source of medical care, and, when they do, it is likely to be a public health facility or an outpatient clinic.
Because of language barriers as well as other cultural differences, Hispanics are less likely than other minority groups to use available health services, such as hospitals, doctors' offices, and clinics.

The Tuskegee Syphilis Study

The study was conducted at the Tuskegee Institute in Macon County, Alabama, a historically Black college.
Begun by the United States Health Service in 1932 as a study of "untreated syphilis in the male negro [sic]", the study intended to advance scientific knowledge about syphilis, a sexually transmitted disease (STD) that when left untreated causes blindness, mental deterioration, and death.
A group (sample) of about 600 African American males, about 400 of whom were affected with syphilis, were chosen for study, the remaining men used as an uninfected control group.
The study continued for forty years (Jones 1997).
During this period, penicillin was discovered as an effective treatment for infectious diseases and was widely available from the early 1950s.
Nonetheless, the scientists conducting the study decided not to give penicillin to the African Americans who made up the study sample on the grounds that it would "interfere" with the study of the physical progress of untreated syphilis.
The U.S. government authorized the study to be continued through the 1960s and into the early 1970s.
By 1972, news of the study began to reach universities and the general public, and the government, through the Department of Health, Education, and Welfare (now the Department of Health and Human Services), put an end to the project.
By then approximately 100 of the African American men in the study had died of syphilis, after suffering through its horrible physical ravages (Jones 1997; Jones 1993).
In 1997, President Clinton formally apologized to the victims, dead and alive, and to their families, sixty-five years after the start of the study.

Social Class and Health Care

Social class has a pronounced effect on health and the availability of health services.
The lower the social class status of the person or family, the less access they have to adequate health care.
People with higher incomes, when asked to rate their own health, tend to rate themselves as healthier than people with lesser incomes.
Reasons lie partly in personal habits that are themselves partly dependent on one's social class.
Social circumstances such as poor living conditions, elevated levels of pollution in low-income neighborhoods, and lack of access to health care facilities all contribute to the high rate of disease among lower classes.
Another contributing factor is the stress caused by financial troubles.

Gender and Health Care

Even though women live longer on average than men, older women are more likely than older men to suffer from stress, overweight, hypertension, and chronic illness.
Researchers cite differences in male and female roles and cultural practices to explain the variation in death rate between the genders.
Smoking patterns have changed, however, and the proportion of smokers who are women has increased in the last several years.
The most recent research shows a convergence in the smoking rates of men and women, and it shows further that more men than women quit smoking.
Some 450,000 people die each year as a direct result of smoking.
Smoking and the tobacco industry have become a major national issue.
When tobacco companies began directing smoking campaigns at children, using commercials and billboards, the federal government passed legislation forbidding such advertising.
To compensate for lost sales as a result of the antismoking trend in the United States, tobacco companies are advertising more and selling more in other countries-particularly in third-world countries with low average incomes-that have little governmental regulation of tobacco advertising and sales.