Medical Sociology

Medical Sociology

• “the study of health care as it is institutionalized in a society, and of health, or illness, and its relationship to social factors”--Ruderman, 1981
• Very broad
• Health disparities: why some people are healthier than others
• Life of physicians: how social location affects which part of medicine you want to be a part of
  • Women think about which specialties they can accomplish while also supporting family
  • Eg: dermatology
    • Skin is interesting but skin emergencies are rare
  • Most emergency fields attract men
    • Except for OB/Gynecology

Historical Development

• Physicians in ancient times perceived a connection among social, economic conditions, lifestyle, health & illness
• Industrial Revolution/Rapid Urbanization created health crisis
• Changed way that medicine was practiced
  • Related to scientific revolution
• Scientific discovery much more possible
• People with communicable disease became concentrated leading to a health crisis
  • We’ve had much greater impact on health by discoveries like sanitation systems than discoveries like vaccinations
• Germ Theory of Disease not developed until 1867
• Took a little while for it to catch on
• Physicians would do an autopsy and then deliver a baby
  • Transmission of germs
  • Rate of maternal mortality was higher in hospitals in the 1800s than it was for home births

The Medical Profession

• Doctors have a great amount of social power, political power, and prestige, for a variety of reasons.
• Comes from management of the profession
• In the early 1900s, the original surgeons just cut off pieces from people
  • Cut off injured parts
  • Cures that very pretty barbaric and not successful
    • Hence less prestige
• As doctors became scientists and success rates increase, the belief that visits to doctors will increase longevity came about
  • More prestige
• They offer a universally valued product: health and longevity.
• There is a limited number of doctors due to the extensive education and training as well as the strict regulation of the profession.
• The harder it is to get into a particular profession, the greater the prestige
• Can also lead to shortages, to maintain the prestige
• As professionals, doctors are concerned not just with their patients but also with the approval of their peers.
• Doctors exhibit “individualized objectivity,” which gives them a certain power over patients.
• Individualized objectivity: share every detail of your life while naked (what patients do)
  • Gives doctors power since they are present in this vulnerable moment
• Doctors use specific props and scripts to assert their power.
• White coat, scrubs, etc.

Trends in Health

• Morbidity: illness in a general sense—the absence of complete health. It could mean something like having  chicken pox (an acute condition) or not being able to walk very well because you have lower back pain (a chronic  condition). 
• Co morbidity: when you have a condition that could make the disease worse
• Mortality: means death—rates refer to the likelihood of an individual or groups of individuals dying.

Life expectancy and mortality

• Life expectancy - the average number of years a person born in a given year can expect to live
• More money = higher life expectancy
• Increases once you make it past childhood
  • For men once you make it past 25 (risk taking behavior)
• Women live with chronic conditions for longer
• Women are better communicators so they see doctors more often
• Average - 67 years
• 75 years in modern countries
• only about 64 years in developing countries
• in the 30s in some developing countries

Life Expectancy Trends

• Since 1900, life expectancy in U.S. has increased by more than 30 years
• Trend began to reverse in 2015, with a reduction of a few months
• 2020,life expectancy dropped by about 3 years
• Greater life expectancy combined with a lower fertility rate has resulted in a larger portion of the U.S. population being over 65 years old
• We spend more on old people than anyone else
  • Healthcare, retirement people
  • Rich old people since poor die young
• “Aging” of the population has many implications
• Women are having children later (avg age 20 years ago was 24, now it’s about 29)
• relative value of quality vs. quantity of life

Life Expectancy Gap (Chetty et al, 2016)

• Between the richest 1% and poorest 1% 
• 14.6 years for men
• 10.1 years for women
• Inequality in life expectancy has increased over time. Between 2001 and 2014, life expectancy increased by: 
• 2.34 years for men and 2.91 years for women in the top 5% of the income distribution
• 0.32 years for men and 0.04 years for women in the bottom 5% 

Trends in Mortality

• Mortality has declined in U.S. by 50% since 1900; continues to drop each year
• largest reduction for females
  • Less likely to die while giving birth
  • Giving birth is still very dangerous due to long term stressors involving racism and poverty
  • The way that we train our OB/Gyns is that they can get a speciality in maternal health and obstetrics without ever studying the care of women (since its combined with neonatal studies)
  • A lot of doctors in the field aren’t trained to pick up on risk factors such as eclampsia
    • Eg: high BP doesn’t have to be high BP just severely elevated from normal
• least reduction for black males
• causes of death have changed, from infectious to chronic, degenerative diseases

Maternal Mortality Rate

• Maternal mortality rate - number of women who die in the process of giving birth for every 1,000 live births
• Lack of prenatal care is the major risk factor
• Every year in the U.S. 700 to 900 women die from pregnancy or childbirth-related causes, and some 65,000 nearly die — by many measures, the worst record in the developed world.
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• Going up steadily in the US since 2000
• Seven Causes account for most pregnancy related deaths
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Incidence v. Prevalence

• Incidence - number of new cases added to the population in a given period
• Prevalence - total number of cases at a given time

Whitehall Study (England, 1967)

• In England people’s jobs are classified by prestige
• Looked at people in secretarial, manufacturing and managerial positions and ranked each position based on prestige
• People studied weren't poor, and had jobs that allowed them to live comfortable
• England had established universal healthcare, allowing same level of healthcare to everyone
• But the issue isn’t getting healthcare
• Men who hold lower ranks (status) have higher morbidity and mortality rates
• Social forces, not just poverty or in ability to access and afford care, impact health and longevity
• This study is conducted in a society where everyone has access to health care regardless of their socioeconomic status.
• None of the participants is poor or  undernourished, and they all have a sufficient salary to survive.

Age and Morbidity

• Factors contributing to morbidity in children & adolescents: 
• Poor diet and lack of exercise
• Use of tobacco, alcohol, and other drugs
• Sexual activity and pregnancy
• Violence

Gender

• Although men have higher mortality rates, women have higher morbidity rates
• Five reasons for gender differences:
• Biological risks
  • Not great at identifying different risks
  • Difficulty realizing the symptoms that women show for different diseases
  • Because men and women show different symptoms
  • Experiments on women were also limited because they thought that experiments on women would harm the baby
    • Hence women not put on many research studies
• Acquired risks due to differences in work and leisure activities, lifestyle and health habits, and psychological distress
  • Different jobs: women more likely to take secretarial, men more likely to take managerial/leadership positions
  • Hence different associated risks
• Psychosocial aspects of symptoms and care
• Health reporting behavior
• Prior experience with health care and care-takers
  • Women and POCs report less trust in medical authorities because they are treated worse

Socio-economic Status

• Discrepancy in health status between the poor and non-poor is greatest between the ages of 35-75
• Relation between SES and longevity is maintained over all levels
• Greater exposure to physical, chemical, biological, and psychosocial hazards 
  • Either from job or living situation of people in lower SES
• Increased stress levels due to inadequate financial resources
  • Everyone from janitors to CEOs in hospitals had stress levels measured
  • You may think that the CEO would be stressed the most, but he had almost no stress
  • People with the least level of control had the highest levels of cortisone and highest stress levels
    • Called away from jobs to emergency clean ups
• Harmful behaviors such as smoking and alcohol consumption
• Poorer eating habits and lack of exercise

Theories on relationship between Socioeconomic Status and Health (they are dumb)

• Selection theory—the connection between low income and poorer health is not causal. 
• Other factors, like genetics, might affect both socioeconomic status and health.
• Drift explanation states that there is a connection between income and health but it runs from health to income. 
• If you have poor health, you may be less likely to find gainful employment.
• Reverse causality

The Social Causes of Disease

• Etiology - identification of the causes of disease patterns
• Proximate risk factors - health-related individual behaviors (diet, exercise, use of tobacco and alcohol, control of stress, and other aspects of lifestyle)
• Things that we think about changing
  • Pulling people up right as they are about to drown
• Fundamental causes - underlying social conditions (socioeconomic status, social inequality, community, exposure to stressful events, etc.)
• Pulling people out before they even get close to drowning

Social Determinants Theory

• Psychosocial interpretation: focuses on individuals’ social class status relative to that of those around them.  Feelings of inadequacy, low worth, and stigma cause people stress and wear down their bodies.
• Materialist interpretation: the differential access to a healthy life—including all monetary, psychological, and environmental risk factors—is a result of SES.
• Fundamental causes: multiple mechanisms exist by which SES(and other dimensions of power) affect health. High-status individuals have greater ability to make use of new information and health resources as they become available

Preterm Birth

• Data from: "Sociodemographic and Community Factors Contributing to Preterm Birth ."Preterm Birth: Causes, Consequences, and Prevention . Washington, DC: The National Academies Press, 2007 .
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Medicalization of Addiction - Experience of Illness Meets Social Change

• Parsons’ Sick Role
• Functionalist
• Illness is a special form of deviance.
• The sick role is “also a social role, characterized by certain exemptions, rights, and obligations, and shaped by the society, groups, and cultural tradition to which the sick person belongs.
• Exemptions for the sick:
  • Temporarily excused from normal social roles
  • Not held responsible for the illness
  • No one likes the malingerer (person who is sick and does nothing about it)
• Behavioral Obligations for the sick:
  • Must want to get well
  • Expected to seek medical advice and cooperate with medical experts
• Critiques
  • Variation
  • Acute v. Chronic Illness
  • Middle class Values
• What is medicalization?
• Medicalization - many believe the powers of the medical institution have expanded far beyond areas of genuine expertise
• An increasing number of behaviors and conditions are being interpreted in medical terms
• Medical practice is understood to be the proper mechanism for controlling, modifying, and eliminating “undesirable behaviors”
• Why do people develop addiction?
• Benefits to pain relieving drugs: 
  • reduced perception of pain
  • relaxation of blood vessels – e.g. helpful in treatment of heart attacks 
  • produces a very rapid onset of euphoria, excitement, reward. 
• Problems
  • people develop tolerance
  • Brain activity changes so that people make decisions differently
• The case of addiction
• Deaths due to overdose have increased by 102% between 1999 and 2010 [CDC]
• Those who study addiction report that high rates of overdose (esp. tainted batches) can act as advertisements to users of potent products
• Injection drug users have a 33% chance of getting some sort of infection (not just HIV)
• According to a 2012 Substance Abuse and Mental Health Services survey, between 2007 and 2012 increased from 373,000 to 669,000.
• Heroin has a similar effect to OxyContin but there is a huge cost difference
  • One OxyContin pill costs $40 on an urban street
  • $40 would buy you 4 bags of heroin, just as potent
• Naloxone is a safe and non-toxic drug that can quickly reverse the effects of overdose, ‘bringing people back to life’ if taken immediately.
• Often times, overdose occurs when users go through detox (sometimes involuntarily through jail)
  • Users try to get high with the same dose prior to detox and OD
  • Phillip Seymour Hoffman was 23 years clean, but experts believe he took a dose similar to when he was using, leading to his death.
• Criminalization of Addiction
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• Medicalization of Addiction
• Conceptual Level
• Language used around a problem is medicalized
  • How can we ‘treat’ this problem?
  • Versus– The War on Drugs
• Professionals consulted about the problem are medical
• Institutional Level
  • Hospitals & Rehab Centers
  • Courts and Prisons
• Personally Mediated Level
  • Who do you see to deal with this problem?
  • How do they treat you?
  • Who might they refer you to?
• Medicalization as social control
• Medicalization: we’re making more things medical problems than we used to
  • May think that it's better because you can find treatment and find a specialist
  • What if instead of blaming the individual, think about how the social world leads to these problems
• Rat Study
  • If we put a rat by itself with a cocaine dispenser it will consume so much cocaine that it dies
  • If put with friends, it will have a little cocaine here and there, but they won't die
• Medical Ideology
  • Social and ideological benefits of medical model
  • For example, the doctor’s excuse
• Collaboration
  • Doctors assist as information providers, gatekeepers, etc.
• Medical Technology
  • Medical control of drugs/screening/status (esp. genetics)
• Problems with Medicalization
• Does viewing this as a medical problem keep us from seeing larger social trends, thus individualizing problems?
• How can we weigh public health vs. public safety?
• Big Change
• “The Obama Administration's approach to the drug problem is borne out of the recognition that drug use is a major public health threat, and that drug addiction is a preventable and treatable disease. Whether struggling with an addiction, worrying about a loved one's substance abuse, or being a victim of drug-related crime, millions of people in this country live with the devastating consequences of illicit drug use. ”
• How does this compare to phrasing around the WAR ON DRUGS of the 1980s?

Creating Social Change: How do we move from a war to a preventable, treatable disease???

• Change happens in at least 2 ways
• People change and social structures are forced to adjust.
• Social structures change and people adjust.
• Is Sociology just about Problems??
• No—We talk about possible solutions!
• In an intro class we cannot always address a problem in depth enough to completely find these solutions.
• BUT—change is hard
  • We can’t always agree on solutions
  • We don’t always see change when it happens Quickly
• Noticing what is wrong with the status quo is the first step to fixing it!
• Behaviorist Model Of Social Change
• “If we change people’s attitudes or thinking they will change their behavior”.
• This hasn’t worked for texting while driving, smoking, drunk driving, obesity, or nearly most violent crimes
• Old Approach: Common Sense Public Policy
• This is frequently how public policy is created.
• Policy makers rely on the common sense and experiences they’ve picked up during their life and apply the lessons learned to the lives of others.
• But remember, common sense is only useful in specific situations and it can rarely be transferred to other situations.  
• This is especially true when privileged social actors try to apply their common sense on to less privileged social actors.
• New Approach: Measure and React
• Carry out a small piece of a plan.
• Evaluate its success.
• Adjust your plan before you carry out the next small piece of your plan.
• Repeat.
• How Sociology Can Change the World
• Sociological methods are the “measure” component of measure and react.
• As we are increasingly able to measure the world around us we ought to change our mindset toward 
  • planning, 
  • predictions, 
  • and public policy.
• Emergent Planning
• We should not look at interventions or public policy planning as a one time event, but as a small step in an ongoing emerging process.  
• This is planning based on the “measure and react” approach.
• Experiment and React
• Experiment with different interventions to find the most effective one.
  • Should we give away or charge for mosquito nets in malaria plagued areas?
  • What is the best way to manage a public park?
• You can’t always do a multiple field tests and experiments
  • Can’t go to war with 1/2 of Iraq
  • But you can break a large plan into very small pieces
  • Take one small step, then reformulate if necessary
• Take Away Point
• Public policy makers need to move from being “planners” to being “searchers”.  
• Find what’s working, using sociological methods, and then replicate the successes as much as possible.

Educational Attainment

Prenatal Care

Context Matters

• The risks for preterm birth are often individualized
• Teen pregnancy
• Smoking or drinking
• Lack of prenatal care
• Poor diet
• Living in poverty
• BUT… often there are contextual issues beyond the individual that we must consider

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