Discussion 6

Health & Illness

Margaret T. Hicken, University of Michigan

Hedwig Lee, Washington University in St. Louis

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Health & Illness

M A R G A R E T T . H I C K E N , U N I V E R S I T Y O F M I C H I G A N

H E D W I G L E E , W A S H I N G T O N U N I V E R S I T Y I N S T . L O U I S

INTRODUCTION

Defining the Boundaries of health & illness

Early sociological studies of health

Social control and definitions of health & illness

HEALTH CARE IN THE U.S.

Health care as a system

Current debates about health care

SOCIAL DETERMINANTS OF HEALTH & HEALTH INEQUITIES

Perspectives for studying health

THE FUTURE OF THE SOCIOLOGY OF HEALTH & ILLNESS

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INTRODUCTION

 Why should sociologists care about health?

 How does the study of health differ for sociologists and epidemiologists?

Nandi Edmonds was 31 when she became pregnant for the first time. She and her

husband, Miles, were so excited about welcoming their twins into the world. On July 11, 2010,

at 30 weeks into her pregnancy, she and Miles were at a childbirth class when Nandi

developed a severe headache and started vomiting. They went home so she could rest; she

woke in the middle of the night in a pool of blood and then passed out. Miles called 911 and

Nandi and their twins were rushed to the emergency room with placental abruption (when the

placenta separates from the uterus too early in the pregnancy) and pre-eclampsia (a set of

symptoms that includes high blood pressure, headache, dizziness, and protein in the urine).

Their son was stillborn; their daughter died three days later.

Nandi was discharged from the intensive care unit (ICU) only four days after this

traumatic birth experience, even though she had nearly died herself during the birth. At home,

her health didn’t improve, but her doctor told her to take her prescribed medication and rest.

When she told her long-time friend, an internal medicine resident, about her symptoms, he

immediately picked her up and took her to the hospital. Nandi had extremely high blood

pressure and likely would have suffered a stroke had she followed her doctor’s orders and

remained at home.

Discussions of health are generally the purview of medicine or public health, which

focuses on describing and preventing disease and illness. We think of doctors and

epidemiologists (who study the frequency, patterns, and causes of health and illness) as the

health experts. Indeed, on the surface, Nandi’s experience appears to be medical in nature.

However, in this chapter, we will show how sociology provides unique and critically important

information about health and illness. While both epidemiology and sociology can describe

who is more likely to become ill or die, epidemiology focuses on biomedical mechanisms and

individual health behaviors; sociology, on the other hand, can clarify the aspects of society

that lead to social patterns in morbidity (having a disease) and mortality (death).

Nandi and Miles are Black Americans, which has social meaning that is reflected in

health. For example, infants born to Black women are substantially more likely to die before

their first birthday than infants born to White women. Figure 1 shows the infant mortality rate (a

measure of deaths during a child’s first year) for the United States and the countries of the

Organization for Economic Cooperation and Development (OECD), a group of countries

committed to global trade and economic development. We also included the infant mortality

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rate for different racial and ethnic groups in the U.S. Epidemiologists may first note that the rate

for the total U.S. is by far the highest among the wealthy OECD countries; even the rate for U.S.

infants born to White women is high. Second, they may note that the mortality rate for infants

born to Black women is more than twice the rate for infants born to White women. As

sociologists, we will discuss these health inequities – differences in health that are due to

unequal social patterns – and focus on the social forces that are likely responsible for them.

Figure 1: Infant Mortality Rate by Country, 2014

(Source: OECD and National Center for Health Statistics)

Sociology can also help us understand how society shapes the definition and

experience of illness (the subjective experience of a disease, condition, or set of symptoms). In

recent years, growing media attention has focused on maternal morbidity, or illnesses and

disabilities related to pregnancy or childbirth, and, in particular, the treatment of Black women

during pregnancy, labor, and the postpartum period. These stories are supported by data

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Infant death within first year, per 1000 live births

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showing that physicians construct their views of who requires medical attention (in others

words, who is sick) around race and gender.1

Viewed through a medical lens, we might focus on the pre-existing conditions or health

behaviors of pregnant woman during the perinatal period (the time immediately before and

after birth) to explain health inequities. Black women do, in fact, have higher rates of high

blood pressure and diabetes compared to White women. However, neither these pre-existing

conditions, nor any health behaviors such as alcohol use or smoking, fully explain the different

rates of infant mortality.2 Viewed through a public health lens, we might focus on racial

inequities in access to high-quality prenatal care or adequate health insurance. However,

research indicates that these conventional public health concerns also don’t explain racial

inequities in infant mortality.

Left to right: Tressie McMillian Cottom, PhD; her baby girl died

during her preterm labor delivery (Source).

Serena Williams; she nearly died after returning home after

delivering her baby girl (Source).

Using a sociological lens, we widen the scope of our questions to understand how

Nandi’s and Miles’s life course social circumstances – the interconnected sequence and

timing of socially-defined life events that unfold over a person’s through their own actions and

behaviors – and the circumstances of their family and friends and even of their broader racial

group, impacted their chances of experiencing the death of their babies.

Public health and medicine can benefit from sociological insights into the social forces

that drive patterns in health – a state of complete physical, mental, and social well-being, not

merely the absence of disease. Sociologists also benefit from studying health. Health is

essential for quality of life and a sensitive indicator of the social forces in a society. In a

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statement to the National Commission to Prevent Infant Mortality, pediatrician Marsden

Wagner outlined the interconnected nature of social forces and the health of our most

vulnerable citizens, our children:

Infant mortality is not a health problem. Infant mortality is a social problem with

health consequences. It is analogous to traffic accident mortality in children: the first

priority for improving traffic accident mortality in children is not to build more and better

medical facilities, but rather to change traffic laws and better educate drivers and

children. In other words, the solution is not primarily medical but environmental, social

and educational. The same is true for infant mortality: the first priority is not more

obstetricians or pediatricians or hospitals, nor even more prenatal clinics or well-baby

clinics, but rather to provide more social, financial and educational support to families

with pregnant women and infants.3

In this chapter, we share layers of Nandi’s experiences that are mirrored in data to show

that her pregnancy experiences can be linked to how American society is structured. We

focus on specific examples from maternal and child health, the field of public health focused

specifically on the health of mothers, infants, children, and adolescents; however, the

concepts we discuss are relevant to any area of disease or illness throughout the life span.

We have three goals for this chapter. We hope to show you that health and illness are

socially constructed concepts; the meanings of health and illness are created through social

norms and interactions. We will also give you the tools to understand why this is the case. We

illustrate the social nature of the medical profession and the health care system, which are

constantly shifting. Indeed, the medical profession has only recently begun to recognize the

role of society in health; in 2015, new sections on the social and behavioral sciences, including

sociology, were added to the Medical College Admission Test (MCAT). Finally, we show that

health and health inequities are not just shaped by differences in access to health care and

health behaviors, but are also determined by social forces embedded in where we live, learn,

work, play, and pray. We hope to convey that sociology provides a critically important lens

through which we can view health and illness.

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DEFINING THE BOUNDARIES OF HEALTH & ILLNESS

 How is disease different from illness?

 What does it mean to say that illness is socially constructed?

Health and illness are not objective states; their

definitions and experiences are socially constructed. While a

person may be diagnosed with a physical or mental disease

(a disorder) or impairment (a loss of function), social and

cultural values and norms give meaning to the illness

experience. Diseases and other medical conditions are not

inherently illnesses; rather, illnesses are the subjective

experiences of the person with the disease, condition, or

impairment. For example, a person may receive a diagnosis

of high blood pressure (also called hypertension), but this

diagnosis doesn’t reveal anything about their experience with

hypertension. Perhaps they haven’t had any major changes

in their daily life with this diagnosis and may not consider

themselves ill at all. In fact, many people who take

medication and are able to control their hypertension don’t

consider themselves to actively have high blood pressure.4

Similarly, mental and physical impairments are not inherently

disabilities, or limitations created when an impairment isn’t accommodated in the physical

and social environment. They become disabilities when a society doesn’t provide such

accommodations, and therefore prevents people with impairments from fully engaging in

everyday life. For example, people with visual impairments may not have difficulty carrying out

their everyday tasks as long as accommodations such as audio tracks are available. In this

section, we discuss how health is socially constructed by examining spatial patterns in health

and how the definitions and experiences of illness function as forms of social control.

Early sociological studies of health

Nandi grew up in the 1980s and 1990s on First Street in Washington, D.C., in a

neighborhood noted for two infamous sites: the Sursum Corda low-income housing

development and Hanover Place, a street that functioned as an open-air drug market. At the

time, Washington, D.C. was in the middle of a major crack cocaine and violent crime

epidemic, much of it centered in Nandi’s neighborhood. Drug use and violent crime (which

ATM with a headphone port for

people with visual impairments.

(Source: Authors)

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are also socially constructed, as discussed in the Deviance and Crime chapter) are social and

public health issues that are not evenly distributed across all neighborhoods, cities, states, or

even countries.

In fact, early studies in demography (the study of patterns in human populations, such

as births, deaths, aging, and migration) and sociology demonstrated that many health

concerns have a spatial pattern. Émile Durkheim, studied suicide rates in France and several

other European countries and showed that different countries, and even different areas within

France, exhibited vastly different suicide rates.5 He argued against the dominant

understanding that suicide was caused by mental illness or personal shortcomings. Instead, he

suggested that social factors outside the individual affect suicide rates.

Similarly, in 1899, W.E.B.

Du Bois (pronounced doo-

BOYSS) published The

Philadelphia Negro, a study of

Black Americans in Philadelphia

that included a detailed

discussion of health.6 In 1906, he

expanded this study in The

Health and Physique of the

Negro American.7 Du Bois

argued that the poor health of

Black Americans compared to White Americans wasn’t due to any individual biological

limitations among African Americans but rather to social conditions. He supported his

argument by showing that mortality rates for Black Philadelphians varied widely by area,

explaining that the high mortality rates occurred specifically in neighborhoods with poor

housing and substantial crowding.

We continue to see that our health depends on where we live and work, and sociology

can help us understand why. As discussed in the Urban Sociology chapter, the U.S. is racially

and economically segregated, meaning families of different racial or ethnic groups and

different socioeconomic status (SES) – a measure of social and economic standing – live in

different neighborhoods of unequal quality.8 Living in racially-segregated cities is harmful for

the health of Black infants, but generally not for White infants, even after accounting for the

poverty level of their neighborhoods.9 This suggests that segregation is about more than just

the unequal distribution of poverty; it leads to the unequal distribution of other resources that

are important for health.10

Let’s return to Nandi’s neighborhood on First Street, in Ward 5. When her mother passed

away in 2008 at the age of 58, Nandi inherited her childhood home; she and Miles lived there

during her pregnancy and childbirth. While her neighborhood has experienced some influx of

“The Ward.” Philadelphia mural honoring W.E.B. Du Bois; painted by Willis

Humphrey in 2008. (Source)

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White residents and the demolition of several racially-segregated low-income housing

developments, it continues to be highly racially segregated. Nandi’s neighborhood also has

some of the highest rates of infant mortality in Washington, D.C. (Figures 2a and 2b).

In Ward 5, 65% of residents are Black. We also see spatial patterns in the availability of

resources. For example, after several of the few remaining hospital maternity wards in Wards 5

and 8 closed in 2018, many women who live there must now travel long distances for their

prenatal care and delivery (Figure 3a). On the other hand, group homes (Figure 3b) and other

social services such as methadone clinics (which treat those addicted to opiates) are over-

represented in these wards. All of these social and health services are important resources,

and ideally they would all be more equally distributed across the city.

Figure 2a: Infant Mortality Rates in

Washington, D.C., by Ward, Highlighting

Ward 5, 2014

Figure 2b: Infant Mortality Rates by Ward

in Washington, D.C., Highlighting Ward 5,

2014

(Source: DC Health Matters)

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Figure 3a: Distribution of Washington,

D.C., Hospitals and Ambulatory Surgical

Centers as of 2014, along with Two

Maternity Wards Closed in 2018

Figure 3b: Distribution of Group

Residences in Washington D.C.,

2014

(Source: DC Department of Health)

Social control and definitions of health & illness

Think about the last time you or one of your close friends or family members were very

sick. Did you visit a doctor? Was there a clear diagnosis? A clear treatment plan? Did your

friends and family understand your illness? Were you embarrassed to share your diagnosis? Did

you wonder if your illness was your fault? Sociologists argue that illness doesn’t reside in the

biological disease, condition, or impairment itself. Rather, social and cultural norms shape their

definitions, meanings, and experiences. This perspective is central to the field of medical

sociology, which focuses on how social control – a society’s efforts to influence behavior and

maintain social order – operates through the medical profession, both directly and indirectly.

When you think of schizophrenia, what comes to mind? Currently, the American

Psychiatric Association defines schizophrenia in biological terms as a chronic brain disorder.

However, there is also a subjective component, as it is characterized by an inability to

distinguish between real and unreal experiences. This makes the label of schizophrenia

vulnerable to being influenced by social and cultural norms. After reviewing hundreds of

patient charts at the infamous (and now closed) Ionia State Hospital for the Criminally Insane,

in Michigan, Jonathan Metzl found that the definition of schizophrenia changed over the 20th

century in ways that coincided with social changes in the U.S.11 Before the 1960s,

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schizophrenia was associated with White housewives who weren’t able to adequately fulfill

their duties as wives and mothers. During the 1960s, as the Civil Rights Movement emerged,

schizophrenia became associated with violence and Black men.

The social shift in how schizophrenia was diagnosed and described shows how the

medical profession can label a set of symptoms as a disease – labels that reflect what is and

isn’t socially acceptable. Eliot Freidson argued that labeling, the process of assigning a

disease or medical condition to a set of symptoms, is a form of power exerted by the medical

profession that can impact the illness experience.12 Indeed, people with contested illnesses

that are disputed or questioned by medical experts, such as chronic fatigue syndrome,

fibromyalgia, or Gulf War syndrome, are often met with skepticism. Their illness experiences are

dismissed as psychosomatic, caused by mental factors such as stress or anxiety.13 While each

of these conditions represents a collection of recognizable symptoms such as muscle pain,

headaches, or fatigue, they don’t have a known underlying biological explanation.

Social control is also exerted through the medicalization of everyday events.14 Irving

Zola argued that medicalization is the description of an aspect of cultural or social life in

medical or biological terms.15 Medicalization erases the cultural or social forces involved in the

situation, reducing it to individual choices and behaviors or biological processes. From this

perspective, health-related problems can be solved not by changing society, but by

changing the individual’s behaviors or discovering a cure.

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Pregnancy and childbirth

aren’t illnesses or disabilities, but

ordinary life experiences.

However, the medical model

dominates discussions of them in

the U.S. In the medical model,

the obstetrician – not the

pregnant woman – is the expert

about the woman’s body.

Childbirth is no longer a natural

event but a medical

circumstance requiring a highly-

trained physician. Of course,

there are circumstances that do

require medical intervention,

such as Nandi’s situation.

However, pregnancy and

childbirth are natural events that

most often don’t require medical

intervention. In countries such as

the U.S., “obstetrician

involvement and medical

interventions have become

routine in normal childbirth,

without evidence of

effectiveness” (emphasis

added).16 On the other hand, in

many European countries, the

midwife-led model of pregnancy and childbirth is often just as common as the medical model.

For example, half of all babies in Great Britain are delivered by midwives. In the midwife-led

model, midwives provide individualized prenatal and postnatal care and support for women

in labor. Research shows that having a midwife present results in positive birth experiences.17

Social control can also be exerted by dictating how we should behave when we are

sick. American cultural norms dictate that we should work hard and be financially responsible

for our families without relying on public assistance. Those who are ill or disabled, however,

may not be able to fulfill these social obligations. For example, a person who is undergoing

chemotherapy for cancer may not be able to continue working or fully caring for their family.

They may be excused from their usual social obligations if they meet certain criteria and fulfill

(Source)

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new social obligations, as outlined by the sick role – a set of rights and responsibilities granted

to some ill people – described by Talcott Parsons.18

In order to be considered sick or disabled in a

socially legitimate way that conforms to social

norms and values, the illness cannot be the person’s

own fault. Some illnesses are considered socially

legitimate while others aren’t. In the U.S., illnesses

and disabilities that are perceived to stem from a

person’s poor lifestyle choices are often

delegitimized and stigmatized. For example,

cigarette smoking is known to cause lung cancer,

and though smoking is both physically and

psychologically addictive, in the U.S. it is often

considered to be a moral weakness and a personal

choice.19 The health consequences are then

considered the smoker’s fault and those with lung

cancer, but not, say, leukemia – which is considered

outside of an individual’s control – are often

stigmatized.20

Similarly, a common form of cervical cancer

is caused by the human papilloma virus (HPV), a

sexually transmitted infection (STI). In the U.S., the

sexual behavior of women is highly stigmatized and

under social control.21 American women are

socialized to avoid appearing highly sexual, and

terms like “slut” are used to punish those who break

this rule. Health problems linked to sexual behaviors

are delegitimized and, as the public learned of the

connection between earlier sexual behavior and cervical cancer, women with cervical

cancer have been stigmatized and may not receive the sympathy and understanding offered

to women with other types of cancer.22

Susan Sontag argued that illness is often explicitly seen as a reflection of personal

shortcomings or moral weaknesses.23 While both lung cancer and cervical cancer may be

delegitimized and stigmatized because they are seen as the person’s fault, Sontag explains

that these diseases may also be viewed as the result of a personal shortcoming such as low

self-control. From this perspective, it’s not just that a person could have avoided the disease;

they should have avoided it, and it’s a moral failure on their part that they didn’t.

Edited poster from a 2012 anti-stigma campaign

by the Lung Cancer Alliance. Original text:

“Crazy old aunts deserve to die if they have lung

cancer. Many people believe that if you have

lung cancer you did something to deserve

it…Lung cancer doesn’t discriminate and neither

should you…” (Source)

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If a person has a socially legitimate illness (meaning it isn’t believed to be their own

fault), they must take on two responsibilities before they can adopt the sick role and be

excused from their social responsibilities. First, they must seek expert advice on how to either

overcome their illness (if it can be cured) or reduce the impact it has on their social

responsibilities (if it’s a chronic condition that can’t be cured). Second, they must follow the

expert advice and try to overcome their disease or condition.

Nandi’s story demonstrates that the sick role doesn’t apply equally to all social groups.

After the death of her babies and her own near death, she spent four days in the ICU and

then was discharged from the hospital. Soon after she returned home, she experienced

dizziness, nausea, vomiting, and severe headaches, and she was seeing spots. Her doctor told

her to continue taking her medication and rest. When her friend who worked at the hospital

took Nandi to the ER, her blood pressure was extremely high. If her friend had not brought her

in for immediate treatment, she would have likely suffered a stroke at home. Nandi fulfilled the

responsibilities of a sick person: she sought expert medical advice from her original doctor and

followed it by taking her medication and staying in bed to rest. However, her story highlights

the complexity around who is allowed to fully adopt the sick role; her doctor failed to

recognize her as having a serious medical condition, and the expert advice she received

didn’t help her get better.

Nandi isn’t alone. Currently, Black women are more than twice as likely to have severe

pregnancy-related complications and nearly four times as likely to die due to these

complications than White women are.24 These inequities persist even after we take into

account health insurance coverage and health problems that existed before the pregnancy.

Political scientist Melissa Harris-Perry explains that society often burdens Black women

with crude stereotypes that obscure their true selves, making it difficult to recognize and treat

them as individuals.25 Writing about the death of her baby, Tressie McMillan Cottom said, “I

was pregnant and in crisis. All the doctors and nurses saw was an incompetent Black

woman”.26 When Nandi received the death certificates for her twins (Figure 4), she was listed

as unmarried, having less than an 8th-grade education, and having attended only six of the

standard 12 prenatal medical visits – none of which was true. Nandi was married, completing

her doctoral degree at a highly prestigious university, and had attended all of her prenatal

care visits. The level of inaccuracy of her certificate reflects studies showing that pregnant

Black women are stereotyped as unmarried, uneducated, and poor.27

To have a socially legitimate illness, medical experts must recognize the illness. While

Black women – and others facing pregnancy-related complications – may require medical

technologies, the medicalization of pregnancy has placed the expertise about women’s

bodies and experiences into the hands of highly-specialized medical doctors. If those doctors

don’t recognize symptoms as a condition in need of medical attention – either because of

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racial stereotypes or because a doctor thinks the symptoms are psychosomatic – women may

be unable to get the medical help they need.

Figure 4: Inaccurate Information on the Death Certificate for Infant Son of Nandi and Miles

(Source: Provided to authors by Nandi)

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In this section, we discussed the ways in which illnesses and the illness experience are

socially constructed. By examining the spatial patterns of morbidity and mortality, we can

understand that diseases are not conditions inherent in the individual but reflections of society.

Through labeling diseases, medicalizing ordinary phenomena, and dictating the behaviors of

a sick person through the sick role, the experience of illness is socially controlled to fit cultural

norms and values. These forms of social control can operate differently in different social

groups. By questioning their social construction, sociologists can contribute to public health

and medicine, clarifying the underlying social forces that result in poor health.

REVIEW SHEET: DEFINING THE BOUNDARIES OF HEALTH & ILLNESS

CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS

AUDIO KEY POINTS

PRACTICE QUIZ KEY PEOPLE

VOCABULARY CROSSWORD PUZZLES KEY TERMS

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HEALTH CARE IN THE U.S.

 What is a health care system?

 What are the health care debates in the U.S. about?

Throughout Nandi’s

pregnancy, she and Miles went to

all of their prenatal care visits and

created a plan for their delivery.

Because Miles had good health

insurance through his employer,

these prenatal visits didn’t cost

them anything. They were

relieved that the costs of labor

and delivery were also covered

by their insurance. You may not

question the need for health

insurance or that their health

insurance came through Miles’s

workplace because this is

standard in the U.S. However, it

wasn’t always this way, and many

other wealthy countries don’t

have the same approach to

paying for health care.

The importance of

insurance in the U.S. health care

system is illustrated by Nandi’s

delivery experience. When Nandi

and Miles arrived at the ER, with

Nandi bleeding uncontrollably,

Nandi was asked for her insurance card. Despite passage of the Emergency Medical

Treatment and Active Labor Act (EMTALA), which states that women in active labor cannot be

denied care regardless of their ability to pay if they are at a hospital that takes federal

insurance such as Medicaid, she wasn’t admitted until she provided her card. In fact, many

hospitals do not comply with this law.28

Example of ER sign required by EMTALA. (Source)

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The American health care system is embedded in the broader society and reflects the

same underlying sociological themes. Health care systems are organized around social

structures and political institutions.29 They also incorporate our larger values and ideologies.

Disagreements about how we should deliver health care in the U.S. stem from differing

ideologies about whether health care is a right or a commodity. Do we view all citizens as

worthy of a healthy life? Or are only some deserving of this privilege? Does it depend on their

ability to pay, or how they behave?

In May 2017, late-night talk show host Jimmy Kimmel discussed his infant son. His

monologue sums up the idea that health care is a right:

We were brought up to believe that we live in the greatest country in the world,

but util a few years ago, millions and millions of us had no access to healthcare at all.

Before 2014, if you were born with congenital heart disease like my son

was, there was a good chance you’d never be able to get health insurance

because you had a pre-existing condition. You were born with a pre-existing

condition. And if your parents didn’t have medical insurance, you might not live

long enough to even get denied because of a pre-existing condition. If your

baby is going to die and it doesn’t have to, it shouldn’t matter how much money

you make. I think that’s something that whether you’re a Republican or a

Democrat or something else, we all agree on that, right? I mean, we do.

Whatever your party, whatever you believe, whoever you support, we

need to make sure that the people who are supposed to represent us, the

people who are meeting about this right now in Washington, understand that

very clearly. Let’s stop with the nonsense. This isn’t football. There are no teams.

We are the team. It’s the United States. Don’t let their partisan squabbles divide

us on something every decent person wants. We need to take care of each

other. I saw a lot of families there and no parent should ever have to decide if

they can afford to save their child’s life. It just shouldn’t happen. Not here.

In an interview on CNN, Republican congressman Mo Brooks from Alabama summed

up the counterargument. Instead of seeing health care as a right, from this perspective only

those who have led “good lives” and are sick through no fault of their own deserve affordable

health care coverage:

My understanding is that [a proposed health care law] will allow insurance

companies to require people who have higher health care costs to contribute more to

the insurance pool. That helps offset all these costs, thereby reducing the cost to those

people who lead good lives, they're healthy, they've done the things to keep their

bodies healthy. And right now, those are the people – who’ve done things the right

way – that are seeing their costs skyrocketing.

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In fairness, a lot of these people with pre-existing conditions, they have those

conditions through no fault of their own and I think our society, under those

circumstances, needs to help.

Left: Jimmy Kimmel, host of “Jimmy Kimmel Live,” with former President Barack Obama. (Source);

Right: Republican Congressman Mo Brooks of Alabama with former Alabama Republican

Senator Luther Strange. (Source)

As we discuss health care systems and health care debates, keep these

underlying opposing ideologies in mind. Who deserves to live a healthy life? Who

deserves to receive high-quality health care when they need it? Should your ability to

pay or your past behavior affect whether you can get care? How you answer these

questions will affect the type of health care system you might support.

Health care as a system

Health care systems include the organizations that deliver care (e.g. health care

providers, hospitals) and fund that care (such as governmental programs and private insurers).

For over 100 years, the U.S. has tried to figure out the best way to deliver health care. Because

it’s expensive, many countries, including the United States, have created health insurance

systems. Without health insurance, we would pay “out of pocket” for all health needs. Health

care, and the method of paying for it, are so intertwined that to speak of health care,

particularly in the U.S., is also to speak of paying for health care.

Globally, health care systems can be classified based on the roles of health care

providers and the medical profession, the government, and the payer:30

 Out-of-pocket model: The patient pays all health care costs personally; there is no

health insurance. This model isn’t used by wealthy countries.

 Beveridge model: The government pays all health care costs and funds it through

taxes. Health care providers, including hospitals and doctors, can be employed by the

government or have their own private practice. It is named after economist William

Beveridge, who designed Great Britain’s National Health Service.

Health & Illness (Fall 2021)

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 Bismarck model: Everyone is required to have health insurance, which is funded jointly

by employers and employees and isn’t intended to make a profit. While health

insurance operates through employers, the government provides oversight of costs.

Health care providers are generally private. It is named after Chancellor Otto von

Bismarck, who designed the German welfare state.

 National Health Insurance model: Combines the Beveridge and Bismarck models. The

government provides insurance funded through taxes or premiums, but supplemental

private insurance may be needed. Health care providers are generally private.

 Semashko model: All parts of the health care system are controlled by the

government. This model was developed in the Soviet Union and is still used, in some

form, by countries in eastern Europe.

Many countries combine features from different models. The U.S. operates with a

patchwork of these models.31 We have two broad categories of health insurance: publicly-

funded and privately-funded. The major types of public or governmental health care

coverage include Medicare, which covers certain health care costs for Americans aged 65

and older, and Medicaid, which covers certain health care costs for low-income Americans.

Other programs cover specific groups, such as the Indian Health Services (for eligible Native

Americans) and the Veterans Administration (for eligible military veterans). People get private

health care coverage for themselves and/or their families through their employers or by

purchasing coverage directly from an insurance company.

Health care costs in the U.S. have reached $3.5 trillion each year – nearly 18% of the

total value of all goods and services produced in the U.S. We spend two to three times as

much per person on health care as any other wealthy nation. Yet our health falls far behind

other countries. In other words, while our health care is expensive, this higher cost doesn’t lead

to better health. This has resulted in many attempts to change our health care system,

including health care delivery and particularly health insurance.

Current debates about health care

In a recent report, sociologists Jason Beckfield and colleagues stated:

Boundaries and construction of exclusion and inclusion regarding healthcare

systems are key issues that are debated within and across countries. … [T]he threat of

illness is universal. Consequently, observing which individuals and groups are considered

worthy of assistance…provides researchers with insight into the broader culture of a

society and into what its members expect of their healthcare system (e.g., how it should

provide services and to whom).32

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA; commonly

known as ACA or Obamacare) was signed into law. The goal was to make health care more

Health & Illness (Fall 2021)

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affordable and accessible for more Americans, particularly those who couldn’t easily cover

the costs themselves. Before the ACA was passed, 18% of Americans under 65 years old didn’t

have insurance, only 50% of poor Americans were covered by Medicaid, and most people

with pre-existing conditions (a condition you had before you enrolled with a particular health

plan) couldn’t afford the high premiums charged by insurance companies.33 The ACA

required a number of changes:

 It established “health exchange” marketplaces where people could shop for health

insurance.

 Insurers are required to cover ten essential services: ambulatory (outpatient)

services, emergency services, hospitalization, maternity and newborn care, mental

health and substance use services, prescription drugs, rehabilitative services and

devices (such as speech-language therapy or physical therapy), laboratory

services, preventive and wellness services and chronic disease management, and

pediatric services, including oral and vision care.34 There are higher premiums (the

annual cost for an insurance plan) for greater coverage.

 Insurers are required to cover people regardless of their health status. In other words,

relatively affordable health insurance was available to those with pre-existing

conditions (which in the past might have made them ineligible for health insurance

or limited what was covered).

 Income-based subsidies are provided for people who can’t afford the premiums.

 Medicaid was expanded to cover more people. The U.S. Supreme Court ruled that

requiring states to expand Medicaid was unconstitutional, so the expansion is

voluntary for states. Thirty-one states expanded Medicaid to cover more of their

residents.35

 All Americans were required to have health insurance, similar to the requirement

that drivers have car insurance. This element was removed by Congress in 2019, so

the “individual mandate” in the ACA is no longer enforced.

 Employers with more than 50 employees are required to provide health insurance

and to extend the coverage to employees’ families and their children until they are

26 years old.

However, the ACA did not achieve universal coverage (coverage for everyone) for

several reasons. First, the Supreme Court ruling that states could choose not to participate in

the Medicaid expansion means that roughly 4.5 million poor and near-poor people are still

uninsured.36 And undocumented immigrants aren’t allowed to purchase insurance on the

marketplace or to receive subsidies to help pay for coverage, so roughly 40% of this group are

estimated to be uninsured.37

Just as with political disagreements about other American institutions such as the

criminal justice system, debates about health care reflect underlying ideological differences. It

Health & Illness (Fall 2021)

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may seem that the debates center on how we can pay for health care. What should the

government’s role be in covering health care costs? This divides the nation based on some

who believe that it is the government’s role to pay for health care versus those who believe

that these costs should be left to the market and individual consumers. More fundamentally,

these debates reflect differences in ideologies about who is worthy. The question isn’t simply,

“Is health care a right or a commodity?” because viewing health care as a right or a

commodity for sale may reflect an underlying value system. Thus the question is: “Who has the

right to live a healthy life?”

Since it was signed into law, the ACA has been the topic of political and dinner table

debates; some political groups have attempted to change the ACA or repeal it entirely.

Several left-leaning proposals attempted to expand the ACA to cover all Americans and

reduce or eliminate individual premiums, while several right-leaning proposals tried to remove

some features. This includes proposals to create separate high-risk pools (where people with

certain conditions would pay more for

coverage) so that healthy people who

“lead good lives,” as Congressman Mo

Brooks said, don’t share the costs of

those with higher health risks.

These disagreements and the

many protests on all sides of this issue

reflect underlying ideological

differences. Policymakers have fueled

the disagreements through political

rhetoric such as calling the ACA

“Obamacare,” which was intended by

opponents to link the bill to President

Obama and to people’s ideas about

him and about who deserves a healthy life. In fact, while the ACA was championed at the

national level by former President Obama, a Democrat, it was modeled after “Romney Care,”

developed by former Massachusetts Governor, and Republican, Mitt Romney. But in opinion

polls, people are more supportive of the ACA than of “Obamacare” – even though they’re

the exact same program. A key role for the sociological study of health care is to understand

these types of connections between political discussions about features of our health care

system and larger societal norms, values, and ideologies.

Former President Barack Obama at an Affordable Care Act

event in 2013. (Source)

Health & Illness (Fall 2021)

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REVIEW SHEET: HEALTH CARE IN THE U.S

CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS

AUDIO KEY POINTS

PRACTICE QUIZ KEY PEOPLE

VOCABULARY CROSSWORD PUZZLES KEY TERMS

SOCIAL DETERMINANTS OF HEALTH & HEALTH INEQUITIES

 What are the major social determinants of health?

 How can the socioecological framework and life course perspective help us

understand social patterns in health?

Figure 5 is a map of life expectancy in different parts of Chicago for 2009-2010. Average

life expectancy for residents of the Loop area of downtown Chicago is 85 years. Residents of

Washington Park, just a few miles away, have a life expectancy of only 69 years. What might

account for this dramatic difference in life expectancy for people who only live a few miles

from each other? In the Loop, 15% of residents live in poverty and only 6% are unemployed. In

Washington Park, 48% of residents are poor and 29% are unemployed.38 These patterns in

Chicago mirror those in other cities, including Washington, D.C., where Nandi and Miles live.

Economic characteristics such as poverty and unemployment are social determinants

of health, a broad category of factors, including “a society’s past and present economic,

political, and legal systems [and] its material and technological resources...”, that drive social

patterns in health.39 The social determinants of health are often described as the “upstream”

determinants of health because they then impact “downstream” determinants, such as

behaviors like smoking and diet. As we have seen throughout this chapter, the health of

Health & Illness (Fall 2021)

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individuals is embedded within a larger social context. This embeddedness can be considered

in a few different ways. First, sociologists have focused particularly on three interrelated

characteristics when studying health: race and ethnicity, gender, and class (also called

socioeconomic status, or SES). More recently, the focus has shifted toward how racism, sexism,

and class inequality make these characteristics relevant to health. A second way that

individual health is socially embedded is illustrated by the socio-ecological model. According

to this model, a person is embedded within their social networks and relationships, which are

then embedded within their neighborhoods and communities, which are embedded within

larger socio-political contexts. Finally, people are embedded in their life course. Examples of

life course events include graduation, marriage, parenthood, divorce, and other key

milestones or transitions. Living in a poor neighborhood for many years will have a different

impact on the health of a child than on a young adult or an older adult. And living in poverty

for five years before finding stable life-long financial security has a different impact on health

than living in poverty for your entire life.

Figure 5: Life expectancy in Chicago, 2009-2010

Many of these social

determinants of health result in

health inequities; the

differences in health that result

from these social patterns are

often due to unequal and

unfair social conditions. For

example, race, ethnicity, and

class are considered

fundamental causes of health

because they can result in

health inequities due to the

unequal distribution of

resources such as adequate

housing or food and also

through stigma and stress.40

While we focus on the most

studied determinants, social

scientists are beginning to

study other social

determinants of health (Source: Center on Society and Health)

Health & Illness (Fall 2021)

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including sexual identity, religious affiliation, skin tone, and immigrant status.41

Race, ethnicity, structural racism, and health. Race and ethnicity are socially

constructed; race is “a system that humans created to classify and stratify groups of people

based mostly on skin tone” and ethnicity is “a common culture, religion, history, or ancestry

shared by a group of people”.42 In the U.S., racial and ethnic categories are developed based

on social norms of who is fundamentally American and seen as worthy of inclusion in

American society.43 Given this, it isn’t surprising that there are racial and ethnic inequities in

health, as different groups experience unequal social, economic, and political contexts. It’s

not race and ethnicity, themselves, that result in health inequities, but structural racism – a set

of beliefs and ideologies and the social structure that they create based on the idea that a

specific racial group is biologically or culturally superior to other groups – that drives these

unequal contexts.

Let’s return to racial inequities in infant

mortality. In recent decades, technological

advances, such as the development of pulmonary

surfactant therapy, have made it possible for infants

born prematurely to survive life-threatening

conditions such as respiratory distress syndrome

(RDS). However, fundamental causes theory

predicts that access to this life-saving technology

would differ along racial lines, as structural racism

leads to unequal access to the resources needed

for a healthy life – and that is in fact what we see.

Before the development of pulmonary surfactant

therapy, there were no racial inequities in infant mortality due to RDS. However, after this

technological advancement, infants born to Black mothers were more likely to die of RDS than

infants born to White mothers, because White parents have greater access to this medical

therapy.44 This suggests that in order to improve the health of all babies, we need to focus

more fundamentally on how our society is socially structured rather than on medical advances

alone.

Gender, structural sexism, and health. Sex and gender are also socially constructed. Sex

refers to the “biological and physiological characteristics of males and females” while gender

refers to the “norms, roles, and relationships among and between groups of women and

men”.45 Some sex-based differences in health, such as differences in breast or prostate

cancer, don’t reflect inequities because breast cancer is extremely rare in men, while only

men can get prostate cancer. Differences between men and women in who gets these

cancers don’t reflect unfair or unequal social patterns. However, there are gender inequities

related to chronic diseases. While women have longer life expectancies than men, they tend

A yawning newborn can breathe due to lung

surfactants. (Source)

Health & Illness (Fall 2021)

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to experience more disabilities, poorer mental health, and a lower quality of life.46 Sociologists

suggest that it isn’t gender itself that drives these health patterns, but structural sexism.

Structural sexism is a set of beliefs and ideologies, and the social structure that they create

through policies and institutions, based on the idea that men are superior to women; it is

distinct from, and perhaps more important for health than, sex discrimination by individuals.47

Sociologist Patricia Homan measured structural sexism as, for example, the size of the pay gap

between men and women in a state, how many women versus men hold seats in the state

legislature, and how many abortion providers there are in a state. These indicators capture the

extent to which women’s lives are valued. While it may not be surprising that the wage gap

would be bad for women’s health because health is related to income, it may not be clear

why other measures of structural sexism are related to women’s health. It’s not necessarily that

women legislators always support gender equality or that there are so many women requiring

access to safe abortions. Rather, these indicators of structural sexism represent a lot of similar

policies and programs that promote gender equality. Homan’s work showed that women who

lived in states with less structural sexism had better health than women who lived in other

states.48 What may be surprising is that men also benefitted from less structural sexism. It’s likely

that empowering women comes with many institutional improvements such as better

education and more social programs, which can improve the health of everyone in the state.

Socioeconomic status (SES). SES, or social class, is one of the most studied social

determinants of health. Features of SES include education, occupation, income, and wealth.

Each represents a different aspect of SES and is related to health along a gradient. It’s not just

that there are health inequities between the rich and poor, but that health declines along the

entire income spectrum; at each level, people have better health than those with lower SES.

Roughly 50 years ago, sociologists Evelyn Kitagawa and Phillip Hauser showed that college-

educated adults had lower mortality than adults with less education.49 Since then, numerous

studies in the U.S. and around the world have shown a strong association between the level

and quality of education and health.

While we know that education and health are linked, it still isn’t clear what about

education is important for health. Public health researchers have focused on a lack of

knowledge about healthy lifestyles. For example, a recent epidemiology text states,

“…schooling may [develop] a set of enduring cognitive or emotional skills that foster health-

promoting decisions through life. Literacy [the ability to read] and numeracy [the ability to

work with numbers] are likely to help individuals make health decisions.”50

Sociologists have focused on a default American lifestyle that has become dependent

upon conveniences such as, for example, driving (replacing physical activity to get around)

and highly-processed and high-calorie food (replacing fresh food, particularly fruits and

vegetables). This American lifestyle also depends on medical interventions to address diseases

rather than focusing on preventing disease in the first place.51 More education may provide

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access to power, prestige, and resources that allow people to avoid the default American

lifestyle. For example, people with higher education may be able to live in neighborhoods and

have workplaces that support walking and biking through walking paths, bike lanes, and

places to park bikes, and may live within safe walking or biking distance of stores, businesses,

and workplaces. They may also be able to afford higher-quality fresh produce and other

healthy food options.

Increased education is also related to higher occupational prestige and income or

wealth. Some occupations have more social prestige than others, giving people with that

occupation higher social standing. Both education and occupation are related to income

and wealth. Higher incomes and wealth give people greater access to resources such as

high-quality housing and neighborhoods with key resources.

In reality, race and ethnicity, gender, and class intersect in many ways that create

complex health patterns. When Nandi was pregnant, she was working on her doctoral degree

in public health at a prestigious university; her husband already had a Master’s degree in

education and taught at a private middle school. Nandi’s mother earned her college degree

before she died at 58 years old, and Nandi’s grandmother was a nurse, a skilled and generally

highly-respected profession. Nandi and Miles owned their home, which they inherited from

Nandi’s mother. In fact, many recent media stories are about Black women with high levels of

education and prestige who still experience poor maternal health.

Figure 6: U.S. Infant Mortality Rate by Mother’s Race, Ethnicity, and Educational Level, 2016

Abbreviations: AIAN, American Indian or Alaska native; API, Asian or Pacific islander; CO, college; HL,

Hispanic or Latino; HS, high school; NHB, non-Hispanic Black; NHW, non-Hispanic White.

(Source: Calculations from Singh & Yu [2019].52 Data derived from the 2016 National Linked Birth/Infant

Death Period File.)

Health & Illness (Fall 2021)

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These stories are reflected in national data. Even with a college degree, Black adults

have poorer health than White adults. More education is beneficial to the health of all groups,

but not as beneficial for Black Americans as it is for White Americans. Figure 6 shows infant

mortality rates by the mother’s race, ethnicity, and educational level. Higher levels of

education are related to lower infant mortality for all racial and ethnic groups. However, there

are racial inequities, with Black and American Indian/Alaska Native women experiencing the

highest rates. In fact, Black women have the least payoff for higher education; Black women

with a college degree or more have an infant mortality rate that is higher than White women

with only a high school diploma – and only slightly lower than White women who have not

even completed high school. Black women simply have to earn much more education to

attain the health outcomes that White women have.

Social networks and health. In Durkheim’s study of suicide, he noted that we are

integrated into society in two ways: through attachment to others and by accepting and

complying with society’s values, beliefs, and norms. Think about the people you know – your

family, friends, neighbors, classmates, coworkers. They make up your social network (a

structure of socially interrelated people) and likely affect your health. The growth of social

media platforms has changed the size and potential influence of our networks.53 Your social

network can affect your health in several ways. One of the more obvious is through contact

with a pathogen (such as a cold virus) or other health risk (for instance, second-hand cigarette

smoke). And through your attachment to the members of your social network, you may

receive social support, opportunities for social engagement, money, and access to

information on jobs or health care that can ultimately lead to better health. Your social

network also exerts social influence through its values, beliefs, and norms, which may or may

not match those of the broader society; your network may support healthy behaviors or might

encourage you to take risks that can harm your health (such as excessive drinking).

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Neighborhoods and health. Your neighborhood can also affect your health.

Neighborhoods are more than the collection of residents; while neighborhood poverty, for

example, is made up of all residents who have an income below the poverty line,

neighborhood poverty can have impacts on health that go beyond a person’s own poverty.

Even if your family isn’t poor, if you live in a neighborhood where many of your neighbors are

poor, the larger city and private businesses may not invest resources in your neighborhood.

These resources are part of the social and physical environment that affect your health, and

may impact you and your family regardless of your income – that is, the poverty of the

neighborhood has an effect that is separate from the income of individual families, and

affects even those who aren’t poor. The social environment – the social elements of your work,

school, or neighborhood – includes

norms, local institutions, social

connections, trust, and safety. The

physical environment includes built

features of the neighborhood such

as housing, green spaces such as

parks, services and amenities such

as grocery stores, and toxic

substances like air pollution.

Research suggests that chronic

diseases such as hypertension and

diabetes are related to numerous

features of the social and physical

environment.54

Neighborhoods don’t occur

naturally. They are planned and

built, meaning neighborhood quality

is subject to the same power

dynamics as other social

determinants of health. While the

U.S. has always been racially

segregated, certain policies have

increased and reinforced

segregation, concentrated poverty,

and increased racial inequities in wealth and neighborhood quality. For example, a new

system of home mortgages was created as part of the New Deal in the 1930s. However, these

programs were available almost exclusively to White Americans. Maps assigned color-coded

grades to different areas of the city based on their racial composition and other

Color-coded residential map of Atlanta developed by the

Homeowners’ Loan Corporation (HOLC), 1939. (Source)

Health & Illness (Fall 2021)

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characteristics. Areas of the city that included mostly Black residents were graded “D” and

coded red. Residents in those “redlined” areas couldn’t secure government-insured

mortgages and weren’t able to take part in the upward mobility offered to residents of White

neighborhoods.55 The impact of those historical policies can be seen in health today. For

example, the racial composition of a neighborhood continues to be the primary determinant

of where industrial polluters are located, and historically redlined neighborhoods have higher

rates of asthma and violence than other neighborhoods.56

Stigma and health. Over 50 years ago, sociologist Erving Goffman wrote about the

stigma of mental illness.57 A stigma is a mark or label that discredits a person as a form of social

control; people are pressured to accept and follow social norms out of fear of being

stigmatized. Sociologists have since refined the concept of stigma, particularly as it relates to

health.58 They note that social, economic, and political power inequities determine the

difference between a harmful stigma versus a stereotype (a widely-shared perception about

the characteristics or abilities of members of a particular group). For example, there are

stereotypes and jokes about lawyers; however, the prestige and power associated with the

law profession prevents these stereotypes from transforming into a stigma. Sociologists identify

several stages of the stigmatization process. First, society as a whole determines which marks

or features are important in distinguishing “us” from “them”; “they” are seen as problematic. In

general, these features characterize groups of people that society would like to control. For

example, a feature may be dark skin tone, specific clothing (such as a hijab), or an accent.

Stereotyping links these features or marks to characteristics such as being a criminal, poor, or a

terrorist. This stereotyping allows us to separate “us” from “them.” Finally, the stigmatized group

experiences discrimination and loses status. This is the key stage that makes stigma a powerful

form of social control.

Bearing the mark of a stigmatized

group, even without sharing the underlying

characteristics, can impact health, which is

called a spillover effect. The growing

stigmatization of Latinx immigrants through

stereotyping them as “illegal” or “criminal”

may cause health effects not only to

undocumented Latinx immigrants but also to

documented Latinx residents and citizens,

even those whose families have been U.S.

citizens for generations. For example, in May

2008, U.S. Immigration and Customs

Enforcement (ICE) suddenly raided a meat-processing plant in Postville, Iowa. Nearly 300 men

were arrested, charged with working in the U.S. without proper documentation, and deported

A meatpacking plant in Postville, Iowa. (Source)

Health & Illness (Fall 2021)

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after serving a five-month prison sentence. News of this raid and allegations of inhumane

treatment toward those arrested in the raid spread quickly through the Spanish-speaking

community in the state. After the raid, there were increases in low-birth-weight babies born to

Latinx mothers in Iowa, even among those who weren’t related to the men who were

deported, suggesting that the stress of a stigmatized identity has health consequences.59

Stress and health. Think about the last time you experienced something stressful. Maybe

you weren’t prepared for a test, or you got into an argument with a close friend. Perhaps a

close family member passed away, or you lost your job. Each of these appears to be an

isolated incident, but through a sociological lens, we can understand that they are

embedded in our broader social context.

How did you feel during that stressful experience? Did your heart rate go up? Did you

feel anxious? For decades, scientists have studied how the body reacts and adjusts to

environmental stimuli. The term “stress” was coined to refer to anything that challenges and

threatens the body’s internal stability and equilibrium, such as blood pressure or even cellular

processes.

Several disciplines, including psychology and endocrinology, pay particular attention to

individual perceptions of stress, coping processes, personality characteristics, and biological

pathways. While the body is resilient and designed to deal with stressful situations, chronic

stress wears away at the body’s stress response system, leading to problems in the immune,

metabolic, and cardiovascular systems. Chronic stress can develop not just from repeatedly

experiencing stressors. Anticipation and worry can transform even a momentary situation into

a chronic stressor.60

Stress has received increasing research and media coverage because of its link to

health. Stress compromises the immune system, whether it is acute stress about an upcoming

exam or the chronic stress of stigma.61 Additionally, major traumatic stress and chronic stress

are related to numerous chronic diseases and conditions including poor mental health,

cardiovascular disease, hypertension, and certain cancers, just to name a few.62

There are social patterns in stress, and social inequities in stress are related to social

inequities in health.63 Inequities in chronic stress are thought to drive many of the health

inequities between the rich and poor, between different genders and sexual identities, and

between different racial and ethnic groups. Early sociological work on stress and racial health

inequities focused on interpersonal discrimination, or unfair treatment of one person by

another, with some attention to structural racism.64 Many sociologists continue to study the

health impact of discrimination; however, some have turned to structural racism as a more

fundamental driver of racial health inequities.

A sociological lens on stress helps us understand the link between social forces and

health inequities. For example, Nandi’s traumatic birth experience was a single event that

cascaded into a series of stressful circumstances, including her inability to focus on her

Health & Illness (Fall 2021)

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doctoral research, which then delayed her graduation and later employment (and the higher

income and health insurance that came with it). Sociologist Leonard Pearlin described this as

stress proliferation, when one stressful event leads to a series of other stressful events and

situations.65 We can go further back and look at the premature death of Nandi’s mother less

than two years earlier. Nandi and her mom had always been very close, so when her mother

fell ill, Nandi moved back to Washington, D.C., in the middle of her doctoral studies, to take

care of her. Could the stressful event of her mother’s death, with the connected stresses of a

major move, delaying her progress in her graduate program, and then caring for her mother’s

affairs, be related to the later death of her babies? Poet Claudia Rankine talked of “the

condition of [B]lack life [as] one of mourning”.66 Sociologists would note that Nandi, as a Black

woman in the U.S., is more likely to experience the death of friends and family as well as other

chronic stressors. These stressors are likely not separate events, but are interconnected,

building on one another to result in poor health.

More recently, sociologist Joe Feagin and anthropologist Philomena Essed have helped

us understand the stressful experiences of Black men and women as they negotiate everyday

American life. Marginalized social groups often anticipate potential prejudice or discrimination

or worry about previous problematic encounters. This anticipation or worry may stem from their

own personal interactions as well as encounters experienced by people in their social

networks – or just as importantly, from experiences of their larger marginalized group, as in the

raid on the meat-processing plant in Iowa. Vigilance includes the anticipation and worry stress

that comes with membership in a socially marginalized and stigmatized group. Vigilance is

consistently related to poor mental and physical health, and racial inequities in vigilance are

also related to numerous health inequities.67

Perspectives for studying health

One of the most widely-used perspectives for studying the social determinants of health

is the socio-ecological framework.68 In this framework, the individual is placed within their

interpersonal, community, and societal contexts. Some sociologists focus on the broadest level

and explain how societal-level factors affect health. Social epidemiologists, on the other

hand, may place more emphasis on the behavioral or biological mechanisms of the

individual. Let’s think about the childhood nutritional environment. Sociologists might focus on

school district policies and practices (which reflect the larger sociopolitical context)

throughout a city to understand differences in the nutritional value and quality of lunches

Health & Illness (Fall 2021)

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served at schools in different

neighborhoods. A social

epidemiologist might instead

document what children

choose to eat in their schools,

focusing on the individual

health behavior. These

approaches target different

areas of the same issue; to

address childhood nutrition,

we can focus on school

district policies to ensure that

all schools provide nutritious

food or we can focus on

individual children (and their

families) to suggest better food choices.

The socio-ecological model has influenced research on public health and guided

interventions and policy recommendations. For example, a recent trend in health promotion

focuses on the social determinants of health more globally. The 8th World Congress on Health

Promotion, held in 2013, led to the “Health in All Policies” (HiAP) model. It addresses issues of

health inequities by recognizing that these inequities ultimately stem from numerous social

factors. The World Health Organization (WHO) stated,

Health and health equity are values in their own right, and are also important

prerequisites for achieving many other societal goals. Many of the determinants of

health and health inequities in populations have social, environmental, and economic

origins that extend beyond the direct influence of the health sector and health policies.

Thus, public policies in all sectors and at different levels of governance can have a

significant impact on population health and health equity.69

The National Academy of Sciences in the United States has also recognized the

importance of the HiAP movement, stating:

Medical services, while vitally important, play a lesser role in overall population

health improvement than the social determinants of health—the environments in which

people live, work, learn, and play. Economic status, educational attainment, structural

racism, and neighborhood characteristics are critical determinants of health and

health inequities. Improvements in a community’s economic, physical, social, and

service environments can help ensure opportunities for health and support healthy

behaviors. However, health agencies rarely have the mandate, authority, or

organizational capacity to make the policy, systems, and environmental changes that

An example of the socio-ecological model of the social determinants

of health. (Source: Authors)

Health & Illness (Fall 2021)

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can promote healthy living through healthy environments. That responsibility falls to

housing, transportation, education, air quality, parks, criminal justice, agriculture,

energy, and employment agencies, among others.70

This means that we can’t address health inequities through conventional medical

approaches targeted at disease management, or with public health approaches that try to

promote better health. We must incorporate a sociological lens that understands how social,

economic, and political contexts ultimately drive health inequities. From this perspective, labor

policies are health policies; education policies are health policies; transportation policies are

health policies; and so on.

Often, health and illness are described in terms of a particular period in the life span –

childhood asthma, vaping among teenagers, hypertension among adults, and cognitive

impairments in older adults. In reality, our social experiences and health are interrelated

throughout our lives, which is a major principle of the life course perspective on health.

Sociologist Glen Elder outlined a theory of the life course related to child development, and

many sociologists have adapted this perspective to the study of health.71 Elder suggested five

basic principles that have been incorporated into studies of health and social structure:

 Life span development: Human development isn’t limited to a single period in the

life span, but is a continuous process throughout one’s life. The health of adults, for

example, represents a progression of health throughout their lives.

 Constrained agency: People make choices and take actions that shape their lives;

they are active participants in how their lives unfold. However, these choices and

actions are constrained by structural circumstances. For example, while we may try

to have more nutritious diets and exercise, our ability to do so depends on the

resources in our neighborhoods (are there safe places to jog?) and the norms of our

social networks (what kind of food is served at social gatherings?).

 Time and place: The course and trajectory of a person’s life is embedded and

shaped not only by their own lived history, but by the history of the spaces they

inhabit. Your health depends on where you live and at what point in your life you

lived there – living in a polluted neighborhood can have different effects on children

than on adults, for example. And the history of your neighborhood, even before you

lived there, can shape your health by affecting the quality of resources available

there now.

 Timing: The ways in which your life unfolds depend on your social experiences and

when in your life you had those experiences. For example, conventional American

norms of the life course are that a person completes their education, gets a job,

gets married, then has children, and later retires. Our social institutions are set up to

support this timing and ordering of the life course; high schools aren’t set up to

accommodate students with children, for instance. Due to structural constraints,

Health & Illness (Fall 2021)

Page 35

different social groups may not be able to adhere to these norms, with implications

for their health.

 Linked lives: Our lives are interconnected directly through our social networks and

indirectly through our place in history. Our health is related to the health of the

members of our social network. We are also connected as, for example, Americans

living at this point in time, as veterans of recent American wars, or as Black men and

women living during the Civil Rights era.

In this section, we introduced several social determinants of health that have been the

focus of sociology for many years. Sociologists have documented the health inequities among

different racial groups and among those with different levels of education. Recently,

sociologists have focused on the features of society that might drive these health inequities,

such as structural racism or unequal access to resources important for health. These social

determinants may impact health differently depending on when in the life course they are

experienced, as outlined by the life course approach. Finally, the social determinants of health

perspective suggests that, in order to improve population health and reduce social inequities

in health, we must focus on social factors rather than on primarily public health, health care, or

medical factors.

REVIEW SHEET: SOCIAL DETERMINANTS OF HEALTH & HEALTH

INEQUITIES

CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS

AUDIO KEY POINTS

PRACTICE QUIZ KEY PEOPLE

VOCABULARY CROSSWORD PUZZLES KEY TERMS

Health & Illness (Fall 2021)

Page 36

THE FUTURE OF SOCIOLOGY IN HEALTH & ILLNESS

 What role does the sociology of health and illness have in the genomics era?

 Is historical context related to contemporary social patterns in health?

An African-American boy at a segregated drinking

fountain in Halifax, North Carolina, 1938. (Source)

With the sequencing of the human genome (the complete set of genes needed to

build and maintain our bodies) in 2003 came the promise of boundless discoveries of cures for

diseases. Since then, it has become clear that health and illness are not simply the product of

our genes, but the likely result of a complex interplay between our genes and our social

experiences, which are ultimately shaped by cultural norms and values and our social

structure. We are witnessing the birth of a new interdisciplinary field of social genomics in

which sociologists and other social scientists work with geneticists to understand how the social

world might alter the structure and function of our genome and affect social patterns in

health.72 As we move into this field, we must be careful not to conflate socially-constructed

races with genetic ancestry, which is composed of specific parts of the genome.73

Physical barriers (such as oceans or mountains) and social forces (such as policies or

traditions that ban or encourage people from different social or cultural groups from marrying)

separate groups of people, and this separation is reflected in our genomes.74 How racial

categories are socially constructed in a particular society or country at a particular point in

time may or may not match the underlying genetic ancestries.75 And importantly, there is no

evidence that genetic differences among racial groups are responsible for the racial

Health & Illness (Fall 2021)

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inequities in common chronic diseases.76 In addition to the social forces that shape the

structure of our genomes, social forces can also affect how our genes are related to health.

For example, studies show that the effect that our genes have on health really depends on the

environment we are in.77 Sociologists have an important role to play in this genomic era, both

by continuing to clarify the social forces that shape health patterns and by working with

geneticists to understand how social forces and our genome contribute to social patterns in

health.

Sociologists have contributed important information about historical patterns in social,

economic, and political aspects of society; some have also linked historical social forces to

contemporary society.78 As the life course perspective highlights, we are linked to history –

which means that our health may also be linked to historical aspects of society. Indeed,

historical elements of structural racism, such as redlining, Jim Crow laws, lynching, legal (e.g.

police) and extra-legal (e.g. Ku Klux Klan) racial violence, and slavery, created racial

boundaries around access to resources, opportunities, and full citizenship that continue to

drive contemporary racial health inequities, such as the disparities in novel coronavirus 2019

(COVID-19) infection and the risk of death once infected.79

We have discussed only two possible future avenues for sociologists to study health –

social genomics and social history. In reality, as society changes, there are new roles for

sociologists, such as understanding the impact of social media on society and health and

using algorithms and artificial intelligence to model the complexity of society and health.

Common to all of these topics of research is the growing integration of sociology with other

fields to create interdisciplinary areas of study. Because sociology provides a unique and

important lens for the study of health, there will be exciting new ways to integrate it with other

social sciences such as economics or psychology, and also with biomedicine, humanities, and

computer science. Ultimately, given the critical ways in which social forces shape health and

the illness experience, the future of sociology and health is one that centers sociology while

extending into other fields of study.

Health & Illness (Fall 2021)

Page 38

An African American protestor's shirt with handwritten messages linking racism to COVID-19

(Source).

REVIEW SHEET: THE FUTURE OF SOCIOLOGY IN HEALTH & ILLNESS

CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS

AUDIO KEY POINTS

PRACTICE QUIZ KEY PEOPLE

VOCABULARY CROSSWORD PUZZLES KEY TERMS

Health & Illness (Fall 2021)

Page 39

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