关于武汉肺炎的社会学的文献与摘录
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关于武汉肺炎的社会学的文献与摘录

病毒，公共卫生，健康与疾病社会学，医疗社会学，医疗模型，社会风险……

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武汉肺炎，即 2019 新型冠状病毒（2019-nCoV）自去年底发自武汉，至今已呈现不可控趋势。十七年前曾参与应对 SARS 的王广发，作为国家医疗专家组专家，在本月 10 日表示整体疫情可控，然而前日（21 日）确证感染。而在官方媒体松口前，医护人员的人传人现象也是钟南山通过专访提前透露确认。闾丘露薇为腾讯所撰写的香港防护措施的文章，数小时后即下架，她在 Twitter 上表示，钟南山或受压力无法再接受媒体访谈。

近二十年过去了，中国在思想政治领域的管控来到了空前的程度，效果也十分显著，从过去几年中社交媒体中的民族主义情绪的激烈喷发可见一斑。而在实际的行政管理层面上，各级权力机构依然难以协调职责与权限，面对公共事件的处理迟缓，决策者对舆情难以掌握。政治科学与社会学等专业人才缺失，理论空白却又对「本土化/中国化」的伪问题争论不休。不论中美贸易摩擦、香港反送中运动后的区议会选举、台湾反红媒/反渗透与大选，中国对这些事件的认知与处理显现出的意识形态单一化。而面对此次公共卫生危机，即使强调与世卫组织等的合作，但在中国决策核心看来，本质上还是个「国内问题」。

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本文旨在摘录社会学视角下的流行病等医学相关的入门材料。虽然时效性不高，但我对医疗社会学或健康与疾病社会学基本不了解，学术词典倒算是个不错的快速切入途径。其中 Blackwell 的比较详细，且给出参考文献，利于拓展；Open Education Sociology Dictionary 的线上资源丰富。摘录篇幅较长，春节诸事繁杂，难以抽身整理，或许日后再回头来汇编一下。

后半部收集的论文和著作，检索自 Oxford Bibliographies、Google Scholar、Academia 等工具，并作筛选和整理。其中一部分参考了孙宇凡的《理论与历史社会学资料》第 4 期所收文章。

KEYWORDS virus, public health, sociology of health and illness, sociology of medicine, globalisation, cosmopolitanism, communication, medical model, social risk, epidemiology, disaster, prevention, intervention, rumor...

病毒，公共卫生，健康与疾病社会学，医疗社会学，全球化，世界主义，传播，医疗模型，社会风险，流行病学，灾害，预防，干涉，谣言……

⏬ 文献下载地址： 百度网盘（密码:vwhx）

Contents

About 2019-nCov

WHO

Imperial College London

CDC

Elsevier

中国大陆相关部门

香港相关部门

台湾相关部门

日本相关部门

Books

Perspectives in Medical Sociology

A selection of theoretical and empirical articles in medical sociology with a focus on the social context of health and illness, the illness experienced both within and outside of encounters with the health care system, and the health care system.

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Social epidemiology

Social epidemiology is the study of how the social world influences -- and in many cases defines -- the fundamental determinants of health. This link was substantiated in the first edition ofSocial Epidemiology, and the generation of research that followed has fundamentally changed the way we understand epidemiology and public health.

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Medical Sociology

A comprehensive overview of medical sociology focusing on the impact of social factors on health, how individuals react to health and illness, the health professions, and social organization of health care.

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The Social Construction of SARS: Studies of a Health Communication Crisis

When the SARS virus began its spread from southern China around the world in spring 2003, it caught regional and international health officials by surprise. The SARS epidemic itself lasted for only a few months, whereas its treatment, in communicative terms, keeps providing us with important lessons that can prepare us all for the much larger pandemic that many are predicting will eventually occur. While the medical aspects of SARS are now relatively well understood, the discursive rhetorical dimensions are much less so. As an international epidemic, SARS arrived in a number of distinctive societies with the result that different communities handled the crisis in different ways, some far more effectively than others. Accordingly, the 12 chapters in The Social Construction of SARS are studies of how a major health-related crisis was understood and dealt with from a communicative perspective in such diverse places as Hong Kong, mainland China, Singapore, Taiwan, Canada and the United States during the SARS outbreak.

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Regulating Bodies: Essays in Medical Sociology

Bryan Turner is generally acknowledged to have been the key figure in opening up the sociological debate about the body. In this coruscating and fascinating book he shows how his thinking on the subject has developed and why sociologists must take the body seriously.

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Leprosy in China: A History

Angela Ki Che Leung's meticulous study begins with the classical annals of the imperial era, which contain the first descriptions of a feared and stigmatized disorder modern researchers now identify as leprosy. She then tracks the relationship between the disease and China's social and political spheres (theories of contagion prompted community and statewide efforts at segregation); religious traditions (Buddhism and Daoism ascribed redemptive meaning to those suffering from the disease), and evolving medical discourse (Chinese doctors have contested the disease's etiology for centuries). Leprosy even pops up in Chinese folklore, attributing the spread of the contagion to contact with immoral women.

Leung next places the history of leprosy into a global context of colonialism, racial politics, and "imperial danger." A perceived global pandemic in the late nineteenth century seemed to confirm Westerners' fears that Chinese immigration threatened public health. Therefore battling to contain, if not eliminate, the disease became a central mission of the modernizing, state-building projects of the late Qing empire, the nationalist government of the first half of the twentieth century, and the People's Republic of China.

Stamping out the curse of leprosy was the first step toward achieving "hygienic modernity" and erasing the cultural and economic backwardness associated with the disease. Leung's final move connects China's experience with leprosy to a larger history of public health and biomedical regimes of power, exploring the cultural and political implications of China's Sino-Western approach to the disease.

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The Great Influenza: The Story of the Deadliest Pandemic in History

At the height of WWI, history’s most lethal influenza virus erupted in an army camp in Kansas, moved east with American troops, then exploded, killing as many as 100 million people worldwide. It killed more people in twenty-four months than AIDS killed in twenty-four years, more in a year than the Black Death killed in a century. But this was not the Middle Ages, and 1918 marked the first collision of science and epidemic disease. Magisterial in its breadth of perspective and depth of research and now revised to reflect the growing danger of the avian flu, The Great Influenza is ultimately a tale of triumph amid tragedy, which provides us with a precise and sobering model as we confront the epidemics looming on our own horizon. John M. Barry has written a new afterword for this edition that brings us up to speed on the terrible threat of the avian flu and suggest ways in which we might head off another flu pandemic.

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The Birth of the Clinic: An Archaeology of Medical Perception

In the eighteenth century, medicine underwent a mutation. For the first time, medical knowledge took on a precision that had formerly belonged only to mathematics. The body became something that could be mapped. Disease became subject to new rules of classification. And doctors begin to describe phenomena that for centuries had remained below the threshold of the visible and expressible.

In The Birth of the Clinic the philosopher and intellectual historian who may be the true heir to Nietzsche charts this dramatic transformation of medical knowledge. As in his classic Madness and Civilization, Michel Foucault shows how much what we think of as pure science owes to social and cultural attitudes — in this case, to the climate of the French Revolution. Brilliant, provocative, and omnivorously learned, his book sheds new light on the origins of our current notions of health and sickness, life and death.

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Purity and Danger: An Analysis of Concepts of Pollution and Taboo

Professor Douglas makes points which illuminate matters in the philosophy of religion and the philosophy of science and help to show the rest of us just why and how anthropology has become a fundamentally intellectual discipline.

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World at Risk

Twenty years ago Ulrich Beck published Risk Society, a book that called our attention to the dangers of environmental catastrophes and changed the way we think about contemporary societies. During the last two decades, the dangers highlighted by Beck have taken on new forms and assumed ever greater significance. Terrorism has shifted to a global arena, financial crises have produced worldwide consequences that are difficult to control and politicians have been forced to accept that climate change is not idle speculation. In short, we have come to see that today we live in a world at risk.

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Risk and technological culture: Towards a sociology of virulence

The question as to whether we are now entering a risk society has become a key debate in contemporary social theory. Risk and Technological Culture presents a critical discussion of the main theories of risk from Ulrich Becks foundational work to that of his contemporaries such as Anthony Giddens and Scott Lash and assesses the extent to which risk has impacted on modern societies. In this discussion van Loon demonstrates how new technologies are transforming the character of risk and examines the relationship between technological culture and society through substantive chapters on topics such as waste, emerging viruses, communication technologies and urban disorders. In so doing this innovative new book extends the debate to encompass theorists such as Bruno Latour, Donna Haraway, Gilles Deleuze, Felix Guattari and Jean-François Lyotard.

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Borderlines in a Globalized World: New Perspectives in a Sociology of the World-System

Scholars of different schools have extensively analyzed world systems as networks of communication under the fashionable heading 'globalization.' Our collected new research pushes the argument one step further. Globalization is not a homogenization of all social life on earth. It is a heterogeneous process that connects the global and the local on different levels. To understand these contemporary developments this book employs innovative concepts, strategies of research, and explanations. Globalization is a metaphor for different borderstructures, new borderlines, and conditions of membership, which emerge in a global world-system. As a world-system expands it incorporates new territories and new peoples. The process of incorporation creates frontiers or boundaries of the world-system. These frontiers or boundary zones are the locus of resistance to incorporation, ethnogenesis, ethnic transformation, and ethnocide.

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Risk and Uncertainty in a Post-truth Society

This edited volume looks at whether it is possible to be more transparent about uncertainty in scientific evidence without undermining public understanding and trust.

With contributions from leading experts in the field, this book explores the communication of risk and decision-making in an increasingly post-truth world. Drawing on case studies from climate change to genetic testing, the authors argue for better quality evidence synthesis to cut through the noise and highlight the need for more structured public dialogue. For uncertainty in scientific evidence to be communicated effectively, they conclude that trustworthiness is vital: the data and methods underlying statistics must be transparent, valid, and sound, and the numbers need to demonstrate practical utility and add social value to people’s lives.

Presenting a conceptual framework to help navigate the reader through the key social and scientific challenges of a post-truth era, this book will be of great relevance to students, scholars, and policy makers with an interest in risk analysis and communication.

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Papers

Rumor and public opinion

Rumor is a collective effort to interpret a problematic and affectively evocative situation. A case study of rumor demonstrates that when a public is keenly interested, rumer tends to be elaborated and diversified, contrary to the expectations and assumptions of Allport and Postman, who generalize on the basis of laboratory experimentation.

Hot Crises and media reassurance: a comparison of emerging diseases and Ebola Zaire

Drawing on the sociology of moral panic, this paper argues that the media will shift from alarming to reassuring coverage when a 'hot crisis' portends a possible grass root panic. To determine whether this moderation effect follows from dread-inspiring events that are developing in unpredictable and potentially threatening ways, the paper compares newspaper and magazine coverage of emerging diseases with their coverage of Ebola Zaire. The results reveal that the mutation-contagion package, with its frightful account of emerging diseases, was quickly abandoned and subverted during the Ebola epidemic. In its place, the media fashion a containment package that uses a strategy of 'othering' to allay the fear. The conclusion discusses the flexibility in the tool kits used by the media to frame events.

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Moral panic versus the risk society: The implications of the changing sites of social anxiety

This paper compares moral panic with the potential political catastrophes of a risk society. The aim of the comparison is threefold: 1. to establish the position of risk society threats alongside more conventional moral panics; 2. to examine the conceptual shifts that accompany the new types of threats; and 3. to outline the changing research agenda. The paper suggests that as new sites of social anxiety have emerged around environmental, nuclear, chemical and medical threats, the questions motivating moral panic research have lost much of their utility. Conceptually, it examines how the roulette dynamics of the risk society accidents expose hidden institutional violations that redound into ‘hot potatoes’ that are passed among and fumbled by various actors. Changing conceptions of folk devils, claims making activities, and of a safety are also discussed.

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Representations of SARS in the British newspapers

In the Spring of 2003, there was a huge interest in the global news media following the emergence of a new infectious disease: severe acute respiratory syndrome (SARS). This study examines how this novel disease threat was depicted in the UK newspapers, using social representations theory and in particular existing work on social representations of HIV/AIDS and Ebola to analyse the meanings of the epidemic. It investigates the way that SARS was presented as a dangerous threat to the UK public, whilst almost immediately the threat was said to be ‘contained’ using the mechanism of ‘othering’: SARS was said to be unlikely to personally affect the UK reader because the Chinese were so different to ‘us’; so ‘other’. In this sense, the SARS scare, despite the remarkable speed with which it was played out in the modern global news media, resonates with the meanings attributed to other epidemics of infectious diseases throughout history. Yet this study also highlights a number of differences in the social representations of SARS compared with earlier epidemics. In particular, this study examines the phenomena of ‘emerging and re-emerging infectious diseases’ over the past 30 or so years and suggests that these have impacted on the faith once widely held that Western biomedicine could ‘conquer’ infectious disease.

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The scale politics of emerging diseases

The concept of scale politics offers historians a useful framework for analyzing the connections between environment and health. This essay examines the public health campaign around emerging diseases during the 1990s, particularly the ways in which different actors employed scale in geographic and political representations; how they configured cause, consequence, and intervention at different scales; and the moments at which they shifted between different scales in the presentation of their arguments. Biomedical scientists, the mass media, and public health and national security experts contributed to this campaign, exploiting Americans' ambivalence about globalization and the role of modernity in the production of new risks, framing them in terms that made particular interventions appear necessary, logical, or practical.

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Social extremity, communities of fate, and the sociology of SARS

This article identifies the chief factors which transform a group of people into a “community of fate”. A community of fate refers to a temporary form of existence, born of duress and social emergency, which cuts across familiar divisions to elicit something socially consequential. One such community materialized during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong. It is examined here in detail together with a range of other crisis communities – from Montreal battling smallpox, to the captives of the Warsaw Ghetto.

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Disease metaphors in new epidemics: the UK media framing of the 2003 SARS epidemic

Since the emergence of HIV/AIDS in the 1980s, social scientists and sociologists of health and illness have been exploring the metaphorical framing of this infectious disease in its social context. Many have focused on the militaristic language used to report and explain this illness, a type of language that has permeated discourses of immunology, bacteriology and infection for at least a century. In this article, we examine how language and metaphor were used in the UK media's coverage of another previously unknown and severe infectious disease: Severe Acute Respiratory Syndrome (SARS). SARS offers an opportunity to explore the cultural framing of a less extraordinary epidemic disease. It therefore provides an analytical counter-weight to the very extensive body of interpretation that has developed around HIV/AIDS. By analysing the total reporting on SARS of five major national newspapers during the epidemic of spring 2003, we investigate how the reporting of SARS in the UK press was framed, and how this related to media, public and governmental responses to the disease. We found that, surprisingly, militaristic language was largely absent, as was the judgemental discourse of plague. Rather, the main conceptual metaphor used was SARS as a killer. SARS as a killer was a single unified entity, not an army or force. We provide some tentative explanations for this shift in linguistic framing by relating it to local political concerns, media cultures, and spatial factors.

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Responding to global infectious disease outbreaks: Lessons from SARS on the role of risk perception, communication and management

With increased globalisation comes the likelihood that infectious disease appearing in one country will spread rapidly to another, severe acute respiratory syndrome (SARS) being a recent example. However, although SARS infected some 10,000 individuals, killing around 1000, it did not lead to the devastating health impact that many feared, but a rather disproportionate economic impact. The disproportionate scale and nature of this impact has caused concern that outbreaks of more serious disease could cause catastrophic impacts on the global economy. Understanding factors that led to the impact of SARS might help to deal with the possible impact and management of such other infectious disease outbreaks. In this respect, the role of risk—its perception, communication and management—is critical.

This paper looks at the role that risk, and especially the perception of risk, its communication and management, played in driving the economic impact of SARS. It considers the public and public health response to SARS, the role of the media and official organisations, and proposes policy and research priorities for establishing a system to better deal with the next global infectious disease outbreak. It is concluded that the potential for the rapid spread of infectious disease is not necessarily a greater threat than it has always been, but the effect that an outbreak can have on the economy is, which requires further research and policy development.

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SARS and New York's Chinatown: the politics of risk and blame during an epidemic of fear

This paper examines the production of risk and blame discourses during the 2003 SARS epidemic and responses to those messages in New York City's Chinatown, a community stigmatized during the SARS epidemic despite having no SARS cases. The study consisted of 6 weeks participant observation and 37 semi-structured, open-ended interviews with community members. Stigmatizing discourses from the late 19th century resurfaced to blame Chinese culture and people for disease, and were recontextualized to fit contemporary local and global political-economic concerns. Many informants discursively distanced themselves from risk but simultaneously reaffirmed the association of Chinese culture with disease by redirecting such discourses onto recent Chinese immigrants. Legitimizing cultural blame obfuscates the structural and biological causes of epidemics and naturalizes health disparities in marginalized populations. This research demonstrates that myriad historical, political, and economic factors shape responses and risk perceptions during an unfamiliar epidemic, even in places without infection.

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Globalizing Risks–The Cosmo‐Politics of SARS and its Impact on Globalizing Sociology

The outbreak of severe acute respiratory syndrome (SARS) in China 2003 endangered individual lives and disrupted societal organization on a trans‐continental level. SARS was rapidly spreading along the international routes of air traffic and therefore was not only treated as a trans‐regionally spread disease but was feared it would become a pandemic threat, i.e. a global epidemic. Drawing on empirical material, the Canadian experience is given special relevance to highlight the global impact of the cosmo‐politics of SARS that directly related local, regional, national and global risk practices, which dramatically reassembled the relations of nature/culture, local/global, private/public etc. The paper also discusses the relevant impact of SARS on a globalizing sociology.

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Health disparities across the lifespan: meaning, methods, and mechanisms

Over the past two decades, exponential growth of empirical research has fueled markedly increased concern about health disparities. In this paper, we show the progression of research on socioeconomic status (SES) and health through several eras. The first era reflected an implicit threshold model of the association of poverty and health. The second era produced evidence for a graded association between SES and health where each improvement in education, income, occupation, or wealth is associated with better health outcomes. Moving from description of the association to exploration of pathways, the third era focused on mechanisms linking SES and health, whereas the fourth era expanded on mechanisms to consider multilevel influences, and a fifth era added a focus on interactions among factors, not just their main effects or contributions as mediators. Questions from earlier eras remain active areas of research, while later eras add depth and complexity.

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The rumouring of SARS during the 2003 epidemic in China

By analysing rumour content as covered by major Chinese newspapers, this article explores the multiple dimensions of SARS‐related rumouring throughout China during the 2003 epidemic. Findings indicate a strong correlation between the scale of SARS infections and level of rumour activities across regions. As for channels of dissemination, the rumour process still found a natural habitat in word of mouth, while internet‐based platforms and cell phone text messaging emerged as viable grapevines. Our particular typology of SARS‐incurred rumours leads us to identify four distinct types of rumours: legendary rumours; aetiological narratives; proto‐memorates; and bogies. The four types of rumours are discussed against the background of superstitious beliefs, folklore practices, popular mentalities, and China’s particular socio‐political information environment.

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Commentary: Social EpidemiologyQuestionable Answers and Answerable Questions

Social epidemiology encompasses the study of relationships between health and a broad range of social factors such as race, social class, gender, social policies, and so on. One could broadly partition the work of social epidemiology into surveillance (ie, descriptive relationships between social factors and health, tracking of health inequalities over time) and etiology (ie, causal effects of social exposures on health).1 Many social epidemiologists believe these twin pursuits should ultimately serve to structure interventions aimed at reducing health-damaging social exposures or increasing exposure to social factors that enhance health.

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Epidemiology, Sociology and Psychology of Health and Disease

This chapter traces the developments in the three interrelated fields of health, namely, epidemiology, medical sociology and health psychology. In epidemiology, people like Chadwick, Snow, Farr and Virchow began to question the bio-centricism of medical thought and highlighted the environmental and economic factors as responsible for the occurrence of certain kinds of diseases in certain kinds of populations. The sanitary movements in England in the late nineteenth century and the discussions on economic causation of disease (relating disease with poverty) are instances of the impact of methodological holism on epidemiology. The entire shift of focus in epidemiological studies from the population to an individual, from social, economic and natural environmental factors of disease aetiology to behavioural and bio-chemo-physiological factors of disease aetiology, is part and parcel of the shift in the philosophical paradigm from methodological holism to methodological individualism. In medical sociology, the prominent figures included Talcott Parsons, Evert Hughes, Robert Merton and August Hollingshead.

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Masking fears: SARS and the politics of public health in China

This paper examines shifts in attitudes to mask-wearing during and in the aftermath of the outbreak of Severe Acute Respiratory Syndrome (SARS) in the People’s Republic of China (PRC) in 2002–2003. In the PRC, as throughout East Asia, face masks were widely adopted as a practical preventative measure. However, the ubiquitous image of the masked Chinese citizen in both the Chinese and international media also acquired a political resonance. Masks were equated with the Party’s attempts to censure dissent and ‘cover up’ the epidemic. A perceived lack of government transparency, at least in the initial phase of SARS, recalled earlier public health incidents and episodes of public dissension, notably the Tiananmen Square protests of 1989. Drawing on samples of qualitative data from a broad range of Chinese and English language sources, the paper shows how debates about mask-wearing in China during SARS became intertwined with political concerns, reflecting a tension between the Party’s liberalizing policy – epitomized by the country’s admission to membership of the World Trade Organization in December 2001 – and real anxieties about the consequential ‘fall-out’ of this new openness. The paper concludes by arguing for an approach to public health which incorporates a critical capacity, particularly in relation to the ways in which political contexts may determine responses to epidemic episodes.

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Dictionaries

The Cambridge Dictionary of Sociology

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cosmopolitanism p94-95

Historically cosmopolitanism has two related meanings. Firstly, a cosmopolitan is someone who embraces plurality and difference. In this respect, modern cities are often seen as providing the backdrop for the development of cosmopolitan sensibilities in that they house a number of distinctive cultures, ethnic groups, and lifestyles. A cosmopolitan is a polyglot who is able to move comfortably within multiple and diverse communities, while resisting the temptation to search for a purer and less complex identity. Cosmopolitan selves and communities, in this understanding, will thrive when the right to be different is respected. Second, a cosmopolitan is literally a citizen of the world. This refers to a set of perspectives that have sought to jettison viewpoints that are solely determined by the nation, or their geographical standing within the world.

The political philosophy of Immanuel Kant (1724–1804) argued that a cosmopolitan democracy should be developed to replace the law of nations with a genuinely morally binding international law. For Kant the spread of commerce and principles of republicanism could help foster cosmopolitan sentiments. Kant’s vision of a peaceful cosmopolitan order based upon the obligation on states to settle their differences through the court of law has gained a new legitimacy in the twentieth century with the founding of the United Nations and the European Union.

More recently a number of political philosophers have argued that Kant’s earlier vision can be revised to provide a new critical politics for an increasingly global age. A cosmopolitan political response is required where national politics has lost much of its power but little of its influence. Globalization has undermined the operation of national democracies as they are increasingly unable to control the flow of money, refugees, and asylum seekers, viruses, media images, and ideas and perspectives. Many have argued that to begin to address these problems requires the construction of overlapping forms of political community connecting citizens into local, national, regional, and global forms of government. The development of cosmopolitan perspectives is fostered by the growing acceptance that many of the problems that face the world’s citizens cannot be resolved by individual states and are shared problems. The cosmopolitan project seeks to revive democracy in an age where it is increasingly under threat.

There are three main criticisms of these arguments. (1) Such proposals are part of the liberal enterprise of state building and fail to appreciate the power of strategic interests apparent on the global stage. In this understanding, many have been concerned that the United States (the world’s last remaining super power) will refuse, and even try to subvert, cosmopolitan institutions. (2) Cosmopolitan politics is an elite top-down version of politics that will inevitably come to represent the interests of the powerful rather than more “ordinary” or excluded populations. In this respect, some have suggested that we focus upon the emergence of cosmopolitanism from below in respect of nongovernmental organizations (NGOs). (3) Finally, some have been concerned that the two meanings of cosmopolitanism are not compatible with one another. Despite the acceptance of universal human rights, the rule of law, and democracy, many communities remain excluded from participatory forms of democracy. Here there is a concern that universal rules fail to appreciate the difference in people’s identities.

NICK STEVENSON

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epidemiology p170-171

Defined as the study of the patterning and determinants of the incidence and distribution of disease, the discipline of epidemiology is concerned with environmental factors – whether physical, biological, chemical, psychological, or social – that affect health, and also considers the course and outcomes of disease in individuals and in groups. Where social variables are emphasized – the distribution of disease by social circumstances and social class, for instance, rather than more strictly biological aspects of sex, race, or geographical environment – the term social epidemiology is often used.

The formal beginning of the discipline was in the nineteenth century with the work of the pioneers of public health. John Snow (1813–55), in his Report on the Cholera Outbreak in the Parish of St. James, Westminster (1854), famously demonstrated the transmission of cholera through contamination of the London water supply, “cured” by the removal of the handle of the Broad St. pump. The epidemiological approach, comparing rates of disease in subgroups of populations, became increasingly used in the late nineteenth and early twentieth century, applied at first mainly to the investigation and control of communicable disease.

Well-known examples of its nature and successes include assisting in the eradication of smallpox in the world by the l970s. A classical triumph of epidemiology was the conclusive demonstration by Sir Richard Doll (1912–2005) in 1954 of the association between smoking and lung cancer. This classical follow-up study of the mortality of almost 35,000 male British doctors continued to offer results for over fifty years. In 2004 a new report in the Lancet celebrated this milestone in public health by showing that the risks of persistent cigarette smoking were actually greater than previously thought, and about one-half to two-thirds of all persistent smokers would eventually be killed by the habit. It was also shown, however, that quitting at any age, even up to the 60s, gains years of life expectancy.

Epidemiology is essentially a statistical discipline, dealing in rates of disease and mortality, but has always acknowledged multiple and interactive causes of illhealth. Behavior and lifestyle are increasingly held to be important in the causal analysis of population, and epidemiology studies their effects, and also how the control and prevention of problems in both can be more effective.

One of the most recent examples of the contribution of epidemiology has been to the study of the HIV/AIDS epidemic, where it has been vital to trace out the worldwide patterns of spread and control, rates of transmission, and changing outcomes. This health crisis has also been responsible for some coming-together of ethnographic and qualitative sociological methods of enquiry with the more statistical science represented by epidemiology, since unconventional methods were necessary to gain knowledge (of, for instance, drug use, prostitution, and intimate sexual behavior) essential for the modeling of epidemiological statistics and predictions.

Medical sociology in some respects grew out of social epidemiology, and still has close links with it. Some divergence between the disciplines, however, relates to the fact that epidemiological statistics are population statistics and so can say nothing about any individual. How doctors present this to patients, and how lay people interpret at a personal level the statistical facts of epidemiology in the form of rates and probabilities, is a topic of interest in medical sociology, particularly in the currently active fields of genetics and risk.

Environmental epidemiology, an important branch of the discipline, faces contemporary challenges of global change. The study of causal pathways at societal levels is sometimes called eco-epidemiology. Globalization is also relevant in relation to the necessity for global control of pandemic diseases.

MILDRED BLAXTER

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health p261-267

The sociology of health was originally known as medical sociology, emerging as a specialized area in the 1950s. “Sociology of health and illness” is now the preferred term, suggesting a wider canvas than the purely “medical,” though medical sociology is still often used for convenience. Despite its youth – little more than half a century – it rapidly became one of the most important of the subdisciplines of sociology, in terms of numbers of practitioners, volume of research, and specialized journals.

In part, this is because of the recognition by medicinal authorities of the importance of a sociological perspective on health and illness in helping general practitioners to understand better their interaction with patients. The subject is now almost universally taught in medical schools and in the education of nurses and other health professionals.

Originally a distinction was made between sociology in medicine and sociology of medicine. The first described the use of sociology in solving medically defined problems, such as the social distribution of disease (covered by social epidemiology), the self-definition of illness which brought people to seek medical help, and illness behavior. The sociology of medicine is seen as less oriented to the professional interests of medicine, and treats the concepts of health and illness as problematic and constructed. Medicine itself is studied as an institution and practice, and there is concern with the issue of power relations between doctors and patients. The larger term, the sociology of health and illness, defines the concept positively, and includes not only the profession of medicine, but also the whole range of caring occupations and activities, and not only the identification, treatment, and experience of illness, but also health-related lifestyles and health as general well-being.

What is called, in its stereotypical form, the biomedical model has been the basic paradigm of medicine since development of germ theory in the nineteenth century. At the beginning of this modern period, medicine was based almost entirely on the methods and principles of biological science. Four postulates were seen as its basis:

(1) the doctrine of specific etiology, that is the idea that all disease is caused by agents which are at least theoretically identifiable germs, parasites, trauma, bacteria. Ideally, the search is for single causes;

(2) the assumption of generic disease, that is the idea that each disease has its distinguishing features that are universal within the human species;

(3) the model of ill-health as deviation from the normal, with health defined as equilibrium and disease as a disturbance of the body’s functions;

(4) the principle of scientific neutrality, that is, the belief that medicine adopts the values of objectivity and neutrality on the part of the observer, and sees the human organism as the product of biological or psychological processes over which the individual has little control.

The actual practice of medicine, as knowledge advanced and medical institutions became more differentiated and complex, threw up many problems relating to these postulates. In his book Man Adapting (1966), Rene ́ Dubos (1901–82) asked, for instance, why infection does not always produce disease. It was realized that for many diseases there are multiple and interacting causes, rather than single ones. The principle of single causes is more easily applicable to acute conditions and infections than to the chronic diseases that became more important in the twentieth century. The assumption of generic diseases stumbled against the realization that diseases are differently defined in different cultures, and medical definitions are not simply a matter of advancing knowledge but also of professional choice. Dis- eases tend to be those things which, at any given time, medicine is able to treat or wishes to treat. Deviation from the normal, though still a foundation of much medical investigation and categorization, is complicated by the fact that it is often unclear where normal variation ends and abnormality begins. What is defined as the normal range (of body mass index, of lung function, of birth weight, of liver function, of blood pressure, and so on) has to be a choice, even if it is one which is scientifically informed. Finally, scientific neutrality was questioned, since the institution of medicine is always embedded in the larger society and subject to social, political, and cultural pressures.

Residues of these postulates can be found in modern medical practice. However, the advance of science has directed attention to necessary and sufficient rather than single causes, and biomedicine now stresses multiple and interactive causes, including the state of the body’s own defenses. The rise of psychology was influential in altering a purely mechanistic model of illness. The medical model current in medical practice should not be presented as separate or in opposition to the social model of health.

The clearest dissatisfaction with the dominant model offered by biomedicine arose around the mid twentieth century. A mechanistic view of human health, together with the rapid rise in knowledge, had resulted in an ever-increasing use of medical technologies. Dubos described the Mirage of Health (1959), whereby we are led to believe that science can produce a utopia of disease- free life: scientists look only for a “magic bullet.” The American philosopher Ivan Illich (1926–2002), in his Medical Nemesis (1976), argued that medical practice had transformed the human condition of pain, illness, and death and dying into merely a technical problem. As a result, medicine had prevented people from dealing with these threatening circumstances with autonomy and dignity. Medicine had parodoxically created a new kind of “unhealth” (1974, Lancet).

Anton Antonovsky, in Health, Stress and Coping (1979), was influential in pointing out that this means more attention to disease than to health – “We do not ask about the smokers who do not get lung cancer, the drinkers who stay out of accidents, the Type As who do not have coronaries” – and advocated thinking “salutogenically,” that is, focusing on what facilitates health, rather than what causes or prevents disease.

The focus on stressors as causes of ill-health has led to much study of the mechanisms and possible buffers, such as coping resources and social support networks. This literature has shown clearly that social integration is positively linked with mental and physical health and with lower mortality. The most powerful form of support is intimate relationships, and emotional support can provide protection against adverse life events. Most recently this has been associated at the societal or group level with theories of social capital.

The concept of social or holistic health is more than simply the recognition that social factors such as poverty or behaviors have to be included in any model of the causes of ill-health. It locates biological processes within their social context, and considers the person as a whole rather than a series of bodily systems. It is organic rather than mechanistic and reductionist. Human beings are living networks formed by cognitive processes and purposive intentions, depending on the meanings ascribed to bodily phenomena, not simply machines.

The development of the social model has been accompanied, among the public, by a growing enthusiasm for alternative and complementary therapies, which tend to be more holistic. These have also been incorporated to some extent into mainstream medicine. In the social model, health is a positive state of wholeness and well-being, associated with, but not entirely explained by, the absence of disease or mental or physical impairment. The concepts of health and ill-health are not simply opposites.

In 1948 the World Health Organization defined health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity,” and this is generally held to epitomize the social definition of health. This definition has been criticized as difficult to measure and impossible to achieve, and as promoting the medicalization of all aspects of daily life. However, it draws attention to the holistic and socially conscious definition of health which is most favored in contemporary western societies and medical systems.

Whether health is considered negatively, in terms of disease, or positively, in terms of holistic health, it is necessary to distinguish between objective and subjective health. In English-speaking countries it is usual to give different meanings to the words disease, illness, and sickness. Disease is the medically defined pathology. Illness is the subjective experience of ill-health. Sickness is the social role of those defined as diseased or ill.

There are problems about this usage, since not every language has equivalent words, but it has value in emphasizing that these concepts are not the same. People may be ill, that is, feel themselves to have something wrong with them, without (known) disease. In the doctor’s office, the person with an illness may be transformed into a patient with a diagnosis, that is, a disease. It is possible to be subjectively ill or to be medically diagnosed as having a disease without adopting the role of the sick person – that is, without assuming or seeking permission to give up normal roles. People may have a disease, or be injured or functionally incapacitated, without being ill or claiming to be sick. It is very common, in surveys of self-defined health, to find people with severe disability claiming that their health is “excellent.” Moreover, it has been noted that modern medicine produces many liminal states which are neither ill nor well – potentially ill, but at present well, in remission but not cured, at known risk of disease which has not yet developed. A commonly cited epigram is “disease (and trauma) is what doctors treat, illness, is what patients experience.” Though attractive, this is somewhat facile: doctors do treat illness, even in the absence of anything that can be diagnosed as disease, and patients do subjectively perceive and self-define disease.

The distinction between disease, illness and sickness is paralleled by the usage, in the field of disability studies, of the terms impairment, disability, and handicap, as promulgated by the World Health Organization in their “International Classifications” of disabling conditions.

In the early days of medical sociology, the American sociologist David Mechanic, in his Medical Sociology (1968), defined illness behavior as the way in which “symptoms are differentially perceived, evaluated and acted upon (or not acted upon) by different kinds of people and in different social situations.” The concept included, as well as what Irving Zola called the pathway from person to patient, the whole process of seeking help, including the “lay referral system.” Classic work, particularly in the United States, mapped out the way in which groups in society might differ in their responses. The concept became extended to include their perceptions of the illness and its treatment, and their heath-promoting or health-harming lifestyles. Many models, largely variants of the “health belief model” described by Irwin Rosenstock (Health Education Monographs, 1974), were used, especially in health psychology, to formalize the processes by which perceived illness is translated into sickness, and offer explanations of actions taken, or not taken, to promote health.

Certain disease labels carry with them public stereotypes. More generally, in early medical sociology the work of Talcott Parsons, defining illness as a form of deviance which disrupted the social system by interfering with normal role performance, gave rise (particularly in the United States) to a body of theory analyzing illness as deviance. Labeling theory was applied to the secondary deviation resulting from the identification as being ill, especially for particular disease labels such as epilepsy. Thomas J. Scheff, for instance, in Being Mentally Ill (1966), claimed that labeling was the single most important cause of the manifestations of mental illness. The work of Erving Goffman on Stigma (1964) was also very influential. These concepts are still important in disability and impairment and are relevant in specific conditions such as HIV/AIDS.

The psychological models of health beliefs and behavior have, in more recent decades, been criticized as abstracted from social settings, and the term illness behavior has become somewhat outmoded. Studies of the perception and experience of illness, based on phenomenology and the methods of qualitative research, are seen as moving away from the medical model, and turning to the patient’s perspective.

The influence of social constructionism has become strong in the sociology of health, especially in many countries of Europe. It is argued that medical knowledge is produced by and reflects the society in which it is found. What counts as disease or abnormality is not given in the same sense as a biological fact is given, but depends on cultural norms and shared rules of interpretation. It is, as the Polish medical philosopher Ludwik Fleck (1896–1961) suggested, a product of the “thought style” of a particular community of scientists and practitioners. In the version of constructionism most favored in the sociology of health, it is not suggested that diseases and pathogens are not “real,” but that health is, like other human experiences, at the same time a socially constructed category. Much of the understanding of how people act in illness began to come from studies of groups suffering from particular chronic conditions, including especially diabetes, asthma, hypertension, heart disease, and epilepsy. Self-regulation and control, and adjustment to illness within a family and social context, are prominent themes, as is illness as biographical disruption, that is, the place of ill-health in the lifecourse. Interest has increased in the analysis of illness narratives, in which, as Arthur Frank notably described in The Wounded Storyteller (1995), individuals make sense of their experience and create new identities.

The search for meaning, or the answer to what the French social anthropologists Claudine Herzlich and Janine Pierret in Illness and Self in Society (1987) called the “Why me? Why now?” question, became a focus of research. Associated themes are moral discourses of health, lay explanations of disease, and particularly the question of self-responsibility. An earlier, and more specifically psychological, model of attitudes to health as either “internal” (health as the outcome of individual behavior) or “external” (health as the consequence of outside influences or simply chance) has, largely, been abandoned. Contemporary discussion still very much emphasizes the question of agency and structure, however: the debate about the extent to which people can, or feel themselves able to, exercise individuality and free will or are subject to various kinds of constraint. Max Weber had provided a theoretical background for these discussions, distinguishing the two concepts of life conduct and life chances. The interplay of these is a dominant theme because of its practical and political importance in the fields of health promotion and health inequalities.

Relevant to this issue is the popular theme of the commodification of health. This emphasizes the range of dietary, leisure, slimming, and body maintenance and decoration products which modern commerce and culture provide, and the emphasis on the young and fit body as a fashionable ideal. Theorizing health as consumption owes much to Pierre Bourdieu, who extended analysis to the explanation of class and group differences in health behavior. Individual practices are connected to culture and structure, and ultimately to power, through the concept of habitus.

The consultation, as a basic unit of the interaction between health professional and patient, is a topic of particular interest in the sociology of health. A distinction has been made between “doctor-centered” consultations, traditionally paternalistic and controlled by the doctor, and “patient-centered” ones, with greater patient involvement and a more mutual relationship. These, and other suggested models, such as the consumerist relationship which may be applicable in particular circumstances, can be appropriate to different stages and types of illness. Different patient characteristics are also shown to be associated with their willingness to assume a participative role.

Within the earlier and more medical model, there had been many studies of compliance, or whether the patient accepts the doctor’s instructions or takes medication as prescribed. This approach, it was suggested, ignored the lay meanings of medications, and their place in the individual life, and the term adherence began to be preferred, implying a more active, collaborative activity. Non-compliance was demonstrated to be, often, a rational response to experience. Concordance is an alternative term especially popular in primary care, suggesting a course of action agreed upon in negotiation between patient and doctor. Doctors’ communication skills are an important topic in teaching and in research, as are decision-making principles and practice, and the characteristics of health care systems which may affect interaction and the outcome of consultations. The role of patients in decisionmaking about treatment is an active theme in contemporary western health systems, since the right of patients to be involved in making informed choices is an increasingly promulgated value.

At a more theoretical level, the relationship of health to social systems has always been one of sociology’s major interests. Most of the significant differences in health between countries and groups within countries are not biologically inevitable, but bound up with the particular society, its place and time, its politics, administration, and health services. At the same time, the relationship is reciprocal: the health of a population has economic consequences. Health is part of a society’s capital. Two of the most influential founding theorists on the relationship of health and society were E ́mile Durkheim and Parsons, offering “functional” models of society. Durkheim emphasized the importance of societal structures, and norms and processes which were outside the individual but integrated them into the structure. In Suicide (1897 [trans. 1951]) he used the example of rates of suicide, developing a three-fold typology of egoistic, where the individual was detached from society; anomic, due to a state of normlessness; and altruistic, a purposive choice. The prevalence of this very individual act of suicide was shown to be determined by ties to society. The concept of anomie, in particular, proved of lasting importance in theories about health and society.

The American sociologist Parsons, influenced by Durkheim and by Weber, as well as by early psychoanalytic theory, was concerned to explain value consensus, social order, and stability. In the major work The Social System (1951), using the medical profession as a model, he analyzed the needs of the system, expressed in the duties and reciprocal entitlements of both doctor and patient. For the doctor, the pattern variables of universalism, performance, or achievement, rather than ascription, specificity, and affective neutrality, were appropriate. The rights, obligations, and privileges of the sick role described the norms of being a patient. This ideal-type contract was what would, theoretically, identify medicine as functional in maintaining equilibrium in society and maintaining social order.

However, structural functionalism lost influence as a theoretical position in the 1960s and 1970s. The emphasis on consensus seemed to favor the status quo and the domination of the powerful, and the approach was found inadequate in the explanation of change. Social conflict theory, with its roots in Karl Marx, suggested that society was not held together by shared norms and values, but by those imposed by economically powerful groups. Weber added that social differences are based not only on economic factors, but also on status and other forms of influence. Conflict theory turned attention, especially, to the sources of ill-health in the economic environment.

In the later decades of the twentieth century, the power and pre-eminence of medicine as an institution, combined with some disillusion about the actual effects of increasingly high-tech medical science, led to an emphasis on a degree of conflict between the interests of patient and of doctor, and on medicine as an instrument of social control in society. The medicalization of society became a popular topic of medical sociology. A separate strand of theory relates to the relationship of economic development to health. This turns attention from the possibly oppressive effects of the system of medicine to its undoubted positive successes, together with economic development, in prolonging life. Obviously, in the long term, the health of populations increases with economic development: even in the already developed nations, life expectancy at birth usually still increases from one generation to the next. At present, two or three years are added with each decade that passes. The causes include not only improving material standards of living, but also changing disease patterns (especially the relative disappearance of infectious disease), advances of public health and hygiene, and the non-material advances in, for instance, education associated with economic progress. How much is due to the advances of medical science or improvements in health care is disputed. Once a certain state of development has been reached, the proportion of Gross National Product spent on medical care, or the way in which care is organized, does not seem to have any clear association with differences in the longevity of populations.

Expectation of life has been markedly influenced by the steep fall in infant mortality in the developed world, rather than by much extension of life in old age: this fall has now reached a stage where little more is possible. The possibility of treating ever more diseases does, however, alter the health profile of populations. The shift from acute (infectious, commonly fatal) disease to chronic (long-term, to be controlled rather than cured) means that longer life may mean an increase in the actual experience of ill-health. This has an effect on the burden placed on health services.

A corollary of the political and economic view of the relationship of health to social structure is that capitalism necessarily creates inequalities between sections of populations. The minimization or correction of these inequalities is a major concern of western health systems, and inequality in health has been one of the most active areas of research and discussion in medical sociology for some three or four decades.

Obviously, simple equality in health is impossible to achieve in any society: differences associated with genetic inheritance, the geographic environment, or pure chance (and of course age) are part of the human condition. The patterning of inequality shows that the issue is not related only to the extent of economic deprivation, with deficiencies in such things as food, living environments, or medical care. In effect, the term “inequality in health has come to mean a special sort of difference – that difference between individuals or groups which is: socially determined, rather than due to biological factors; felt to be unjust and inequitable, and not the individual’s own responsibility; held not to be inevitable, that is, it could, with current technologies and knowledge, be alleviated.

Thus the concept of equality in western societies is highly constructed and dependent on the progress of science and on ethical positions. It is more than equity of health-service provision, though “equality of provision for equal need” is a common way in which policy tries to find a services-relevant description.

The measures of equality most often used are rates of death or life expectancy. Since life expectancy at, say, age 65 and at birth may be differently patterned, years of healthy life, or potential years of life lost (PYLL) before the age of 70, are measures which can be used. Inequalities may also be measured in absolute terms (simple differences between two groups) or in relative terms (for instance, the ratio of death rates in the lowest social group to those in the highest). The latter may appear to exaggerate inequality if rates are low.

Approaches to the problem of inequality in health vary widely throughout the world. In low-income countries, the causes may clearly be material and the urgent questions may be political and economic ones, including the provision of health care. A strong emphasis on equality of access is also found among some of the wealthiest nations, such as the United States, with largely privatized health services. Countries with large ethnic or indigenous groups may also be particularly concerned with the health care of different races.

In the United Kingdom there has been a tradition of public concern about unequal health ever since the mid nineteenth century, when pioneers such as Edwin Chadwick (1800–90) described the living conditions of the poor and noted their low expectation of life. Concern about inequality remained in the early years of the twentieth century, and was offered as one major justification for the setting up of the National Health Service in 1948, following the Beveridge Report of l942. The rediscovery of inequality was marked by the Report of the United Kingdom Department of Health (known as the Black Report) in 1980, and in the following decades many other countries, especially those of western Europe, took up the issue, and the theme was one of those around which the World Health Organization has based its strategies.

The field has been primarily occupied with understanding why differences linked with socio-economic status arise, persist, and even grow greater. In Europe, it has been usual to rely on occupation-based measures of social class to demonstrate this. In the United Kingdom this classification has been used, sometimes collapsed into the two classes of manual and non-manual, for almost a century, to measure differences by class in mortality rates. Increasingly, however, the classification scheme is seen to have problematic features in modern society, and others are being developed for the purpose of health statistics.

The experience of illness health also varies by social class, though not as strongly or as regularly as mortality. Other dimensions of inequality in health include ethnicity and region. Certain regions within countries show consistent health disadvantages over others, associated with, but in addition to, their economic or social class composition. Everywhere, minority or migrant ethnic groups tend to show higher rates of many sorts of ill-health than the native population.

Two aspects of the statistics on inequality have attracted particular attention in recent decades. One is that, measured by social class and by death rates, inequality appears to be growing in many developed nations. The second issue relates to what is known as the “continuous gradient” or “fine grain” of inequality. The “threshold model,” suggesting that inequality only occurs at a level of deprivation below which health is likely to be affected, does not seem to be correct: there is no sharp discontinuity between the minority who lack the basic needs of life and the majority whose living conditions meet at least minimum standards. Rather, a straight line relationship between socioeconomic status and health is found everywhere.

The main issue of debate in inequality studies is about causality, and especially causes of the apparent increase in inequality in developed countries. The 1980 Black Report in the United Kingdom discussed three types of explanation of real inequalities, if the social class differences were not, as is generally agreed, simply artifacts of statistics and the changing composition of social classes over time. These explanations were: natural and social selection and mobility (the healthy move up the social scale and the unhealthy suffer occupational disadvantage); the lifestyles and health-related habits typical of particular groups (in particular smoking, or general lack of health aware- ness or preventive behavior); the direct materialist effect of living and working conditions.

It is now generally agreed that the types of explanation are interconnected, and each makes a contribution. Simple models stressing only the importance of behavioral patterns, for instance, have to allow for the fact that lifestyles depend on social relationships and the cultures of areas and of groups. Cohort studies, following populations from the day of their birth, have demonstrated in Britain and in other countries how the causes of unequal health begin at birth or even before, and can accumulate through the life-course. A poor start in life, associated with poorer family circumstances and vulnerability to illness, can be reinforced throughout childhood by inadequacies in education and thus lower adult socio-economic success, less healthy behavior, and poorerhealth.

This overview has shown that the sociology of health and illness is multifaceted, ranging from the statistical to the qualitative and philosophical, and from concern with social structures and historical processes to individual experience and social psychology.

Subspecialities flourish, some with their own institutions and journals. Some of the most important topics have been noted, but others include: the sociology of nursing and the professions allied to medicine; social pharmacy; the sociology of mental health; media and cultural studies of medicine and health; community care; death and dying; the sociology of reproductive behavior and the social epidemiology of fertility; health promotion; and health service organization and evaluation.

Discourses of risk are pervasive in health, as in other areas of life. Risk assessment is a key element of public health, and the perception and management of voluntary risks to health, and the relative importance of lifestyle factors and environmentally and socially imposed risks, are central questions of health promotion. Expert and lay concepts of health risk are a topic of particular sociological interest, and Ulrich Beck’s Risk Society (1986) [trans. 1992] has been influential in discussions of attitudes and responses to global ecological, genetic, nuclear, and economic risks to health.

Currently, sociological research and discussion focuses especially on the consequences of the explosive rate of change and development in medical science and technology. Techniques such as microsurgery and nanotechnology (technology at the level of molecules), and new technologies of imaging, change attitudes to the body. It has been argued that the image is becoming privileged over the actual body: simulations have come to constitute reality. Other technologies which are changing the practice of medicine relate to the information revolution. Telemetry (the transfer of measurements at a distance) and telemedicine (distant, or even automated, contact between patient and professional), alter the doctor–patient relationship.

The application of genetics is a very important topic. There is, for instance, much discussion of predictive genetic testing for disease as an ethical issue, how it is perceived by the public, and what changes it may bring to medical practice, family life, and social relationships. Developments in reproductive technology call into question when a new life commences. Technologies such as in-vitro fertilization, cloning, surrogate motherhood or the use of fetuses for genetic therapy raise questions about the family and person-hood. At the end of life, modern techniques of keeping alive, especially in the context of transplant surgery, blur the boundaries between life and death. The replacement of body parts, including xenotransplantation (where animals are bred to carry genes from another species) and stem cell technology (which is capable of supplying transferable tissue), also blur the distinction between the body and not-body and call human identities into question. The integration of machine parts into the body is sometimes called cybermedicine.

MILDRED BLAXTER

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public health p478-481

This term includes the separate notions of a perspective, infra-structure, and philosophy of government. In 1988, the Institute of Medicine in the United States defined public health as “the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort.” This definition reflects the public health thinking behind the World Health Organization’s Alma Ata Declaration of Health for All (1978) and the Ottawa Charter (1986) which were endorsed by the United Kingdom Association of Public Health and the American Public Health Association as well as by many governments.

The public health perspective emphasizes: health rather than medicine; the public good rather than that of the individual; and, prevention rather than intervention after the problem has occurred. Public health efforts are focused on communities at the local, regional, and national levels, emphasizing partnerships among govern- ment agencies, states, municipalities, industry, and non-government organizations. In most coun- tries, public health efforts are conceived and organized under the direction of government ministries of health and delivered by local and regional health authorities. The role of the state is a key variable, because public health problems and interventions are closely linked to the larger political economy of the nation, socioeconomic disparities, poverty, immigration, health care systems, and how the state builds and maintains health infrastructures.

Public health consists of three domains: health protection, health improvement, and health ser- vices. Health protection involves monitoring and oversight of clean air, water, food, infectious diseases, emergency responses to disasters, war and terrorism, radiation, chemicals and poisons, and environmental health hazards. Health im- provement focuses on improving health, reducing inequalities, employment, housing, family and community, education, and lifestyles. Health ser- vices refer to service planning, clinical effective- ness, clinical governance, efficiency, research, audit, and evaluation. The exercise of responsibi- lity in these domains requires a substantial infrastructure, including a trained workforce, knowledge and information, organizations, re- search institutes like the United States Center for Disease Control, facilities to monitor and deliver vaccinations, and testing of air, water, food, and the environment.

The critical functions of the public health system are to assess potential problems, develop policies to address these risks, and institute moni- toring and intervention strategies to assure the health safety of the public. For example, the United Kingdom response to “mad cow” disease, the European attention to genetically engineered crops, and the United States efforts to acknow- ledge and react to the obesity epidemic are in- stances of public health at work in western countries where there are well-established public health infrastructures. In non-western countries, China has struggled with but coordinated a public health plan to deal with SARS (Severe Acute Respiratory Syndrome) and Asian and African countries are struggling with the HIV (Human Immunodeficiency Virus) and the AIDS (Acquired Immunodeficiency Syndrome) epidemic, but often without the resources of richer countries. Public health efforts are also evident on a worldwide level. Because of global warming, inexorable growth in the world population, and increased use of fossil fuels, the world has looming public health problems associated with basic resources like water, clean air, and the food supply. Familiar diseases like tuberculosis have re-emerged in drug-resistant forms and potential scourges like ebola virus and new forms of influenza have emerged to challenge global public health efforts. The World Health Organization usually takes the lead in such initiatives, supported by the World Health Assembly composed of the Ministers of Health of the United Nations member states. The outcomes of these prevention and intervention efforts are measured in terms of numbers of identified cases, morbidity, disability, mortality, and cost to the community or nation. Cost–benefit analyses show how much benefit public-health interventions produce on health and quality of life outcomes per unit cost. Historically, research on the health of nations indicates that public health measures are the most cost-beneficial forms of health interventions. These results are calculated in terms of deaths, morbidity, and dis- ability avoided due to the application of public- health measures. For example, reducing the amount of obesity in a population through educa- tion, changes in nutrition, and exercise will save billions of dollars of lost income and medical care costs due to associated conditions like diabetes, heart disease, cancer, and vision problems. At a basic level, large improvements in the health of a population are realized by just having a clean water supply, sewage disposal system, vaccinations and prophylactic drugs for infectious diseases, and effective health education programs about mater- nal and child health and reproduction.

The response to public health problems is con- tingent on the resources, infrastructures, and pol- itical economic climates of individual nations and communities. Resources are usually measured in terms of amount of money spent per capita on health, the facilities, workforce, equipment, and supplies available for the task. Infrastructures refer to basic transportation and communication systems, the ability to deliver public health inter- ventions when needed, and stable political eco- nomic systems. Political economic systems reflect the values, political organization, and market dy- namics of a country. For instance, the United King- dom is a democracy with a public health system that is closely articulated with the National Health Service. As a result there can be integrated intervention efforts between the two systems to address problems like smoking, alcohol use, road rage, and obesity. In contrast, the United States is a capitalist democracy where public health is or- ganized and delivered through government agen- cies but this system is not well articulated with a patchwork of for-profit and not-for-profit medical care delivery organizations and institutions. In addition, there is a heated debate in the United States around religious values that are expressed in discussions about sex, alcohol, drugs, and the “right to life.” As a consequence, even though the United States has considerable resources, sex edu- cation, use of condoms, clean needle exchange programs for drug injectors, and adolescent preg- nancy cannot be addressed in the United States as they can in the United Kingdom, continental Europe, or Japan. Public health efforts are, then, dependent on local values and circumstances.

There is a strong interplay in theory, methods, research, and applications between sociology and public health. Sociology analyzes the social world in terms of the interaction between individuals, groups, communities, and the larger social, polit- ical, economic, and physical environment. Thus, in methodology, there is considerable interest in considering activity within context through multilevel modeling, mixed models, and network analysis. Public health uses the sociological per- spective in analyzing and pragmatically address- ing problems, dealing with the health of groups and populations. Public health can contribute to sociology through its development of environmen- tal models, focus on translating theory and re- search into practice, use of participative action research, and in research methods such as evalu- ation research and statistics such as Cox regres- sion and mixed models. There is much to be gained by maintaining a close working relation- ship between these two fields.

GARY L. ALBRECHT AND MARK SHERRY

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The Sage Dictionary of Sociology

The Sociologist 2.021.jpeg

EPIDEMIOLOGY p88

The study of the prevalence and distribution of disease and illness in human populations has its origins in a recognition that, although illness presents itself as a characteristic of the sick individual, many diseases are in various ways group properties. Susceptibility to certain illnesses may be a group characteristic. An example of a gender-based ailment is haemophilia (the lack of the clotting agent that prevents excessive bleeding), which can be carried by women but afflicts only their male offspring. An example of a ‘racial’ disease is sickle-cell anaemia which primarily affects people of African origin. In these examples, the group characteristic is biological and genetic but epidemiologists also trace patterns of disease that are in two senses social in origins. First, social properties such as poverty create a dis- position to suffer from certain ailments. Second, the origins of diseases can often by illuminated by working backwards through the social pattern of spread. Obviously the transmission of diseases that pass from one person to another is clearly a social matter and, as in the case of AIDS, the study of pat- terns of spread can be extremely useful in allowing us to understand the causes of some illnesses. But even where the agent is acquired directly from a non-human source, epidemiology can be important in under- standing illness. The discipline’s first great success was of this nature. Dr John Snow mapped the incidence of cholera in an 1854 London outbreak. He showed first that almost all the victims lived closed to a water pump in Broad Street and second that the exceptions could be explained. A large work- house close to the pump had no cases but it had its own well. Two elderly ladies who lived 10 miles away died; it turned out that they liked the taste of the Broad Street water so much they had a large bottle delivered every day. When the handle was removed from the pump, the epidemic subsided.

MEDICAL MODEL p191-192

Since the development of the germ theory of disease in the 19th century, the principal form of explanation in scientific medicine has assumed some or all of the following: all diseases are caused by a specific agent such as a virus, parasite or bac- terium; because illness is a characteristic of the body as a machine rather than of the per- son in a wider social context, the patient is treated as the passive target for medical intervention; and restoring health requires the use of medical technology and advanced procedures.

Although the medical model has been immensely successful, the last quarter of the 20th century saw an increasing demand for more ‘holistic’ approaches to health and ill- ness. In part this demand can be understood in terms of the impersonal nature of many medical encounters and the social gulf that sometimes separates people from medical professionals. In part it is a perverse result of the success of medicine and improvements in diet. As people live longer they come more commonly to experience problems (many cancers and degenerative diseases, for example) about which the medical profession can do little. One of the appeals of alternative or complementary medicine is that its practition- ers claim to treat the entire person rather than just the single presenting symptom. These supposed benefits should not be taken for granted: in reality a Reiki healer who spends only 30 minutes with a stranger is less likely to have a sense of the whole person than the family doctor (if one is lucky enough to have one) who has treated that person’s symptoms for 20 years and kept detailed records. Nonetheless the medical model, like science generally, has an image problem among those drawn to New Age spirituality.

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COMMUNICATION p43

While definitions differ according to the theoretical frame of reference, they all include the following five fundamental elements: an initiator, a recipient, a mode of communication, a message and an effect.

Humans differ from other animals in the vast capacity for communication that language gives. One of the aspects of communication that particularly interests sociologists is the way that modern technologies allow time and space to be transcended. Writing, printing, and such technological forms of communication as the radio, television, telegraph, fax, mobile phone and e-mail all allow easy storage of communicated information and almost instant communication across great distances. The consequences of modern communication are paradoxical. On the one hand, effective com- munication allows effective control and there is much concern about the enhanced powers of the modern state to monitor its citizens through such things as the recording of credit card payments and closed-circuit television monitoring of shopping precincts. On the other hand, the Internet and the mobile phone have been extremely effective in allowing individuals to subvert government attempts at censor- ship and information control. A good example was the 2003 failure of the Chinese government to restrict news of an outbreak of Sudden Acute Respiratory Syndrome (or SARS).

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The Penguin Dictionary of Sociology

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epidemiology

Literally the study of epidemics, this is the study of the causes of the incidence and distribution of diseases and illness in human populations. Epidemiology developed in conjunction with social medicine and public health movements in nineteenth century. It demonstrated in particular how poverty was a major cause of sickness. While the ‘epidemiological revolution’ adequately describes the growth of chronic illness, globalisation has brought about a return of old infectious diseases such as tuberculosis (TB), malaria, and sexually transmitted disease (STDs) and the spread of new ones such as ebola, Marburg virus, Lassa fever, Ross River virus and swine flu. The idea that different diseases had specific geographical niches has been replaced by the notion of global velocity and interconnectedness. The globalisation of flu epidemics is a good illustration. The globalisation fo infectious illness now includes the eruption of new areas such as cholera in Latin America, diseases produced by new technologies such as toxic shock syndrome and Legionnaires’ Disease, and diseases which spring from animals to humans such as SARS.

SEE ALSO: AIDS; sociology of health and illness.

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sociology of health and illness p371-372

This term is often preferred to SOCIOLOGY OF MEDICINE, because it reflects the theoretical interests of sociology rather than the professional interests of medicine. The sociological study of health and illness has the following features: (1) it is critical of MEDICAL MODEL and treats the concepts of health and illness as highly problematic and political; (2) it is concerned with the phenomenology of health and illness and gives special attention to how patients experience and express their distress; (3) it has been significantly influenced by concept if the SICK ROLE but is also critical of this legacy; (4) it argues that modern societies have a residual conception of health, because the medical PROFESSION has been primarily concerned with illness (5) it has been critical of the MEDICALIZATION of social problems. In practice, there is considerable overlap between the sociology of medicine and sociology of health and illness.

SEE ALSO: clinical sociology.

READING: Turner (2004)

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The Blackwell Encyclopedia of Sociology

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Ritzer, G. (Ed.). (2007). The Blackwell encyclopedia of sociology (Vol. 1479). New York, NY, USA: Blackwell Publishing.

AIDS, sociology of p106-111

Susan Kippax and Heather Worth

AIDS or acquired immune deficiency syn drome is caused by a retrovirus identified in 1984, the human immunodeficiency virus (HIV). Twenty years later, it is estimated that over 20 million people have died of AIDS and 40 million people are living with HIV, with 95 percent living in developing countries. The world is facing a global pandemic: a pandemic marked by inequalities of class, gender, race, and sexual preference. The spread of HIV and AIDS is not evenly distributed and prevalence rates range from less than 1 percent of the adult population in much of the developed world to more than 30 percent in some south ern African countries. Some countries in northwestern Europe and Australia have ‘‘local’’ epidemics mainly confined to gay men; some such as Botswana, Namibia, South Africa, and Zimbabwe are experiencing ‘‘gen eralized’’ epidemics where the entire sexually active population is affected; others such as Russia are experiencing an accelerating epi demic initially confined to transmission among injecting drug users but now becoming gen eralized; while still others such as the United States and some countries in South America are experiencing multiple epidemics – among people who inject drugs, among gay men, and increasingly among the poor. In Asia and the Pacific regions the patterning of the epidemic continues to emerge, but there are fears that some countries, such as India, will experience a generalized epidemic.

Globalization has played a central and unique role in both the spread of and the response to the AIDS pandemic, and presents both risks and opportunities for future action. As AIDS has become an intensely globalized problem, a number of pressing issues have come to the fore, not only economic but also political, social, cultural, and security issues. By the mid 1990s serious concerns were being raised about the massive global debt being incurred by developing countries in their fight against HIV and AIDS. While widespread financial and donor support for HIV programs is now available, particularly through the Glo bal Fund for TB, Malaria, and HIV and international donors, the World Bank and the International Monetary Fund were slow to recognize the severity of the economic toll AIDS would exact and thus slow to fund.

Structural adjustment policies, set up as a condition for receiving loans, required that countries adopt austerity programs – including major cuts in health spending. Critics have argued that this helped create the very social and economic conditions and forces that con tributed to the spread of HIV infection in developing countries. There is no doubt that many nations will experience severe economic downturn because of AIDS. In Africa, there has already been a decline in agricultural output and a threat to food security. Ill health means: less time spent on growing crops and more time spent caring for the sick; a concomitant decline in household expenditure on education; a return to rural areas to die, thus adding to the problem of scarce village resources; a dramatic increase in health expenditure; and, as a conse quence of parental deaths, a rapid increase in the number of children orphaned.

While pressure is being exerted by develop ing countries over their right to parallel import and produce their own anti retroviral AIDS drugs under the emergency conditions of the AIDS crisis, the World Trade Organi zation (WTO) TRIPS agreement concerning patent protection to pharmaceutical companies may substantially widen the gap in global access to such therapies. In November 2001 in Doha, the Ministerial Conference of the WTO declared that the TRIPS should be interpreted to support public health and allow for patents to be overridden if required to respond to emergencies such as the AIDS epidemic.

Massive global flows of population (forced and by choice) are an integral part of globali zation and the spread of HIV is implicated in these transient flows of populations. The war in the region of the Horn of Africa in the early 1980s as well as the 1994 war in Rwanda brought into sharp relief the connection between refugees and HIV. The worldwide number of refugees and internally displaced people has been estimated at over 22 million, with an HIV prevalence rate of up to 5 per cent in some countries. Migration for work also renders men and women vulnerable to HIV because of their living and working con ditions – poverty, powerlessness, precarious family situations and separations, and inade quate access to health services.

AIDS is an issue of global governance invol ving various UN agencies, medical establish ments, pharmaceutical companies, researchers, governments, non government and community based organizations. The global politics, policies, and practices of AIDS prevention and support radically affect nationally based health care sys tems and education programs, as well as local grassroots efforts.

HIV PREVENTION

As a blood borne virus, HIV is most com monly transmitted by sexual practice, particu larly penetrative intercourse (vaginal and anal) with an HIV infected person. It is also trans mitted by the sharing of HIV contaminated needles and syringes, from an HIV positive mother to her child during birth and breast feeding, and via the transfusion of infected blood and blood products. The population most affected by HIV is young men and women of reproductive age.

Although in 1996 treatments – in the form of anti retroviral therapy (ART) and fusion inhi bitors that block HIV from entering the body’s immune cells to effectively slow the progres sion from HIV to AIDS to death – were devel oped, there is at present no cure for AIDS or an effective prophylactic vaccine for HIV. Peri natal transmission (sometimes referred to as ‘‘mother to child’’ transmission) can be drama tically reduced by using anti retroviral therapy, while changes in sexual practice and injection drug use can almost completely prevent HIV transmission. These changes in practice include abstinence (from sex and from injecting drug use), the use of condoms for sex, and the use of clean needles and syringes for drug injection.

There is now indisputable evidence that countries which have established needle and syringe programs supplying clean needles and syringes to people who inject drugs have curbed injecting drug related HIV transmission. Embracing this ‘‘harm reduction’’ approach has proved far more effective than abstinence based and related drug supply reduction pro grams, such as the ‘‘war on drugs,’’ and there is little evidence to support the claim that needle and syringe programs promote illegal behaviors.

In countries and regions, for example, in much of Western Europe and in the Uni ted States, Australasia, Thailand, Cambodia, Senegal, and Uganda, where condom promo tion has been successful, there has been a dramatic decline in HIV prevalence. In these countries, the adoption of condoms has proved more effective than abstinence or reliance on monogamy. In other words, ‘‘safe sex’’ (some times ‘‘safer sex’’) rather than no sex has been effective. It is also clear that where there are or were barriers to condom uptake, HIV pre valence rates are high, with some countries exhibiting prevalence levels of 30 to 35 per cent among their sexually active populations.

HIV prevalence rates fall in countries where governments: acknowledge HIV is a virus that affects everyone; are committed to and fund prevention and health promotion including education programs; promote condom use and needle and syringe programs; support social movements by funding at risk commu nities to combat HIV transmission; and pro vide treatment, care, and support to all those living with HIV and AIDS. In the absence of these factors, prevention efforts falter.

Nonetheless, debate continues about the provision of needle and syringe programs and the content of sex and relationship education for the young, some arguing that young peo ple have the right to sex education that recog nizes the central role of condoms in halting HIV transmission, with others claiming that sex education should focus on promoting abstinence. Moral agendas in many countries thwart prevention efforts: some governments claim that sex education promotes sexual activity among the young; others, particularly those with religious affiliations, promote monogamy, which is now acknowledged to be a risk factor – at least for married women.

The conservative policies of some countries, including the United States, and the related advocacy of abstinence and monogamy, have had a profound and, many would claim, nega tive impact on HIV prevention and education programs.

AIDS AND HUMAN RIGHTS

The promotion and protection of human rights constitute an essential component in preventing transmission of HIV and reducing vulnerability to infection and to the impact of HIV/AIDS. Because HIV most affects stig matized and marginalized populations, human rights issues have been central to the response to HIV. Denying the rights of people living with HIV and those most at risk imperils not only their well being, but also life itself. Human rights violations include sexual vio lence and coercion faced by women and girls, stigmatization of men who have sex with men, abuses against sex workers and injecting drug users, refugees, and migrants, lack of access to condoms and harm reduction measures in prisons, and violations of the right of young persons to information on HIV transmission. Human rights violations constitute a major barrier to both prevention efforts and access to treatments and care.

HIV exacerbates the differential power between men and women and the gendered patterns of social and economic dependency. Social structures and the beliefs, customs, and practices that define ‘‘masculine’’ and ‘‘fem inine’’ attributes play a central role in who is vulnerable to infection, and who will receive care, support, or treatment. In the early years of the pandemic men accounted for the major ity of those living with HIV. However, this is changing: to the end of 2004 in Sub Saharan Africa, 57 percent of all adults living with HIV were women.

For men and boys, institutions and struc tures that form societal expectations about gender create social pressure for men to take sexual risks, putting them at risk of HIV. In many countries, men’s labor takes them far from families, increasing their (and their part ners’) vulnerability to HIV. The problems facing men are often overlooked because of their apparent physical and emotional invul nerability. A disregard for their own health and that of their sexual partners puts men in danger. Young men have the greatest number of unprotected sexual acts, are most likely to inject drugs, are most likely to engage in male sex work, and to be the victims of male to male sexual violence. On the other hand, older men may seek very young women as partners and wives because they believe they are less likely to be HIV positive, thus placing young women at increased risk of becoming infected.

Women have less access than men to edu cation and economic resources, which signifi cantly reduces their capacity to fight HIV, but at the same time women are often positioned as vectors of HIV. In some societies, there is a belief that women and girls should be both ignorant about sex and passive during sex. Lack of knowledge of sexual matters is often viewed as a sign of purity and innocence, and prevents young women from seeking informa tion about sex. On the other hand, girls are often pressured by boys to have sex as a proof of love. Data on HIV transmission indicate that in much of Africa and in countries such as India, most married women are infected as a consequence of normal marital sexual rela tions with their husbands. It is estimated that some 60 to 80 percent of African women in steady relationships who become infected with HIV have one sexual partner – their husband or regular partner.

Women’s subordinate place and the empha sis on women’s innocence make it difficult for them to discuss sex and safe sex openly with their partners. Women may also have little control over how, when, and where sex takes place, which considerably constrains their abil ity to insist on safe sex. Further, violence against girls and women, including rape, exacerbates their susceptibility to HIV, and this increases in times of conflict and war.

People living with HIV and AIDS are parti cularly subject to stigmatization and discrimi nation in society, including in the workplace and in access to government services. Funda mental human rights, such as the right to non discrimination, equal protection and equality before the law, privacy, liberty of movement, work, equal access to education, housing, health care, social security, assistance, and welfare, are often violated based on known or presumed HIV/AIDS status. The Commission on Human Rights in 2001 and again in 2002 confirmed that access to AIDS medication is a key component of the right to the highest attainable standard of health, enshrined in the Universal Declaration of Human Rights, the International Covenant on Economic, Social, and Cultural Rights, and the Convention on the Rights of the Child.

On a political level, the response to the AIDS pandemic is hindered by countries which do not recognize freedoms of speech and associa tion, nor the right to information and education by infected and affected groups and by civil society as a whole. Respect, protection, and fulfillment of human rights are central to the AIDS agenda, and equally, HIV/AIDS needs to be at the center of the global human rights agenda.

While some uncertainties remain as to why some countries have a higher prevalence than others, and why some countries have managed to reduce prevalence levels radically, it is evi dent that a successful response to HIV is dependent on a human rights approach that empowers civil society and ensures the com munities have a secure place within the national dialogue. In general, in the developed world and also, in some instances, in the developing world, where a modern public health approach has been adopted, an approach in which com munities encourage and support individuals, understood as rational agents, to reduce harm to themselves and others, and where people have access to prevention education and treat ment, HIV transmission has been slowed. On the other hand, economic and social disadvan tage and civil disruption, and associated mar ginalization and stigma, increase vulnerability to HIV.

HIV TREATMENTS

The issue of human rights is central to treat ment access: all who are infected with HIV have the right to treatment. In the developed world where most people living with HIV have access to these therapies, there has been an 80 percent fall in deaths related to AIDS. In the developing world, however, only approximately 5 percent of those who are infected are currently receiving the most effec tive therapy. Prospects for access to treat ments continue to be thwarted by poverty and global inequalities despite the recent moves for treatment ‘‘access for all’’: the Glo bal Fund’s commitment to buy and distribute cheap generic drugs to poor countries; and the ‘‘3 by 5’’ initiative of the World Health Orga nization (WHO) to provide ART therapy to 3 million people by 2005. To the middle of 2004, only 400,000 of the 3 million had been treated with ART.

The ‘‘3 by 5’’ initiative, although welcomed by many, has placed an additional burden on much of the developing world – the burden to test their populations. There are estimates that between 180 million and 300 million people will need to be HIV tested at least once in order to reach the target of 3 million people on ART. People have been slow to come for ward for testing, however, because of the stigma and discrimination often associated with an HIV positive diagnosis. As a result of the poor response, routine ‘‘opt out’’ test ing is being adopted in countries with high prevalence rates. While some interpret this response as necessary, others are concerned that the pressure to test will undermine human rights and increase stigma and discri mination rather than reduce it.

An added incentive to treatment rollout is the possibility that if treatment uptake is extensive, then ART may also act in a pre ventive fashion. It is yet to be proven whether widespread testing and subsequent uptake of treatment among those who are HIV infected will reduce the population viral load and hence make HIV transmission less likely. In the developed world, high uptake of treatment has not led – at least not initially – to a reduction in HIV transmission. In some coun tries such as the United States and Australia, treatment uptake is related to a relaxation in ‘‘safe sex’’ and an apparent concomitant increase in HIV incidence.

The current push for routine testing and treatment carries with it the risk of downplay ing prevention. In recognition of this problem, some are advocating prevention in the clinic – voluntary counseling and testing have become a site for prevention. While prevention in the clinic may be a useful addendum to health promotion, it is unlikely to succeed alone. What is needed to sustain changes in sexual and drug injection practice is cultural and normative authority, and such authority is best achieved in the social realm. The clinic is by its very nature private, confidential, and indi vidualistic and thus unlikely to provide the appropriate environment for sustained preven tion. More importantly – perhaps most impor tantly – extending testing so as to make it a major prevention tool will give governments the excuse to draw back from HIV, the excuse not to have to deal with and face the complex ities of talking about sex and drugs, the excuse not to train teachers and those in contact with the young, to raise issues in connection with HIV transmission. It will excise the public and collective voice.

The current conservative global climate appears to be producing a flight from ‘‘beha vioral’’ prevention. While it is imperative that the quest continue for a cure to HIV and AIDS and for an effective prophylactic vac cine and other prevention technologies, it is equally vital that such endeavors do not undermine the gains already made. The chal lenge for modern public health is to address the social, cultural, and economic dimensions of health, to address issues of power between and within countries, and to attack discrimina tion and prejudice.

SEE ALSO: Drug Use; Gender, Development and; Globalization, Sexuality and; Health Risk Behavior; HIV/AIDS and Population; Human Rights; Prevention, Intervention; Safer Sex

REFERENCES AND SUGGESTED READINGS

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disasters p1174-1176

Hilary Silver

Disasters are sudden, unexpected, localized, rare, and acute events that disrupt the environment and social structure, and inflict substantial harm on individuals, groups, and property. They differ from accidents in the greater scale of their individual and collective impacts. Roughly speaking, such catastrophes entail over a hundred deaths in a short period of time.

The sociological study of disasters dates to the late 1940s, when governments sought to comprehend the damage of World War II and started planning for potential nuclear holocaust. First at the National Opinion Research Center (NORC) and later at the Disaster Research Center at Ohio State, sociologists drew upon experience from natural disasters. Over time, disaster scholars borrowed from other subfields in the discipline.

The number of disasters has increased, especially since 1990. Ulrich Beck argues that, unlike modern industrial society based upon the distribution of goods, contemporary risk society is founded upon the distribution of dangers. Science and industry are creating more and deadlier risks with impacts less limited in time and space. These physical risks are situated in social systems that aim to control them. How ever, many technically risky activities require society to depend upon and trust inaccessible, unaccountable, and unintelligible organizations and institutions. Scientific realism should be tempered with the viewpoints of ordinary citizens who may be affected by oversights in rational systems. This means modernization must become ‘‘reflexive.’’ These observations hold for most disasters, regardless of cause. For some purposes, however, sociologists classify disasters by type, often distinguishing between natural and technological disasters. Increasingly, political disasters have become a third category of study.

Natural disasters are often viewed as ‘‘acts of God.’’ Yet numerous studies of the social impacts of floods, earthquakes, tornadoes, hurricanes, wildfires, eruptions, famines, plagues, and pandemics demonstrate the importance of social structure and cultural context in deter mining the incidence and outcomes of these events. For example, Mike Davis’s Ecology of Fear (1998) argues that profit driven, sprawling urban development in Southern California without regard to its fragile ecosystem causes any one natural disaster in the area to set off others. John Barry’s Rising Tide (1997) similarly finds that engineering ineptitude and greed of planters and bankers helped cause the great Mississippi flood of 1927. Similarly, Eric Klinenberg’s ‘‘social autopsy’’ of the 1995 Chicago Heat Wave (2003) demonstrates the con tributions of selective government preparations, privatized service delivery, and biased coverage of the local media to the death of over 700 people.

Technological disasters are often attributed to human error or worse. Thus, some say, they produce more enduring and debilitating impacts – anger, fear, uncertainty, stress, and distrust – than natural ones. Sociologists have studied explosions, dam breaks, blackouts, oil and toxic spills, fires, genetic mishaps, mad cow disease, Y2K and computer viruses, and accidents at nuclear power plants, chemical plants, and NASA. Such studies refute the usual risk management response based upon ‘‘high reliability theory’’ which maintains that decentralized authority and built in redundancy enhance reliability and safety.

Vaughan’s study of organizational deviance in The Challenger Launch Decision (1996) identifies risk taking, ignored warnings, and deception trickling down from the top to the bottom of the space agency. In uncertain environments such as agency competition for scarce federal funds, formal organizations like NASA develop technical cultures and bureaucratic and political accountability systems that tolerate mistakes, misconduct, and risk taking for the sake of ultimate goals. Social constructions of reality unnecessarily produce disastrous accidents.

However, Charles Perrow, in Normal Accidents (1999), says social constructionist explanations miss the power structure that devises such risky complex systems in the first place. ‘‘Normal accidents’’ are inevitable in complex (vs. linear) interaction systems with tightly coupled, interdependent components. In such systems, failures multiply and spread in unexpected ways, making rational planning impossible and high reliability approaches even more damaging. Yet such catastrophes, Perrow points out, are rare because they have no one cause. Disasters require a ‘‘negative synergy’’ of combined conditions, from lack of warning to concentrated population.

Webb (2002) notes that sociologists currently know far less about political disasters – riots, revolutions, and terrorism – than about natural and technological ones. Man made disasters are not accidental, but deliberate. Terrorist disasters are designed to inflict as much death and damage as possible on symbolic victims. The sheer arbitrariness of their targets diffuses fear among entire populations, thereby magnifying the disastrous effects. After the World Trade Center catastrophe, the study of urban disasters became a growth industry. Savitch (2001) identifies three factors – social breakdown; resource mobilization; and global target proneness (including international media centrality) – that are responsible for which cities around the world are more vulnerable to terrorist disasters. Nancy Foner’s collection Wounded City (2005) shows there was also variation in the impact of 9/11 among New York City communities. Vale and Campanella (2005) analyze the recovery of a wide range of cities throughout the world. They identify a dozen ‘‘axioms of resilience,’’ including narratives to interpret and remember the disaster and the importance of surviving property.

Whether natural or man made, disasters have many similar social consequences. The majority of property losses in urban disasters are due to housing damage. Disaster victims disproportionately consist of the aged, the isolated, and the destitute. African Americans and renters are also over represented.

Disasters tend to have a life cycle, says Drabek (1986), progressing through the stages of preparedness, response, recovery, and mitigation. Most scholarly attention has focused on the second. There are widespread myths that, in an emergency, the population will panic and loot, and first responders will abandon their posts, requiring a paramilitary, command and control structure to impose order. In fact, during the immediate crisis, studies find that people become more cohesive and converge upon the disaster site, offering help. This ‘‘therapeutic community’’ reaction is more typical in the wake of disaster than conflict, or what Freudenberg (1997) calls ‘‘corrosive community.’’ Established, expanding, extending, and emergent organizations, Dynes (1970) argues, together provide flexible and diverse responses.

Once disasters recede into the past, the political incentives to prepare for future contingencies diminish. Mitigation usually entails tradeoffs between profit and safety, security and civil liberties. Private insurers may withdraw from communities hit by natural catastrophes, forcing the federal government to become the insurer of last resort. Policy continues to be dis aster driven, offering short term compensation rather than long term prevention strategies.

During the recovery stage, there is an opportunity for social change, but it may not be seized. In some cases, community corrosion ensues, prolonged by endless litigation, uncertainty about long term health, organizational competition, and ‘‘recreancy’’ (perceived governmental failure). As Kai Erikson’s Everything in Its Path (1978), a classic study of the Buffalo Creek flood, concludes, the survivors of disasters suffer from both individual and collective trauma. Disasters disrupt the social bonds, net works of relations, and common patterns of life that would otherwise support people. Thus, sociologists are now studying disastermemorials and the social construction of collective memory. Commemorations cement social bonds after a common tragedy.

SEE ALSO: Dangerousness; Ecological Problems; Organizational Deviance; Organizational Failure; Organizational Learning; Risk, Risk Society, Risk Behavior, and Social Problems; Social Structure of Victims

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disease, social causation p1184-1187

Joseph T. Young

Social causation of disease is defined as the origin of illness that results from social conditions and social interactions. This definition assumes that human biological factors are not the sole cause of disease. The definition further assumes that social factors such as socioeconomic status (SES), religion, and social networks have an effect on the level and severity of illness and mortality. The idea that social interaction and culture play parts in the causation of disease has been present in social thought since John Gaunt’s discussion of the interaction between politics and mortality in 1662.

Social causes of disease can be divided into fundamental causes (Link & Phelan 1995) and proximate (or lifestyle) causes. Proximate causes of illness directly produce illness by affecting biological processes and are individually con trolled. For example, diet, smoking, alcohol and drug use, seatbelt use, and exercise behaviors are lifestyle choices that directly affect disease prevalence.

Fundamental causes of disease can be defined as indirect causes of disease that act through specific proximate statuses and behaviors caused by variable access to resources (social capital) that may help people avoid disease, and the negative consequences of disease (Link & Phelan 1995: 81). Social capital is available to an individual through social networks, education, occupation, income and wealth, religious ties, and social power. The amount of social capital avail able to an individual, as well as other social factors, partially determines the severity and type of diseases the individual is afflicted with and may ultimately be more important as causes of disease than proximate causes (Link & Phelan 1995).

Why is the study of social causation of disease important? The obvious answer is that with adequate linkage between the causes of disease, society is able to achieve remedies for the dis ease states and reduce the negative effects of these causes of disease on the individual and society as a whole. Understanding causative factors for disease supports disease prevention, potentially improves health, longevity, and quality of life, informs health policy, improves access to care, and increases the level of health know ledge. Major social causes include occupation, income, gender, education, social networks, health care access availability, institutional causes (such as insurance), diet and nutrition, and stress (event related) and psychological factors.

Biological explanations of disease do not fully explain either the prevalence levels or the severity of disease. Disease is thus multicausal in origin and is manifest from multiple causal path ways. We have moved from attempting to eliminate the causal connection between lifestyle, proximate causes, and disease to looking at the reasons that people have such behaviors that negatively impact their health. Those reasons for negative behavior are uniformly social in nature.

Methods used to delineate social causes of disease must, of necessity, be complex because of the complex nature of the topic and the many interactions between levels of inquiry and factors involved. The methods primarily used are quantitative in nature and involve multilevel regression models of various types. General linear models, hierarchical models, and structural equation models are becoming the norms of inquiry, because the data are layered from individual factors to neighborhood factors and social institutions. These interactions require sophisticated models for accurate description, which makes inquiry in the area of study quite intricate.

The difficulty in delineating social causes of disease (hereinafter fundamental causes, because we shall assume that fundamental causes are more important to disease causation) is thus equally methodologically and theoretically complex. The effects of fundamental causes on dis ease are often indirect, working through more proximate statuses and behaviors, and thus the magnitude of their effect may be difficult to delineate. Methodological problems are com pounded by the bidirectional nature of disease causation and the difficulty in defining the social causes. In other words, a single disease may have multiple causes, acting in concert to produce the resultant disorder and its effects. Further, the causes of the disease may interact with the resultant disease to cause further disease. For example, persons who smoke may have sedentary lifestyles, lower educational status, poorer jobs, more stress, and poorer diets because of less income, which may affect the levels of heart, lung, and kidney disease. If one disease state is present, this may lead to other disease states that synergistically affect the overall health of the individual (such as hypertension leading to renal failure, leading to heart disease and stroke). Indirect and direct causes may combine in a complex of causative factors that may be difficult to untangle, both from a methodological and a theoretical standpoint. Further lost in this decidedly social discussion of disease is the obvious effect of genetics and biology that do play some part in disease causation.

The difficulty in measuring social factors (how do we define a social factor and how do we measure it? what is the direction of causation and its level of effect?) may affect the resultant influence of the social factor on dis ease causation. Factors such as social integration, stress, social support, social capital, and life events must be defined uniformly and systematically in order for meaning to be ascribed to their effects. The measure used to show the effect of social factors on health and disease must be equally precise. For example, mortality as an outcome is relatively precise. We all die, and we all die of something, but that ‘‘some thing’’ may not be a single disease or have a single cause. If we use cure, or worse yet control, in chronic disease states as a measure of outcome, the standard of what is cure and what is control may vary with the research involved. Standards for outcomes are not present in the literature, in many cases, to guide research.

The old dichotomy of causation, direct and indirect causes, seems to be too imprecise to explain social causation of disease. Direct physical causes of disease occur in a social context. Smoking may have social causes. Direct physical harm from injury occurs in a social milieu (e.g., driving too fast without a seatbelt may be the result of low SES, cultural preference, and excess alcohol use because the stress of life is too much to directly confront). All of these factors comprise a complex interplay of causation grounded in the fundamental causes of disease, which are primarily social in nature. The work of McKeown and associates on public health and smoking, and of Dubos (1959) on environmental factors in health and disease, makes a strong case for multifactorial causation of disease. The effect of nutritional deficits due to poor economic status may affect lifelong immunity and susceptibility to disease. To complicate matters, Barker and associates hypothesized that diseases, thought to be chronic and afflicting the more aged of the population, are perhaps genetically programmed before birth through poor nutrition of the mother, to be later expressed by metabolic pathways (e.g., metabolic syndrome leading to heart, vascular, endocrine, and kidney disease) later in life. Fundamental and social causes of disease may therefore have direct and indirect effects as a result of large, and as yet not fully delineated, social contexts of wealth, power, social capital, and social control, which may partially determine the level and severity of disease in the individual. The theoretical underpinnings of the social causation of illness are material, cultural, behavioral, psychosocial, sociopolitical, and longitudinal in nature. The common thread of all the theories is that differences in social factors lead to differences in illness levels and the ability to maintain and regain healthy status (Bartley 2004).

The material or socioeconomic status theory (Kitigawa & Hauser 1973; Kawachi & Kennedy 1997) links levels of illness to income. Income determines behaviors, diet, and type of work done, and is linked to housing quality and environmental determinants of illness as well as stress levels and work related levels of self identity and worth.

The cultural/behavioral theory states that socialized values and norms determine behavior and social identity, which in turn control health behaviors and levels of disease. A subset of behavioral/cultural theory, psychosocial theory (Wilkinson 1996; Elstad 1998), suggests that social status levels, social networks, and bio chemical processes in the body are linked to behavior and thus to levels of illness.

Political economy theory (Lynch 2000) suggests that health and illness differentials are caused by differentials in social power controlled by external political and institutional hierarchies. Finally, life course theory states that events before and after birth affect physical health, the ability to maintain and repair health, and the level of illness through biological and social/ behavioral pathways that change with age and the evolution of social institutions. A unified theory of social causation of illness must contain material, socialization and network, longitudinal and biological, stress and psychological, and behavioral/cultural factors. As yet, all the theories ignore the global aspects of illness causation and the interactions between the various aspects of social causation (Young 2004).

The term ‘‘social causes of disease’’ has been supplanted, first by the term social determinants of disease, and now by a field of study termed ‘‘social epidemiology,’’ which includes the social determinants of health and disease (Kawachi 2002). This subfield of public health, health sociology, and epidemiology has helped to define social policy related to neighborhood improvement, health services access, and socio economic improvements that have decreased disease prevalence and delineated the pathways of social causation of disease.

Future research will depend on the ability of researchers to meet the demands of large, complex longitudinal databases and methodological issues required for adequate analysis of this topic. Certainly, topics extending the idea of the life course perspective will require longitudinal multilevel analysis (Hayward et al. 2000). Other areas of future research should include the relationship of direct causes of dis ease to social causes and social outcomes; the effects of social causation of disease on the developing world and development (Sen 1987); the development of biomarkers and their reliability in linking health to social variables; and GIS techniques for analysis of area effects. We have only scratched the surface of all the environmental effects on illness and health.

Social epidemiology provides an avenue for formal empirical and theoretical research into the multifactorial causes of disease so that social and medical scientists can work together to improve global health and well being.

SEE ALSO: Epidemiology; Illness Experience; Social Capital; Social Capital and Health; Social Epidemiology

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epidemiology p1433-1434

Hung En Sung

Epidemiology is the study of the distribution of disease as well as its determinants and consequences in human populations (Bhopal 2002). It uses statistical methods to answer questions on how much disease there is, what specific factors put individuals at risk, and how severe disease outcomes are in patient populations, in order to inform public health policymaking. The term disease encompasses not only physical or mental illnesses but also behavioral pat terns with negative health consequences, such as substance abuse or violence.

The measurement of disease occurrence begins with the estimation of incidence and prevalence. Disease incidence is the number of new cases in a population within a specific period of time. First ever incidence picks up only first ever onsets; in contrast, episode incidence records all onsets of disease events, including those of recurrent episodes. Cumulative incidence expresses the risk of contracting a disease as the proportion of the population who would experience the onset over a specific time period.

Prevalence is the number of people in a population with a specific disease. Point prevalence counts all diseased individuals at a point in time, whereas period prevalence records those with the disease during a stated time period. Cumulative prevalence includes all those with the disease during their lives or between two specific time points. The nature of the disease itself determines the appropriate choice of measure. For example, for single episode conditions with a clearly defined onset such as chickenpox, first ever and cumulative incidence rates are most useful, but for recur rent conditions with ill defined onsets such as allergy, period and cumulative prevalence rates are most often analyzed.

Population epidemiology attempts to unravel causal mechanisms of disease with a view to prevention. Since most diseases are determined by multiple genetic and environmental factors, exposures to single risk factors are usually neither sufficient nor necessary causes of a disease. Consequently, efforts are devoted to quantify the level of increased risk when exposed to a particular risk factor. Risk is normally measured as either a ratio of the prevalence of disease in two populations or the ratio of the odds of exposure to a particular risk factor between two groups. Clinical epidemiology, in turn, aims at the identification of dis ease outcomes with the goal of controlling the damage done to patients.

The successful application of epidemiological methods to the study of social maladies (e.g., divorce, homicide, drug addiction, etc.) and the emergence of social epidemiology using socio logical constructs (e.g., social inequalities, racial discrimination, sexism, residential segregation, etc.) in the analysis of disease herald an even closer collaboration between epidemiologists and sociologists in the coming years (Berkman & Kawachi 2000).

SEE ALSO: Disease, Social Causation; Gender, Health, and Mortality; Health and Social Class; Health Risk Behavior; Race/Ethnicity, Health, and Mortality; Social Epidemiology

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health and medicine p2067-2072

Jeffrey Michael Clair and Jason Wasserman

Medical sociologists embrace a range of socio logical concerns indigenous to the human condition – cultural, symbolic, personal, social, ecological, and biological. Medical sociology research can help us develop meaningful ways of thinking about the linkages between health and medicine, which involve a multitude of social factors. Health, medicine, and person hood dynamically interact through patient care. But despite this common insight, there is still much we do not know about the personal health and medicine relationship.

HISTORICAL RELATIONSHIP OF SOCIOLOGY TO HEALTH AND MEDICINE

The seed thoughts for a sociology applicable to health and medicine developed in Europe. The origins can be traced back to German physician Rudolf Virchow, who maintained that medicine was a social science and should be used to improve social conditions (Warbasse 1909, 1935; Walsh 1915; Rosen 1947, 1949, 1962, 1979; Ackerknecht 1953; Hyman 1967). Sixty years ago, medical historian Henry Sigerist (1946: 130) advocated the incorporation of a social science perspective into medical school curricula, arguing that ‘‘Social medicine is not so much a technique as rather an attitude and approach to the problems of medicine, one which I have no doubt will some day permeate the entire curriculum. This, however, will require a new type of clinical teacher and new textbooks.’’ While sociologists have remained underrepresented in this new type of clinical role, sociological insights could increasingly benefit medical practice.

While there is a growing awareness that few, if any, patient care decisions are purely medical, the coming together of social and medical perspectives remains elusory (Kleinman et al. 1978; Eisenberg & Kleinman 1981). Often there seems to be little correspondence between the flow of new social knowledge and its application, despite the fact that social insights and data clearly can inform the medical clinician’s view of the problem. However, applicable findings tend to remain on the periphery of medical practice with much sociological evidence thought to be too abstract and uncertain to be helpful (Mechanic & Aiken 1986; Clair & Allman 1993).

Straus’s (1957) dichotomy of sociological work ‘‘in’’ and ‘‘of ’’ medicine characterizes two approaches to medical sociology. Some sociologists have tended to be critical toward applied sociology ‘‘in’’ medicine work. Research design and data collection structured more to serve medical interests have sometimes not been regarded as true sociological work. As a result, training has focused on sociology ‘‘of ’’ medicine and health, where, while still focused on the medical/health arena as a source of data, the overall aim remained committed to contribute to the development of sociological theory.

HEALTH CARE UTILIZATION: HOW PATIENTS APPROACH MEDICINE

Although we know much about the volume and cost of medical care utilization, we still have difficulty explaining cause and variation in health care utilization rates. It is unclear whether service use is based on need or other factors (Cockerham 2005). The relationship between patients’ health and their use of medical services is not necessarily direct, but related to class, race, and all sorts of social variables. Little is known about the decision making process of patients across various social contexts and the ways in which they define a set of health symptoms as requiring medical treatment.

Previous work includes only ‘‘users’’ of health care services when testing health care seeking patterns. This common approach can be seen as inherently problematic because it reduces relevant data and introduces severe sampling bias. It is a fair assumption that those studies focusing on only users of health services are really measuring frequency of use rather than the more generic issue of who is using and not using health services.

The vast majority of somaticized illnesses are managed almost exclusively outside institutionalized biomedical clinics (Kleinman et al. 1978). It is important to understand why large segments of the population are seeking alternative forms of health services. We now know that Americans are embracing complementary and alternative medicine (CAM) more than ever before. Sixty eight percent of the adult population will use CAM at some point in their life (Eisenberg et al. 2001). Other studies consistently find that between 40 and 45 million American adults have used CAM within the previous 12 months (Astin 1998; Harris & Rees 2000). In 1997, Americans spent $27 billion out of pocket on CAM visits, a total dollar amount greater than that spent on conventional care that year (Eisenberg et al. 1998).

This is a phenomenon not limited to the United States. About half the citizens of other industrialized countries also use CAM (Bodeker & Kronenberg 2002). CAM visits are an estimated 49 percent for the French (Fisher & Ward 1994), 48 percent of the Australian population (MacLennan et al. 1996), and the World Health Organization (2003) estimates traditional herbal cures account for 30 to 50 percent of all medicinal consumption in China. If the term alternative medicine is expanded to include traditional (i.e., indigenous) medicine (T/CAM), the figure rises to almost 80 percent in Africa (Bodeker & Kronenberg 2002). Clearly, alternative medicine appears to be asizable current in the medical stream.

We can see, then, that the decision to go to a doctor with an illness is the result of an interpretive process, taking place within the structural parameters of the distribution of available medical services. Factors other than need may be important in health care utilization. To routinely exclude non users (or T/CAM users) from health services utilization analyses is severely problematic.

Explanations of individual determinants of health care utilization are classified into the three major factors of predisposing, enabling, and need (illness) characteristics (Andersen 1968; Andersen & Newman 1973). The model assumes that predisposing, enabling, and ill ness need characteristics determine the use of health services. The predisposing variables represent individuals’ inclinations to seek med ical care. Predisposing characteristics exist prior to the incidence of an illness episode, and include subsets of demographic and social structural variables. An important assumption of this model is that we should observe differ ent patterns of health care utilization among individuals with different demographic and social structural characteristics.

The enabling characteristics reflect persons’ access to social and institutional resources. The two levels of means are distinguished as family and community resources. When sufficient family and community resources exist, such as income and access to available medical care, then individuals needing health services are more likely to seek them out.

The illness need characteristics of health care utilization are the third component in the behavioral model. Even when one is predisposed and able to access medical care services, there must be some perceived (individually assessed) or functional (physician assessed) condition serving as an impetus for health care utilization to occur.

Health care utilization is the outcome component of the behavioral model, and can be classified on a continuum between discretionary and non discretionary use (Andersen 1968). At the discretionary end would be medical care use such as a dental visit. Although oral health care is vital to health and longevity, especially among older adults, dental services still tend to be an individual choice, even among those enabled to use them. The non discretionary end of the continuum represents hospitalization, based on decisions made by physicians. In the middle of the continuum would be physician visits, ranging from initial perceived need directed health care visits to more evaluative, physician directed follow up visits (see Andersen 1968; Andersen & Newman 1973; Wolinsky 1990).

Health and illness behaviors are ultimately influenced by how people think about their health. Individuals who place greater value on health potentially have different utilization pat terns than those who attach less value. Indeed, individuals who have a greater confidence in their own ability to influence their health and those who are somewhat skeptical of the ability or trustworthiness of medical science are less likely to consult professionals.

There are over 40 million Americans with no health insurance. When we look at utilization research on this segment of the population, a variety of explanations are manifest. First, some research found a pattern of underusage by the uninsured, prior to the enactment of Medicare/ Medicaid programs. Explanation for this pat tern suggests that the poor are skeptical of the motives of professional practitioners, lack awareness and knowledge about their symptoms, do not practice preventive care, and tend to delay seeking medical care until symptoms are quite serious. These patterns place the poor at greater risk and result in higher health care costs. This traditional pattern finds the poor underutilizing medical services despite greater need, and attributes underutilization to financial problems, a culture of poverty, and/or systems barriers, both bureaucratic and inter personal (Clair & Allman 1993).

The alternative pattern of health care seeking behavior by uninsured patients finds that this population tends to utilize professional health services to a much greater extent than insured groups. Research by Cockerham (2005) and colleagues in a series of studies in Illinois, Germany, and the Netherlands shows that less educated, low income patients tend not to dis criminate between symptoms on the basis of severity, are more likely to place responsibility for their health on physicians rather than them selves, and are relatively passive recipients of care. When ill, these poor tended to automatically visit physicians, while the more affluent were more likely to engage in self treatment or to recognize minor ailments as self limiting – likely to resolve without treatment. Earlier research in Illinois showed that blacks and the less educated had very positive attitudes about the health care system and believed that visiting doctors was the desirable course of action whenever any symptoms were present.

These two patterns of behavior are clearly influenced by the temporal context of the data. The traditional pattern of non use has tended to be eroded among the poorest poor, those who qualify for Medicaid. Public policy has increased health care access for these groups and research suggests that they now tend to overuse medical care. But the working poor, who do not qualify for Medicaid, but also cannot afford private insurance, may still practice avoidance, thereby underusing medical care. Regard less, a planned intervention could substantially correct for the hypothesized extremes in the care seeking behavior of the lower income population. The most efficacious provision of health care services must be based on communicating successfully with both those patients who delay too long before seeking help and those who arrive too early.

BIOMEDICAL CAREGIVING: HOW MEDICINE APPROACHES PATIENTS Knowledge and practice of medicine, and the experience of illness, reveal key aspects of how social systems of meaning and identity are structured. The study of biomedical caregiving is important because a person’s health is intimately related to social behavior and has pervasive effects on the performance of social roles and matrices of interpersonal relationships.

Evidence on the effect of social support in alleviating life stress is conceptualized largely in terms of informal support from family and friends. However, the effects of formal social support, such as effective physician communication and guidance, also are important. Examining social support at both informal and formal levels provides insight on how the formal social support network affects the ability of the patient and his or her informal care network to deal with the stressful physiological and psychosocial circumstances of an illness. From this perspective, physicians, representing the health care system, can be seen as providing formal support counseling when caring for patients and their network of caregivers.

The life stress paradigm assumes that external stressors such as life events, role strains, and daily hassles, if unchecked, disrupt an individual’s psychosocial equilibrium, induce physio logical or psychological responses in the form of distress, and overall, challenge social resources. The premise is that psychosocial resources both alleviate existing distress and prevent or mitigate its occurrence. In addition to directly reducing distress, psychosocial resources play a primary role in mediating the detrimental effects of physiological and social stressors on the distress of both patients and caregivers (Lin et al. 1986; Clair et al. 1995). The concept of psychosocial resources should include not only personal coping and informal family and friend ship support but also the formal support of professional health care providers.

Research on the mediation effect between life stressors, psychosocial resources, and distress is important. Such a focus can be expressed by the following propositions: (1) the frequency of undesirable life events and the daily pressures for individuals and caregivers are inversely related to social supports and psychological resources; (2) the extent and quality of an individual’s informal and formal social supports and psychological resources are related inversely and directly to the extent of burden; and (3) the extent and quality of an individual’s informal and formal social supports and psychological resources mediate the effects of undesirable life events and the daily pressures on burden.

Satisfaction with physician services, and the facilitation of services that extend beyond the medical mission of the clinic, are mutable conditions. Actions can be taken to improve physician–patient communication, and to expand a medical facility’s domain so that a broader vision of illness and care can reduce burden on patients, family members, and/or primary caregivers.

CURRENT ISSUES AND FUTURE DIRECTIONS

Given a preponderance of health research based on self reported health measures, it would seem advisable for researchers to gain close up, first hand knowledge of issues related to health service utilization by varied subcultural groupings in society, in an effort to determine the extent to which actual health behavior correlates with these self reports. Such studies would then form the basis for generating research questions that are relevant and salient for the populations being studied.

As evidenced by informal health care behavior (e.g., T/CAM), those who utilize formal medical care are not necessarily sicker than those who do not. In fact, these two groups are indistinguishable when one compares the number and type of their symptoms. It would appear, then, that symbolic and cultural definitions of health are quite salient here. Those who manage their illnesses independent of traditional medicine may do so for a variety of reasons, one of which may entail negative experiences with, and reactions to, the idea of seeking traditional medical care. Given the growing rate of both uninsured and underinsured persons, it is not hard to envision access to health care services becoming one of the major policy challenges of this century. Addressing issues of health care behavior and use as related to both access and differing symbolic and cultural meanings of health and illness is among the foremost future challenges for sociology.

How health information is being communicated to patients is another important social issue. Information must be presented in a way that takes into account patients’ knowledge and values. Ignoring patients’ broader social con texts may pose a barrier to adequate health care by creating misunderstandings about recommended treatment and prevention strategies. More importantly, patients may further aggravate their health by failing to adhere to such advice. A fuller understanding of uninsured patients’ health values and beliefs, as well as health care seeking behaviors, could yield appropriate intervention data.

Further, we may expect to see increasing use of home health care services as the ‘‘baby boomer’’ generation ages. Efforts should be made to integrate the care regimen across formal and informal structures. For example, home care should be carefully coordinated with clinic and hospital care through centralizing patient records, with a formal health care provider taking responsibility for closely documenting what treatments and services are provided at both loci. Formal–informal service coordination is especially important for caregivers of function ally impaired patients. Home based formal sup port services may be the critical link to reducing burden, but such services should also enhance informal support services. Formal care providers may have to take responsibilities for what goes on outside the clinic by interjecting them selves into family support systems. For example, a care coordinator from the clinic could call a family meeting to institute a care sharing system among family members. This would reduce burden on the patient, family, and primary care givers. Current drives for universal health care are based on the premise that traditional bio centric medicine must expand its domain to include health promotion and prevention to be effective. Similarly, the scope of services can be broadened to include meaningful assistance to caregivers, because the patient’s welfare and that of his or her caregivers go hand in hand.

Worldwide increases in the proportion of frail elderly raises a number of important questions regarding the motivations, satisfaction, and cop ing abilities of caregivers. Studying caregiver social networks and the appropriate responses to their needs is highly important and locating caregiving theoretically and empirically in a matrix of other roles and experiences adds substantially to our understanding of this critically important activity.

Caregivers are an especially important class of social actors in a society with an aging population, expanding health costs, and growing federal debt. Undoubtedly, individuals will be called on to do more caregiving, rather than less, in the near future. Under such circum stances, it is essential that we understand the caregiver distress process. To accomplish this difficult task, greater effort must be made to ground our knowledge of caregiving in more general psychosocial models of distress and to recognize the substantial impact of informal caregiving networks on patient care. Until this is accomplished, we cannot hope to design successful intervention programs for these critical health care providers. Instead we will remain puzzled as to why such programs have borne little fruit.

Proponents of alternative orientations toward the practice of medicine (and medical sociology) would like to see the emergence of new approaches and broadening conceptualizations of health and medicine, based on both traditional scientific methodology and new ways of knowing. To be sure, ‘‘any evaluation of sociology ought to focus not only on the way sociology is produced, but also on how it is consumed’’ (Merton & Wolfe 1995: 15). Sociology can be at the center of an integrative net work of health and illness. However, by failing to make findings more accessible, sociologists enable health care providers to continue to view social factors as being outside their professional concern. Indeed, disciplinary jargons continue to be major obstacles (Freeman & Levine 1989). It will fall on sociologists to find ways of dealing with differences in our conceptual languages in order to infiltrate medicine and other physical and mental health settings, since invitations are not abundantly forthcoming.

SEE ALSO: Aging and Health Policy; Caregiv ing; Complementary and Alternative Medicine; Health Care Delivery Systems; Health and Culture; Health Locus of Control; Health and Race; Help Seeking; Medical Sociology; Medicine, Sociology of; Social Support; Sociology in Medicine

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health risk behavior p2083-2085

Deborah Lupton

Health risk behavior involves actions and related attitudes and perceptions that contribute to people’s propensity to engage in, or avoid, activities that have been deemed by experts to be hazardous or dangerous to their health. Considerable research in public health and medicine has been devoted to identifying health risks and the behaviors associated with these risks in the attempt to assist people to avoid them.

The juxtaposition of the words ‘‘risk’’ and ‘‘behavior’’ often implies a psychological approach to understanding the processes by which people think about and react to risk. Cognitive science is a major approach within psychology that focuses on risk behaviors, including those related to states of health. From this perspective, people’s behaviors are considered very much on an individual level. Research questions revolve around how people process information about risk and what they then do with this information. The ‘‘objective facts’’ of risk, as identified by scientists, medical researchers, and other experts, are considered the standard by which lay understandings are compared, and often found wanting. An individual’s propensity to make inaccurate judgments about health risks is seen as based, for the most part, on ignorance, deficiency in self efficacy, or biases.

One example of this perspective is the influential health belief model. People are seen as undergoing a series of cognitive steps when processing the possible threat posed by a health risk, presenting a linear relationship between knowledge, attitudes, and eventual practice. According to this model, risk taking is an irrational and deviant act. Little attention is paid to the symbolic and emotional meanings that are associated with risk perception and risk taking. People are represented as atomized and autonomous, largely removed from the influences of society and culture.

Sociological researchers often take a rather different perspective on health risk behaviors and beliefs. They are interested in exploring the ways in which people recognize phenomena as ‘‘health risks,’’ how people identify the relationship between risk and behavior, which kind of risks they consider most threatening, who they see as posing the risks (e.g., are the risks viewed as imposed by outsiders or are they regarded as a product of personal lifestyle choices?), how social and cultural factors such as age, gender, ethnicity, and socioeconomic status influence health beliefs and behaviors, and what kinds of broader social and cultural meanings and beliefs are associated with health risk beliefs and understandings.

Various theoretical and methodological approaches have been taken by sociologists when researching health risk behavior and beliefs. Sociologists drawing on a critical approach based on Marxist or feminist writings focus their attention on the ways in which health risks are closely associated with social disadvantage and inequality. Rather than draw attention to an individual’s personal responsibility for risks, therefore, such researchers emphasize that a person’s social location is a major influence on their exposure to health risks and the opportunities they have to avoid them. People in disadvantaged areas both live in environments which are more conducive to health risk exposure, such as a subculture that supports cigarette smoking and a physical environment that is more polluted, and have less access to sources of knowledge and assistance in avoiding health risks than do those from more privileged backgrounds.

One influential sociologist, Ulrich Beck (1992), has written extensively on what he sees as the move to ‘‘risk society’’ in contemporary western societies. Risk society is characterized by a sensibility which is highly aware of, and concerned about, risks, including health risks. Beck is interested in the reasons why certain phenomena are singled out as ‘‘risks’’ and the political uses this serves. Many health risks, he argues, are seen as the result of human action, of modernizing processes that have gone too far: examples include pollution, chemical con tamination of food, and epidemics of bacterial infections caused by the inappropriate use of antibiotics. Anthony Giddens’s (1991) sociological writings on risk also emphasize these political aspects of risk. He particularly draws attention to lay people’s growing loss of trust in experts, and the subsequent confusion they experience in knowing how best to deal with risks.

Researchers working from a social constructionist perspective are interested in the dis courses, or organized ways of representing phenomena in language and practice, that surround health risks and give meaning to them. This perspective challenges the ‘‘objective facts’’ of risk themselves. Expert risk knowledge is viewed as equally subject to the influence of social and cultural processes as lay knowledge. Taking this perspective is not necessarily to challenge the accuracy of expert knowledge, but rather to emphasize that it is constructed in a social and cultural environment that shapes the knowledge in various ways. What phenomenaare identified as ‘‘health risks,’’ and therefore as hazardous and important for people to avoid, is partly a function of particular social and cultural environments and associated ‘‘ways of seeing,’’ for both lay people and experts. Thus, for example, it may be argued that the current emphasis on the risks associated with over weight and obesity in western countries is influenced by a growing anxiety in the last decades of the twentieth century and into the first years of the twenty first century about the shape and size of the body, not only in relation to health but also to physical attractiveness.

Sociologists are also interested in the ways that discourses about health risks serve to encourage people to view themselves and their bodies in certain ways. Thus, for example, the dominant popular and medical discourses surrounding health risks and cigarette smoking represent the smoker’s body as vulnerable and open to serious illness, cigarette smoke itself as a contaminating substance, and smokers as ignorant or weak willed, not interested enough in their health to give up the practice. Discourses are mutable, subject to change over time. Com pare the positive discourses around cigarette smoking that were evident in the mid twentieth century, which emphasized the glamor and health giving effects of cigarettes, with those described above.

For sociologists, therefore, health risk behavior is not simply an individual’s autonomous response to expert advice. Health risk behavior and the beliefs that accompany it are complex products of socialization and acculturation into certain expectations, assumptions, and norms. Behavior and beliefs are intimately associated with people’s place in society, and are both political and surrounded by cultural meaning.

SEE ALSO: Health Behavior; Health and Culture; Health Lifestyles; Health Locus of Control; Health, Neighborhood Disadvantage; Health and Social Class; Risk, Risk Society, Risk Behavior, and Social Problems; Smoking

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medical sociology p2932-2936

William C. Cockerham

Medical sociology is a subdiscipline of sociology that studies the social causes and consequences of health and illness (Cockerham 2004). Major areas of investigation include the social aspects of health and disease, the social behavior of health care workers and the people who utilize their services, the social functions of health organizations and institutions, the social pat terns of health services, the relationship of health care delivery systems to other social systems, and health policy. What makes medical sociology important is the significant role social factors play in determining the health of individuals, groups, and the larger society. Social conditions and situations not only cause illness, but they also help prevent it.

In recognition of the broad impact of social factors on health, medical sociology is some times referred to as ‘‘health sociology’’ or the ‘‘sociology of health.’’ However, the traditional name ‘‘medical sociology’’ persists because it is preferred by many of its practitioners. Medical sociologists comprise one of the largest groups of sociologists in the world. They have employment opportunities both within and outside of academia. Medical sociologists work not only in university sociology departments, medical, nursing, and public health schools and various other health related professional schools, but also in research organizations and government agencies.

Medical sociology is a relatively new socio logical specialty. It came of age in the late 1940s and early 1950s in an intellectual climate far different from sociology’s traditional specialties. Specialties like theory, social stratification, urbanization, social change, and religion had direct roots to nineteenth century European social thought. These specialties were grounded in classical theory with major works by the sub discipline’s founding figures. However, sociology’s early theorists ignored medicine because it was not an institution shaping society. An exception is Emile Durkheim’s Suicide (1951 [1897)], which is sometimes claimed as the first major work in the field. Medical sociology appeared in strength only in the mid twentieth century as an applied field in which sociologists could produce knowledge useful in medical practice and developing public policy in health matters.

Moreover, physicians, not sociologists, produced much of the earliest literature in medical sociology. In the United States, John Shaw Billings, organizer of the National Library of Medicine and compiler of the Index Medicus, wrote about hygiene and sociology in 1879; Charles McIntire defined medical sociology in 1894; Elizabeth Blackwell, the first woman to graduate from an American medical school, published a collection of essays on medical sociology in 1902, as did James Warbasse in 1909 (Bloom 2002). The most important contribution came from Lawrence Henderson, a physician who taught a sociology course at Harvard in the 1930s. Henderson espoused structural functionalist theory and published a 1935 work on the patient–physician relationship as a social system. Henderson’s most direct influence on medical sociology was through Talcott Parsons, one of his students who became a leading figure in sociology (Bloom 2002). The first sociologist to publish extensively on medical sociology was Bernhard Stern, who wrote historical accounts of the role of medicine in society from the late 1920s until the early 1940s.

Medical sociology evolved as a specialty in sociology in response to funding agencies and policymakers after World War II who viewed it as an applied field that could produce knowledge for use in medical practice, public health campaigns, and health policy formulation. Ample funding for research to help solve the health problems of industrial society and the welfare state in the West during the post World War II era stimulated its growth. In 1949, for example, the Russell Sage Foundation in the United States funded a program to improve the utilization of social science in medical practice that resulted in books on social science and medicine and the role of sociology in public health. Particularly important was the establishment of the National Institute of Mental Health (NIMH) in the United States that funded and promoted cooperative projects between sociologists and physicians. A significant result of such cooperation was the publication in 1958 of Social Class and Mental Illness: A Community Study by August Hollingshead (a sociologist) and Frederick Redlich (a psychiatrist). This landmark study produced important evidence that social factors were correlated with different types of mental disorders and the manner in which people received psychiatric care. The book remains the seminal study of the relationship between mental disorder and social class. This study also played a key role in the debate during the 1960s leading to the establishment of community mental health centers in the United States.

At the beginning of medical sociology’s expansion, many people in the field had tenuous roots in mainstream sociology and an orientation toward applied rather than theoretical work. Some had no training in medical sociology whatsoever. Many had been attracted to the subdiscipline because of the availability of jobs and funding for research. This situation led Robert Straus (1957) to suggest that medical sociology had become divided into two areas: sociology in medicine and sociology of medicine. The sociologist in medicine performed applied research and analysis primarily motivated by a medical problem rather than a sociological problem. Sociologists in medicine typically worked in medical, nursing, public health or similar professional schools, public health agencies, or health organizations like CDC and WHO.

Sociologists of medicine primarily worked in academic sociology departments and engaged in research and analysis of health from a socio logical perspective. The division in orientation created problems in the United States. Medical sociologists in universities were in a stronger position to produce work that satisfied sociologists as good sociology. Sociologists in medical institutions had the advantage of participation in medicine as well as research opportunities unavailable to those outside clinical settings. Disagreement developed between the two groups over whose work was the most important. What resolved this situation over time was a general evolution in medical sociology that saw both applied and theoretical work emerge on the part of medical sociologists in all settings. Medical sociologists in universities responded to funding requests for applied research, while some of their counter parts in medical institutions, like Anselm Strauss, produced important theoretical work.

A related problem in the early development of medical sociology was its potential to become dependent on medicine for its direction and research orientation. However, this did not hap pen, as medical sociologists adopted an independent course and made the practice of medicine one of its major subjects of inquiry, including its core relationships with patients and the organizational structure of health care delivery systems (Bloom 2002). Medical sociologists, in turn, brought their own topics to the study of health such as social stress, health lifestyles, and the social determinants of disease.

TALCOTT PARSONS

A decisive event took place in medical sociology in 1951 that provided a theoretical direction to a formerly applied field. This was the appearance of Parsons’s The Social System. This book, written to explain a complex structural functionalist model of society, contained Parsons’s concept of the sick role. Parsons had become the best known sociologist in the world and having a theorist of his stature provide the first major theory in medical sociology called attention to the young subdiscipline – particularly among academic sociologists. Anything he published attracted interest. Not only was Parsons’s concept of the sick role a distinctly sociological analysis of sickness, but it was widely believed by many sociologists at the time that Parsons was charting a future course for all of sociology through his theoretical approach. This did not happen. Nevertheless, Parsons brought medical sociology intellectual recognition that it needed in its early development by endowing it with theory. Moreover, following Parsons, other leading sociologists of the time such as Robert Merton and Erving Goffman published work in medical sociology that further promoted the academic legitimacy of the field.

THE POST PARSONS ERA

The next major area of research after Parsons developed his sick role concept was medical education. Merton and his colleagues (1957) extended the structural functionalist mode of analysis to the socialization of medical students, with Rene ́e Fox’s paper on training for uncertainty ranking as a major contribution. Four years later, Howard Becker and his associates published Boys in White (1961), a study of medical school socialization conducted from a symbolic interactionist perspective. This study became a sociological classic and was important for both its theoretical and methodological con tent. The techniques in participant observation provided a basis for the seminal work on death and dying and subsequent innovations in theory and methods by Barney Glaser and Anselm Strauss (1965, 1967).

With the introduction of symbolic interaction into a field that had previously been dominated by structural functionalism, medical sociology became a significant arena of debate between two of sociology’s major theoretical schools. This debate helped stimulate a virtual flood of publications in medical sociology in the 1960s. Moreover, the Medical Sociology Section of the American Sociological Association (ASA) was formed in 1959 and grew to become one of the largest and most active ASA sections. American influence was also important in founding Research Committee 15 (Health Sociology) of the International Sociological Association in 1967 (Bloom 2002). The Medical Sociology Group of the British Sociological Association (BSA) was organized in 1964 and became the largest specialty group in the BSA, with its own annual conference.

In 1966 the Journal of Health and Social Behavior, founded in 1960, became an official ASA publication, making medical sociology one of the few sociological subdisciplines publishing its own journal under ASA auspices. In the meantime, in Great Britain, a new journal, Social Science and Medicine, was founded in 1967 and became an especially important journal for medical sociologists throughout the world. The growing literature in medical sociology also led to the publication of textbooks. The first textbook was Norman Hawkins’s Medical Sociology (1958), but the early leaders were the first editions of books by David Mechanic (1968) and Rodney Coe (1970). Howard Free man, Sol Levine, and Leo Reeder likewise made an important contribution by publishing the Handbook of Medical Sociology, which contained summary essays on major topics by leading medical sociologists. The first edition appeared in 1963 and the fifth edition in 2000, edited by Chloe Bird, Peter Conrad, and Allen Fremont.

During the 1960s, the symbolic interactionist perspective temporarily dominated a significant portion of the literature. One feature of this domination was the numerous studies conducted with reference to labeling theory and the mental patient experience. Sociologists expanded their work on mental health to include studies of stigma, stress, families coping with mental disorder, and other areas of practical and theoretical relevance. For example, Goff man’s Asylums (1961), a study of life in a mental hospital, presented his concept of ‘‘total institutions’’ that stands as a significant sociological statement about social life in an externally con trolled environment. An abundant literature emerged at this time that established the sociology of mental disorder as a major subfield within medical sociology (Cockerham 2006).

PERIOD OF MATURITY: 1970–2000

Between 1970 and 2000 medical sociology emerged as a mature sociological subdiscipline. This period was marked by the publication of two especially important books, Eliot Friedson’s Professional Dominance (1970) and Paul Starr’s The Social Transformation of American Medicine (1982). Friedson formulated his influential ‘‘professional dominance’’ theory to account for an unprecedented level of professional control by physicians over health care delivery that was true at the time but no longer exists. Starr’s book won the Pulitzer Prize and countered Friedson’s thesis by examining the decline in status and professional power of the medical profession as large corporate health care delivery systems oriented toward profit effectively entered an unregulated medical market. Donald Light (1993) subsequently used the term ‘‘countervailing power’’ to show how the medical profession was but one of many powerful groups in society – the state, employers, health insurance companies, patients, pharmaceutical and other companies providing medical products – maneuvering to fulfill its interests in health care.

Another major work was Bryan Turner’s Body and Society (1984), which initiated the sociological debate on this topic. Theoretical developments concerning the sociological under standing of the control, use, and phenomenological experience of the body, including emotions, followed. Much of this work has been carried out in Great Britain and features social constructionism as its theoretical foundation. Social constructionism has its origins in the work of the French social theorist Michel Foucault and takes the view that knowledge about the body, health, and illness reflects subjective, historically specific human concerns and is subject to change and reinterpretation. Other areas in which British medical sociologists have excelled include studies of medical practice, emotions, and the experience of illness. Medical sociology also became a major socio logical specialty in Finland, the Netherlands, Germany, Italy, Spain, and Israel, and began to emerge in Russia and Eastern Europe in the 1990s after the collapse of communism. In the meantime, the European Society for Health and Medical Sociology was formed in 1983 and hosts a biannual conference for European medical sociologists. In Japan, the Japanese Society for Medical Sociology was established in 1974 and, since 1990, has published an annual review of work in the field. Elsewhere in Asia, medical sociology is especially active in Singapore, Thailand, and India, and is beginning to appear in China. In Africa, medical sociology is strongest in South Africa. Medical sociology is also an important field in Latin America, and because of its special Latin character, many practitioners prefer to publish their work in books and journals in Mexico, Brazil, Argentina, and Chile (Castro 2000).

From the 1970s through the 1990s, medical sociology flourished as it attracted large numbers of practitioners in both academic and applied settings and sponsored an explosion of publications based upon empirical research. Major areas of investigation included stress, the medicalization of deviance, mental health, inequality and class differences in health, health care utilization, managed care and other organizational changes, AIDS, and women’s health and gender. Several books, edited collections of readings, and textbooks appeared. The leading reader was edited by Peter Conrad and Rochelle Kern in 1981 and is now in a seventh edition (2005), with Conrad the sole editor. The leading textbook was William Cockerham’s Medical Sociology, first published in 1978 and due to appear in a tenth edition in 2007. Another major medical sociology journal, the Sociology of Health and Illness, was started in Britain in 1978, as was a new journal, Health, in 1999.

However, the success of medical sociology also brought problems in the 1980s. Research funding opportunities lessened and the field faced serious competition for existing resources with health economics, health psychology, med ical anthropology, health services research, and public health. Not only did these fields adopt sociological research methods in the forms of social surveys, participation observation, and focus groups, some also employed medical sociologists in large numbers. While these developments were positive in many ways, the distinctiveness of medical sociology as a unique subdiscipline was nevertheless challenged as other fields moved into similar areas of research. Furthermore, some of the medical sociology programs at leading American universities had declined or disappeared over time as practitioners retired or were hired away. Yet the overall situation for medical sociology was positive as the job market remained good, almost all graduate programs in sociology offered a specialization in medical sociology, and sociologists were on the faculties of most medical schools in the United States, Canada, and Western Europe (Bloom 2002).

The 1990s saw medical sociology move closer to its parent discipline of sociology. This was seen in a number of areas, with medical socio logical work appearing more frequently in general sociology journals and the increasing application of sociological theory to the analysis of health problems. The American Journal of Sociology published a special issue on medical sociology in 1992, and papers on health related topics are not unusual in the American Sociological Review. While medical sociology drew closer to sociology, sociology in turn moved closer to medical sociology as the field remains one of the largest and most robust sociological specialties.

THE PRESENT

Ultimately, what allows medical sociology to retain its unique character is (1) its utilization and mastery of sociological theory in the study of health and (2) the sociological perspective that accounts for collective causes and out comes of health problems and issues. No other field is able to bring these skills to health related research and analysis. Today it can be said that medical sociology produces literature intended to inform medicine and policymakers, but research in the field is also grounded in examining health related situations that inform sociology as well. Medical sociology no longer functions as a field whose ties to the mother discipline are tenuous, nor has it evolved as an enterprise subject to medical control. It now works most often with medicine in the form of a partner and, in some cases, an objective critic. Moreover, medical sociology owes more to medicine than to sociology for its origin and initial financial support, so the relationship that has evolved is essentially supportive. As medical sociology continues on its present course, it is likely to emerge as one of sociology’s core specialties as the pursuit of health increasingly becomes important in everyday social life.

SEE ALSO: Goffman, Erving; Health and Medicine; Medical School Socialization; Medical Sociology and Genetics; Medicine, Sociology of; Merton, Robert K.; Parsons, Talcott; Sociology in Medicine

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medicine, sociology of p2941-2942

Carey L. Usher

Sociology of medicine is the sociological investigation of medicine as a subsystem of society. This label is given to the traditional study within medical sociology of the influences social forces have on the sciences, practices, and teachings of medicine, and how these components of medicine, in turn, affect society. Thus, the sociologist of medicine aspires to contribute to the development of sociological knowledge using medicine as a social institution worthy of study in itself. In the pure versus applied dichotomy of the social sciences, the work of the sociologist of medicine represents the academic or pure pursuit of knowledge. The sociologist of medicine is most often positioned outside the medical setting, in contrast to the position of the medical sociologist work ing in collaboration with medical or health organizations. The dichotomy of sociology of medicine and sociology in medicine was formalized by Robert Straus in 1957, in an effort to identify the affiliations and activities of medical sociologists in the United States for creation of a communication network among this newly institutionalized professional group. The distinction is in part based on the structural position of the scholar, on where the basic professional affiliation of the scholar is held. Sociologists of medicine are likely to hold academic appointments in sociology departments.

Early in the institutionalization process of medical sociology, examination of the methodologies, organization, and structure of the medical institution was an obvious avenue of study, due to medicine’s influence over as well as dependence on social forces. Organizational structure, role relationships, value systems, rituals, functions of medicine as a system of behavior, and social components of health and illness have been and still are predominant areas of study for the sociologist of medicine. During the 1950s and 1960s, however, sociology of medicine took a backseat to sociology in medicine. A majority of medical sociologists were involved in the applied side of the new discipline due to increases in research funding and expansion of medical schools, and well over half of the medical sociologists in the United States were positioned within medical or health organizations. Inadequate access to quality resources was a tremendous difficulty faced by sociologists of medicine who were operating from outside medicine rather than within medicine. Sociology of medicine recovered substantially during the Cold War as sociology in medicine’s influence declined dramatically and medical sociologists moved into sociology departments in large numbers.

The sociologist of medicine uses the basic research methods of sociology to generate insights into the properties and patterns of social relationships and social organization of health and medicine. Potential hazards in this pure pursuit of knowledge have, however, been thoroughly documented. Similar to any sociologist involved in scrutiny of organizational systems, a danger faced by sociologists of medicine is a loss of objectivity through identification with the medical organization. Retention of a sociological perspective to serve the basic

interests of the discipline while studying health and medicine has proven difficult. This danger has been combated by the positioning of the sociologist of medicine outside of the medical organization. In a response to this positioning, it is argued that medicine’s failure to respond to the sociological critique may be caused in large part by the failure of sociologists of medicine in becoming more actively involved in the social organization and culture of medicine. Thus, maintaining allegiance to the objective pursuit of knowledge for the sake of sociology has often restricted the voice of sociologists of medicine in potential influences of the medical system. This restriction, however, is experiencing change.

From the 1990s onward, sociologists of medicine have had increasing access to research opportunities within the field of medicine, and emphasis in the parent discipline on applied sociological work has led to some convergence of sociology of and sociology in medicine. Sociology of medicine retains its focus on the organizational and professional structures, roles, values, rituals, and functions of medicine as a subsystem of the social structure, and on the social psychology of health and illness. The acceptance and pursuit of applicable studies in sociology departments is increasingly pushing medical sociology to deliver a sociology with medicine rather than the dichotomous sociologies of and in medicine. A sociology with medicine contributes to a sociological under standing of medicine as a reflection of social life in general, as well as the opportunity to influence medical and health systems with applicable knowledge.

SEE ALSO: Health and Medicine; Medical Sociology; Sociology in Medicine

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prevention, intervention p3618-3620

Franz Xaver Kaufmann

The terms ‘‘prevention’’ and ‘‘intervention’’ are used in many social sciences, from international politics to social work. They concern certain classes of intentional behavior by collective actors which are considered as interfering with given situations. Prevention means measures or actions to reduce potential risks, i.e., to hinder the future happening of certain kinds of damage, e.g., accidents at work, deviant behavior, or the spreading of contagious infections. Intervention, by contrast, means the interference with some actual situation or process in order to change the course of an ongoing problematic event ‘‘to its best.’’ From an analytical perspective, both terms are rather equivalent: prevention in the ordinary sense means an interference in ear lier stages of an assumed causal process than intervention.

Given the pervasive character of both kinds of actions, it is impossible to discuss here their implications with respect to specific fields of action. This is rather an attempt to specify their sociological character as a tool for reflecting on the operation of applied social sciences. Therefore, both terms are used here as concepts of a sociological observer interpreting actions of an actor pursuing defined goals in social situations defined by herself as problematic. The task of social science consists first in working out the implications of that very widespread form of social action. It has then to demonstrate the utility of such an inquiry.

There are three main fields of sociological inquiry related to the subject, namely, research and discourse about social problems, evaluation research, and political governance. For a long time, applied social science took for granted the definitions of social problems by certain (‘‘focal’’) actors themselves and discussed only the means to influence or solve the problem. Meanwhile, the sociology of social problems has worked out the implications and contingencies of processes of the definition of social problems. In order to contribute valid knowledge for action, applied social science has to reflect the multiple perspectives of actors involved in a process of intervention and to reconstruct itself the problem at stake and its issues.

Evaluation research began as the measurement of outputs and moved then to program evaluation. This paradigm supposed a technological understanding of intervention: the program was considered as a causal process introduced by an external authority pursuing certain goals. Evaluation then had to measure program effects, i.e., the changes observed in consequence of the introduction of a program were attributed to the program alone. This causal model of intervention makes sense in a laboratory, where the researcher has control over the whole situation and possesses standardized knowledge about the operation of intervening factors.

This model is not applicable to intervention in real life social situations, as the development of evaluation research has shown (Guba & Lincoln 1989). Compared to, for example, biochemical interventions, the bulk of social interventions are poorly standardized, and their ‘‘technological kernel’’ remains weak. The operator of the intervention cannot be left out side the conceptualization of the intervention process. Social intervention implies focal actors, their aims, resources, and relationships to the field of intervention, not only their action. Social intervention is directly or indirectly a process of interaction between the intervening actor and selective, reacting persons, whose perceptions and interests are mostly unknown to the former. Moreover, the target persons of an intervention live in circumstances and opportunity structures which can never be wholly con trolled or kept constant by the intervening actor. The measurable changes of, for example, the behavior of target persons may be attributed to the intervention or to other changes in their situation.

Research on social intervention becomes therefore a more complicated task than the measurement of program inputs and outputs, the operation of the program remaining a ‘‘black box.’’ The research design has to include:

  1. Relevant properties of the intervening (focal) actors: What is their authority? Their pro blem? How do they define the situation? What are the resources and instruments at their disposal? In short, what are their pro grams or models of problem solution? More over, focal actors are usually not individuals but collective, especially corporate, actors. In the case of corporate actors, a division of labor takes place so that intervention becomes a multistep process coordinating diverse operations, i.e., a process of governance.
  2. Relevant properties of the target persons or addressees: How do they perceive the inten tions of the program? Does it meet their problems? Have they competencies to resist the intervention or to use the operations of the program for other purposes than those intended by the focal actor?
  3. Relevant properties of the field of intervention: What other factors contribute to the situation deemed problematic by the intervening actor? To what extent does the focal actor depend on third parties for affecting her program? Are the target persons isolated or may they interact? Are there in the field institutions shaping opportunity structures which may divert the operation from the aims of the program? To what extent is a program in accordance with value orientations shared by institutions and actors in the field?

Though not every one of these and related questions may find clear cut answers in a research situation, the different approach to an experimental design is evident. Especially in the case of complex multistep interventions (such as the introduction or modification of a policy), this kind of inquiry sensitizes researchers to the pitfalls of naıve quasi technological programming. The aim of intervention research is then not only the evaluation of outputs but also the inquiry into the processes of governance operating a program, as well as into the conditions for its implementation.

Such a program of research is not very promising for generalized knowledge. If each problematic situation and the operation of social intervention is unique, how can professional knowledge emerge? In fact, the results of evaluation research and of implementation research have not thus far proved to be particularly suitable for establishing generalized knowledge.

Professional knowledge is related not to the concept of intervention but to the institutionalized fields of action. For economists, the tools of economic policy are rather well known, and they may even be able to distinguish among the conditions under which such tools are promising. Nevertheless, even the practice of economicpolicy is not a science but an art in the Aristotelian sense. Its success depends on a capacity of diagnosis and a feeling for the peculiarities of a situation. This is even more true for fields of action where the impact of institutional structures and the functions of utility are less clear and where there is less ‘‘technological’’ knowledge available than in the economic field.

‘‘Prevention’’ and ‘‘intervention’’ are useful as sensitizing concepts. They reconstruct political or social action so as to make us aware of their intricacies. To be sure this may not be helpful for quick decisions, but this has never been the task of social science. Applied social science may become useful in this context insofar as the sociologist is involved in the processes of planning and implementing an intervention as a kind of participant observer using tools of sociological observation and continuously providing evidence about the operation of a program. Social interventions are seldom effective without continuous processes of learning.

Though intervention may be openly hostile (e.g., in foreign affairs or in a criminal situation), discourse about social or sociopolitical intervention normally presumes it to be in the primary interest not of the intervening actor but of the ‘‘beneficiaries’’ of the intervention. From a humanistic point of view, this ‘‘reformist’’ cultural orientation merits being taken seriously. The ‘‘goods’’ which may be provided through sociopolitical intervention are of four kinds, and it is possible to organize ‘‘technological’’ knowledge about intervention following these four dimensions of social participation or inclusion:

To be sure, improvements of the situation of socially disadvantaged people need interventions in several or all of the dimensions just mentioned. Prevention intends to ban risks before they become actual. From an action point of view, one may distinguish two kinds of preventive measures: those influencing conditions and opportunity structures in order to minimize the frequency of risk, and those influencing per sons, their resources and competencies, to cope with risky situations. From the actor’s point of view, preventive seems preferable to corrective intervention. From the perspective of a sociological observer, the situation is more complicated, however.

Preventive action presupposes the idea of a coherent chain of events which can be interrupted at various points. One can prevent a risk or damage only if one can control its causes. In the physical world, appropriate knowledge is often available and follows the laws of simple or probable causality. In the social world, such knowledge is – if available at all – incoherent and fuzzy. Normally, several factors, not just one, may influence the emergence of risk with unknown probabilities. The contingency is higher as potential risk is more remote from actual damage. The preventive control of specific factors therefore remains uncertain and may have additional undesirable side effects. Preventive measures thus have to be assessed for alternative consequences. A somewhat general improvement of the situation may often be preferable to targeted measures.

SEE ALSO: Actor Network Theory; Evaluation; Intervention Studies; Knowledge; Political Process Theory; Political Sociology; Risk, Risk Society, Risk Behavior, and Social Problems; Social Integration and Inclusion; Social Policy, Welfare State; Social Problems, Concept and Perspectives; Social Problems, Politics of; Social Work: Theory and Methods

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risk, risk society, risk behavior, and social problems p3934-3940

Alfons Bora

Modern society is undergoing a deep rooted structural change. This change concerns both the internal relations between all parts of society and external relations with nature. During the nineteenth century, the industrial and technological revolution shook up the structures of a society that had been shaped traditionally by crafts and agriculture. In the same dramatic way, the ‘‘second modernity’’ or ‘‘risk society,’’ as Ulrich Beck (1992) calls the period at the end of the second millennium, transforms the nucleus of the industrial society. New technologies confront society with problems that are connected to the term ‘‘risk’’ (Perrow 1987). This is not so much because the quantitative amount of dangerous situations has increased – this amount might have been relatively higher in earlier societies. However, what has significantly changed is the fact that social actors and institutions are being made accountable for those dangers. The new quality of the risk society consists of socially generated risks – or, at least, of the increase in assigning dangers to social behavior. Socially caused dangers will regularly produce more social conflict than inevitable natural dis asters. In this sense, science and technology contain risks for each individual, for social groups, for contemporary society as a whole, and for future generations. The examples for this diagnosis are numerous. One may think of nuclear energy, IT technologies, biotechnology, or nano technologies, for instance. All these technological innovations are embedded in rapid social change, entailing growing individualization, patchwork biographies, significant changes in employment structures and occupational situation, and an accelerating transformation of many established institutions of the welfare state. They make clear that the issue of ‘‘risk’’ is a central category in societal self observation and self description.

RISK AND INFORMATION THEORY

Generally, the risk of a certain event (R(E)) is defined as the probability of a dangerous event (p(E)) multiplied by the amount of the expected damage (D) connected to this event: R(E) 1⁄4 p(E) D. We can call this concept of risk an information theoretical concept. Insurance companies usually work with this approach. Law courts and administrations make use of it when deciding cases. In this conception, risk is a question of complete or incomplete knowledge. Risk management, in this perspective, has the task of dealing with an information problem, namely, the problem of acquiring as much information as possible about probability and damage. Therefore, in the information theoretical perspective, risk management is mainly information management, trying to shift an imaginary border between knowledge and non knowledge. In the best case, this shift will dissolve non knowledge.

The information theoretical approach has historical roots. The idea of risk was born in the emerging seafaring and long distance trade, where shipowners and traders tried to secure their investments by the first insurances calculating probability and estimated damage. Until today, this connection with information is constitutive for the understanding of risk. It also has coined risk research from its early stages (Knight 1921). In addition, newer risk theories are influenced by information theory (Elster 1993).

However, the information theoretical concept brings with it certain problems. One critical issue in many cases is the quantification of possible benefits and damages. What if they are qualitatively different? It is often impossible to compare both sides on the same scale. Often there is no clear indicator for the estimation of the damage. This holds true for ‘‘catastrophic’’ damage, as for instance in the case of a nuclear catastrophe. Therefore, many situations in technological decision making, as well as in everyday life, make it difficult to establish a uniform risk mea sure. The socially contested cases are often those in which, owing to a lack of empirical experience, an exact calculation of probabilities is not feasible. Last but not least, commercial calculations in many cases lie across the risk perceptions of individual actors and of the political public. In summary, the information theoretical risk concept can be said to be closely related to a concept of knowledge that is rather static and which treats the relation between knowledge and non knowledge as a zero sum game. Complementary to this approach, it can therefore be argued from a sociological point of view that new knowledge in every case instantly creates new non knowledge. It is, for epistemological reasons, impossible to eliminate non knowledge. Risk theory can try to take profit from this insight.

RISK AND DECISION THEORY

Risk research has turned its attention toward all forms of social knowledge and non knowledge. From this sociological perspective, the distinction between specific and unspecific nonknowledge (Japp 1997) is of great importance. Specific non knowledge describes the case in which an actor explicitly knows that she lacks knowledge in a certain aspect. Specific non knowledge, therefore, is a reason to start an inquiry and to try to produce new knowledge. It is the characteristic condition of scientific research: we try to expand our knowledge in an area where we still do not have (enough) knowledge. From the point of view of risk research, positively knowing about the existence of our non knowledge is decisive. This form of specific non knowledge has to be sharply distinguished from any kind of unspecific non knowledge. Unspecific non knowledge describes a case of categorical ignorance, a case in which an actor cannot know that she lacks knowledge in a certain aspect. Unspecific non knowledge transcends the barriers of our epistemic capacities in a given moment.

Social forces produce all kinds of damage, danger, and catastrophe. The causes for risk, therefore, are social, and not primarily natural. Under such a condition, the question of causation and accountability gains increasing importance. Consequently, the distinction between the social roles of decision maker and those affected by the decision come increasingly to the center of interest. Accordingly, a growing amount of social protest can be expected from those who are (even potentially) affected by decisions. Insofar as events are understood as consequences of social decisions and not as effects of natural processes, the category of decision becomes relevant for the analysis and understanding of risk. For these reasons, deci sion theory becomes relevant for a sociological analysis of risk.

The central characteristic of a risk decision consists of a situation arising from the need to select between different options, which may all entail negative consequences for third parties and therefore will provoke the issue of res ponsibility (Luhmann 1991). The risk of deci sion making expresses a specific form of what Luhmann calls ‘‘temporal coupling’’ (Zeitbin dung). A decision becomes risky insofar as three aspects are intertwined. These are (1) the knowledge that non decision is impossible; even inactivity contains a decision; (2) the knowledge that unspecific knowledge is unavoidable; this knowledge makes us aware that consequences will appear later that are epistemologically unknown when the decision is taken, and that they will bear negative effects for others; and (3) the knowledge that future consequences will be attributed to the decision and to the decision maker’s responsibility. In the co occurrence of these three aspects, some fundamental dilemmas become apparent. Firstly, we observe the control dilemma that Collingridge (1980) mentioned. The term indicates that at a time when it is still possible to control a new technology, our technological knowledge goes far beyond the knowledge about social factors and consequences. The social effects of a given technology are not visible at the moment of the decision. However, when they are detected, the technology is often very deeply embedded in the social practice, so that it is usually almost impossible to control it. This dilemma clearly points to the temporal structure of decision making. At the same time it leads to a second dilemma, what we call the risk dilemma, which consists of the constitutive connection between the pressure to decide and the impossibility of holding the necessary knowledge. This aspect of uncertainty entails a paradoxical moment, which Clausen and Dombrowsky (1984) called the warning paradox. According to this paradox, warning against possible dangers does not help to decide risky cases. The reason is that we can learn whether the warning was reasonable only if we fail to heed it. If we follow the warning, we will never know whether it was well founded or not.

RISK AS A SOCIAL PROBLEM

The notion of risk, as formulated in the decision theory of risk, is sharply distinguished from the notion of danger. Whether an event will be perceived as risk or as danger mainly depends on the question of whether it can be attributed to the decision in the social dimension. Risk – in contrast to a natural disaster, for instance – is caused by social decisions, and is therefore related to the decision making actor or institution. Danger, on the other hand, relates to those who are affected by the consequences of the decision. This differentiation not only helps to describe the historical trend from danger to risk, it also indicates a change in social attitude toward the future. A greater number of far reaching consequences have to be taken into consideration. Very distant futures are relevant to our contemporary decisions. The effects of acting as well as of not acting are equally complex and uncertain. Modern societies are fundamentally characterized by the difference between decision makers and those affected by their decisions. Every individual may occupy either side of this distinction in various social contexts.

Looking at those affected by a decision and threatened by the danger of a negative consequence, we can see that this side of risk decisions is related to social inequalities. These inequalities can be conceived under the terms inclusion and exclusion. The distinction between inclusion and exclusion describes a very general form of social inequality (Stichweh 2000). This inequality can be realized in different gradual forms and modalities. Social regions of exclusion, which may be highly integrated internally but are characterized by strong differentiation from all central political and legal institutions, usually show a dramatic potential for social dangers. Absence of health care, low levels of edu cation, high rates of criminal victimization, as well as a high level of environmental damage and poor nutrition, are significant indicators for social exclusion. It is in this area that social movements find cause to protest, pointing out the dangers for the excluded that stem from social decisions taken elsewhere. Social communication about risk becomes politicized under these conditions.

RISK THEORIES IN THE SOCIAL SCIENCES

Scientific concern with risk theory reaches from medical epidemiology via mathematics and economic theory to the legal and social sciences. Within the realm of the social sciences, three groups of risk theory can be distinguished. Psychology and cognition theory. Approaches from psychology and cognition theory refer to the difficulties resulting from the dilemma of risk decision. Given that in a fundamental sense we never have sufficient information to make an ex ante assessment of risks, the question rises as to how decision making actors (individuals as well as organizations) empirically arrive at their decision ( Jungermann & Slovic 1993). Psychological risk analysis is interested in analyzing individual and collective attitudes to risk behavior and risk management under given situational conditions. In this respect, it has produced numerous valuable insights into the mechanisms of risk behavior (see, e.g., Jungermann & Slovic 1993). It shows that risks which are undertaken voluntarily are viewed as much more acceptable than those which are not voluntarily assumed. Moreover, the acceptance of a given risk depends on the amount of perceived control over the risk and/or over the source of the risk. Risks from new technologies will usually be estimated as much higher than those from older or ‘‘well known’’ technologies. The fairer the possible consequences seem to be, the lower the risk of a decision will be judged. Risk acceptance in particular depends on the perceived reversibility of the decision.

Cultural theory. Whilst the cognitive approaches are mainly concerned with individual perceptions, cultural theory looks at social groups as the decisive factor. This approach understands risk as a collective social construct (in the sense of an interpretive pattern, or Deu tungsmuster). The particular form of this con struct depends on the properties of the social group in which it occurs. Cultural theory categorizes social groups along two main dimensions, namely, ‘‘group’’ and ‘‘grid’’ (Douglas & Wildavsky 1982; Thompson 1999). Group stands for the external boundaries of a social collective and describes the extent of the group’s differentiation from its social environment. Grid refers to the social distinctions within the group that regulate its internal behavior. By cross tabulation of these two dimensions, four types of social groups (cultures) can be found, each with a specific concept of risk:

  1. Hierarchical culture has high values in both dimensions. It is characterized by high differentiation against the external world and by high internal integration. In this culture, risks are treated as manageable.
  2. Individualistic market culture bears low grid and low group values. It attributes risks to the sphere of individual action frames and generally accepts them as calculable issues.
  3. Egalitarian culture (sometimes also called ‘‘sectarian’’ culture) has low grid and high group values. Usually it is highly risk aversive and very sensitive to every kind of danger.
  4. Fatalist culture is characterized by high grid and low group values. Risks are conceived as imposed by others. They provoke passive reactions rather than active avoidance or risk management.

Based on these differentiations, cultural theory analyzes social categorizations of risk. It explains these categories from the structures of the different risk cultures (for an overview see Thompson 1999). In contrast to psychological theories, cultural theory allows an understand ing of risk as a social (i.e., socially constructed) phenomenon and thus as a social problem.

Systems theory. The new (or autopoietic) sociological systems theory also looks at risk as a social phenomenon. It describes the characteristic features of risky decisions (Luhmann 1991; Japp 2000). Risk is the result of a tension between temporal and issue dimensions. In modern society, the increasing use of risk as a category of social observation and interpretation indicates a change in the relation of society and its environment:

  1. Risk communications show that dangers increasingly are attributed to decisions. This holds true even for phenomena that until recently had been understood as inevitable natural disasters, such as flooding, for example.
  2. The future increasingly becomes a relevant dimension with respect to the legitimation of decisions, and is no longer seen as constitutively incalculable. The issue of risk assessment becomes pervasive for all social systems.
  3. Social differentiation between decision makers and those affected by the consequences of decisions helps to explain why social movements mobilize protest through risk communication and why they politicize decisions with respect to risk.
  4. At the same time, social systems tend to externalize risks and to shift responsibility for risky decisions to other functional systems. This process can be observed, for instance, in the relation between politics, law, and economy (Luhmann 1991).

These three types of social risk theory refer to decision making processes in different aspects. They are distinguished from each other by their central term of reference – individual behavior, rational calculus, group identity, social systems. Thus, they differ from each other with respect to their level of generalization. It is doubtful whether approaches related to individuals and groups can cover the general (sociological) aspects of risk decisions. Nevertheless, they offer highly developed tools for the description of particular strategies in decision making. Systems theory, in contrast, focuses on the general sociological problems of risk decisions.

RISK PERCEPTION, TRUST, AND EXPERTISE

Individual assessment of risk depends on a large number of factors, such as the opportunity for control. Besides the individual perspective, pub lic opinion about risk and risk regulation is of great importance for the understanding of modern society. Public opinion, as numerous studies show, is far from being averse to modern technology in general. This holds true for all countries and regions (Durant et al. 1998; Hampel & Renn 1999; Gaskell & Bauer 2001). With regard to certain issues, such as different applications of biotechnology (e.g., plant biotechnology, human stem cells, to mention two prominent examples), public opinion is ambivalent. How ever, what is more relevant than the attitude toward the technological issue at stake is the fact that public opinion does not depend on the level of information about a particular technology. A common hypothesis contending that more information and enlightenment would raise acceptance (the so called ‘‘deficit hypothesis’’) must be considered inadequate from a sociological point of view. On the contrary, a higher level of education probably leads to a more critical attitude toward risk and technology, as other studies report (Levidow & Marris 2001). Obviously, public opinion is strongly influenced by very general patterns of interpretation and often by a generalized suspicion toward misapplications of any kind. The options for regulat ing risk and technology that modern society provides for are usually estimated as too low or insufficient (Durant et al. 1998; Hampel & Renn 1999). A significant number of people think that the possibility of controlling and regulating risk through the law and legal institutions is inadequate. More than 80 percent say that existing laws are not applied and that surveillance is not strong enough. As a result, political and legal instruments of regulation can be said to be one – if not the – factor for explaining public opinion toward risk: risk perception is a question of trust in institutions. The role of the mass media in this process is important, but not as decisive as might be supposed (Durant et al. 1998; Hampel & Renn 1999). At the European level, for instance, no significant correlation could be observed between media coverage and public perception (Durant et al. 1998).

Historically, the first answer to the perceived weakness of regulatory means has been expertise (control by knowledge, in Max Weber’s formulation). The assumption is that the relevant knowledge for the control of risks can best be produced by scientific expertise. Law and politics have made use of this model from the very beginning of regulatory activities in technology and risk. However, as debates over the last few decades have shown, the expert model is burdened with some serious difficulties. Experts are, for epistemological reasons, not able to eliminate risk. Their status is embedded in what has been called ‘‘mode 2’’ of knowledge production (Gibbons et al. 1994). Mode 2 means that the process of knowledge is not linear but undirected, more like a large reservoir to which many different institutions have an input. Expertise is often contested and uncertain. Society itself becomes a large laboratory, in which ‘‘real world experiments’’ are conducted (Groß et al. 2003). On the other hand, on the basic level of cognition, there is no way out from expertise, because it is only scientific knowledge that aims to deal with our questions about truth and reliable information. No delegitimization of expertise could destroy its basic function for society. One may even speak of an increasing importance of expertise in politics and law (Weingart 1999, 2001).

The crisis of expertise mentioned above has led to an increase in participatory decision making. Participation is usually understood as a form of dialogical process shaping technology and managing possible risks. It can be observed in areas where research, regulation, and public opinion overlap. In most political contexts, participation is a relevant tool for decision making. It is conceptually based on a critique of expertise and on a discourse of ‘‘democratizing expertise’’ (Liberatore & Funtowicz 2003). Participatory procedures, according to a common hypothesis, are more likely to evoke the motivation to engage in decision making, to broaden the basis of knowledge and values involved, to initiate learning processes, to produce new possibilities for conflict resolution, to realize common interests, and to increase acceptance and legitimacy of a decision (Durant 1999; Fischer 1999; Joss & Bellucci 2002). The term ‘‘participatory procedure’’ describes instruments and methods aimed at the inclusion of laypersons and/or stake holders. Scientific expertise is a relevant feature in participatory procedures, but is usually embedded in concepts of deliberation among laypersons and stakeholders. This combination results from the fact that the function of such procedures is to integrate the issue dimension (e.g., information, facts, truth) and the social dimension (e.g., acceptance, trust, legitimacy, values, preferences). With respect to risk deci sions, such procedures represent an important mechanism of risk externalization. The broad inclusion of those people potentially affected by a decision may help to absorb protest. Some one who has participated in the decision making process will find it difficult to blame decision makers for any negative effects.

In addition to the possible advantages of participation, its weaknesses should be considered. Participatory procedures will not develop sufficient commitment from all parties unless they lead to a real win win solution. Participants’ loyalty to their organizational background may even force them to leave the procedure if serious conflicts arise. The functional differentiation of society may create insurmountable barriers to communication. Furthermore, these procedures often provoke questions such as their political representativity, imbalance of power, or lack of political mandate for those involved. One cause of such problems may be seen in their lack of embeddedness in the institutions of representative democracy. Participation, therefore, is a means to cope with risk decisions and their problems. At the same time, it creates new problems.

The regulation of risks challenges science and practice in modern society. The concept of deci sion theory sheds light on the fact that every regulatory approach entails new consequences, which can be found in the realm of unspecific non knowledge. They consequently provoke effects that cannot be known in advance and that will raise serious problems of risk and danger, thereby leading to social protest and conflict. The value of this theoretical approach for political, legal, and scientific practice could lie in its ability to reduce expectations about social capacities for eliminating risk from social life to a realistic amount.

SEE ALSO: Autopoiesis; Benefit and Victimized Zones; Expertise, ‘‘Scientification,’’ and the Authority of Science; Luhmann, Niklas; Reflexive Modernization; Science and the Mea surement of Risk; Science and the Precautionary Principle; Science and Public Participation: The Democratization of Science; Technological Determinism; Technological Innovation; Trust

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social epidemiology p4411-4414

James House

Social epidemiology lies at the intersection between the traditionally biomedical field of epidemiology, which is concerned with under standing the distribution, spread, and determinants of disease in populations, and the parts of sociology and other social sciences concerned with understanding the role of social factors, forces, and processes in the epidemiology of health and illness of individuals and populations (Syme 2001). As a field, social epidemiology has been largely created over the past half century by the combined efforts of persons trained in sociology and related social sciences to study the nature, etiology, and course of physical and mental health and illness in human populations. In some cases, they ended up more as epidemiologists than sociologists (e.g., Leonard Syme and Saxon Graham). There were also a number of pioneering physician epidemiologists, mostly from England and the British Commonwealth (e.g., John Cassel, Michael Marmot, and Mervyn Susser) who recognized the importance of incorporating psychosocial factors into the epidemiology of human health and illness.

The result has been the development and growth of a major new and vibrant interdisciplinary field and the transformation of scientific and popular understanding of the nature of determinants of physical health and illness. From a hegemonic paradigm that, for about a century through the 1950s, viewed physical health as largely a function of biomedical factors, physical health and illness are now under stood by both scientists and lay persons as equally or more a function of social, psychological, and behavioral factors. Early understand ing (e.g,. Freudian) of mental health and illness as being as much or more psychosocial as bio medical in nature, contributed importantly to the development of the social epidemiology of physical health and illness. Mental health epidemiology and treatment, in contrast, have headed in a more biological direction.

The 1950s have been aptly described as the high water mark of the medical profession’s dominance of the health care system and the preeminence of the biomedical paradigm of physical health and illness which had developed out of the great discoveries in bacteriology of the nineteenth century (Mishler 1981). Faith in biomedical science and practice was fueled by a sense of triumph in the development of vaccines, antibiotics, and other prophylactic agents, from antiseptics to pesticides to prevent or treat, and even virtually eradicate, many forms of previously fatal or highly debilitating infectious diseases, capped by the dramatic conquest of polio in the 1950s.

Even then, however, this biomedical dominance was already being challenged by several developments. First, as the prevalence and impact of infectious diseases waned, chronic diseases such as cardiovascular disease and cancer increased to ‘‘epidemic’’ proportions, virtually halting, from the mid 1950s to the early 1970s, the long term increase in life expectancy in Western Europe and the US that had continued almost unabated since the eighteenth century. In contrast to most infectious diseases, the newly epidemic chronic diseases were produced by the interplay of multiple contingent ‘‘risk factors,’’ no one of which was generally either necessary or sufficient to produce disease (House 2002). Initially, these risk factors were biomedical in nature (i.e., blood pressure, cholesterol), but they soon became environmental, behavioral, and psychosocial in nature.

Using methods similar to those used to identify biomedical risk factors, most notably the prospective cohort study, first health behaviors and lifestyles (from smoking to immoderate consumption of food and alcohol to lack of physical activity), then the Type A or coronary prone behavior pattern, and then a broad range of psychosocial factors – social relationships and supports, acute (or life event) and chronic stress, and psychological disposition, such as control/ mastery/self efficacy and anger/hostility – were shown to be consequential risk factors for morbidity and mortality from a wide range of causes (House 2002). Just over 40 years ago cigarette smoking was identified, on the basis of prospective epidemiological studies and laboratory research on animals, as a major risk factor for cancers of the lung and other sites, as well as for cardiovascular disease (DHEW 1964). Within 20 more years, Berkman and Breslow’s (1983) analyses of the Alameda County Study, which Breslow had initiated in the early 1960s, combined with other research to expand the list of behavioral risk factors for health to include not only smoking, but also low levels of physical activity and immoderate levels of drinking alcoholic beverages and of food consumption/ weight. The Alameda County Study also produced the first modern epidemiological evidence that lack of social relationships and support could be as risky as a cause of mortality as cigarette smoking, a finding repeatedly con firmed and generalized over the last two decades (House et al. 1988; Berkman and Glass 2000).

In the seminal decades of the 1960s through the 1980s, the identification by Friedman and Rosenman (1974) of the Type A behavior pat tern and its certification by the National Heart, Lung, and Blood Institute (Review Panel 1981) as a risk factor for coronary artery disease like smoking, high blood pressure, and cholesterol, was of major importance in legitimating social epidemiology in NIH and the broader biomedical arena. Subsequently, dispositional anger and hostility have been identified as the key toxic ingredient of the broader Type A pattern (Smith 2001), and has joined a number of other psychological dispositions such as self efficacy/ mastery/control, optimism/pessimism, and depressive affect as potential consequential risk factors (House 2002).

Parallel to these developments in psychosocial risk factor epidemiology were two others that reinforced the importance of psychosocial factors, and hence social epidemiology, in under standing patterns of individual and especially population health. McKeown (1976) initiated a field of research showing that even the dramatic reduction in infectious diseases and consequent increases in life expectancy of the mid eighteenth to early twentieth centuries occurred prior to, and hence could not be due to, the development of the germ theory of disease or its application in preventive vaccination or pharmacologic therapy. Rather, the bulk of the dramatic growth in human population and life expectancy over the period was attributable to broad patterns of economic development and attendant improvements in public health, nutrition, clothing, housing, and sanitation (Bengtsson 2001). Finally, the development of stress and adaptation theory in physiology (e.g., Cannon and Selye), psychology (e.g., Lazarus), and sociology and related social sciences (e.g., Levine and Scotch), along with subsequent developments in psychoneuroimmunology, provided explanations of how psychosocial risk factors got ‘‘under the skin’’ to cause physical illness and even death (House 2002; Taylor et al. 1997).

By the late 1980s, social epidemiology was increasingly well established within and between the biomedical and social sciences, focusing increasingly on uncovering new psychosocial risk factors and showing how interventions could be used to modify these risk factors and hence improve health. But social epidemiology and psychosocial risk factors to health also came increasingly to share in the problems of biomedical and environmental risk factors epidemiology: tendencies to proliferate disparate and scattered risk factors, each with small to modest effects and often a limited or disputable evidentiary base.

Over the last two decades, psychosocial risk factor epidemiology has come to be overshadowed and also positively transformed by a reemergent social epidemiology of socioeconomic and racial/ethnic disparities in health. The Black Report in England startled many in the early 1980s by showing that despite the operation of the National Health Service for a quarter of a century, occupational class differ ence in mortality and life expectancy had not diminished and had perhaps even increased in England and Wales between the late 1940s and mid 1970s (Black et al. 1982). This finding stimulated similar research and findings and a broader rediscovery of the strength and persistence of socioeconomic and also racial/ ethnic disparities in health in the US, UK, and many other developed and developing countries.

These disparities generally outstripped those due to any single or small set of risk factors, reflecting the powerful tendency for the more health damaging aspects or levels of almost any social, psychological, behavioral, and even bio medical risk factor to be more prevalent among disadvantaged socioeconomic and racial groups, even as the major disease threats to health and risk factors for them varied over historical time and social space. Socioeconomic and racial/ethnic health disparities prior to the mid twentieth century were largely a product of differential exposure and susceptibility to infectious disease due to poorer nutrition, clothing, housing, sanitation, and other conditions of life and work. But as chronic diseases supplanted infectious diseases as the leading causes of morbidity and mortality by the later twentieth century, socio economic and racial/ethnic disparities in health came to be a function of differential experience of and exposure to these diseases and their risk factors. Indeed, over the course of the twentieth century, the increasingly leading cause of death – cardiovascular disease – and the major risk factor for it as well as cancer – cigarette smoking – went from being more prevalent and incident in the advantaged socioeconomic and racial/ethnic groups in the early twentieth century to being more incident and prevalent in less advantaged socioeconomic and racial/ethnic groups by the end of the century. Thus, socioeconomic and racial/ethnic stratification appear to operate as a fundamental cause or determinant of health via their influence on the experience of and exposure to virtually any and all risk factors for health in the past, present, or future (Link & Phelan 1995; House & Williams 2001).

In the first decade of the twenty first century, understanding and hence alleviating socioeconomic and racial disparities in health has been identified as one of the (arguably the) most important goals for public health policy and research, and the most promising avenue for achieving continued improvement in overall population health (DHHS 2000). The most advantaged portions of the human population, both within and across societies, are increasingly approaching the biological limits of life expectancy and health, or what James Fries has termed the ‘‘compression’’ of mortality and morbidity against the biological limits of the human life span. Hence, the greatest opportunities for improving population health lie in bringing the health of the broad lower range of the population in terms of socioeconomic position and race/ethnicity increasingly closer to the biological optimum that the more advantaged are already starting to realize. In the case of the US, reducing socioeconomic and racial/ethnic disparities in health is also the necessary route to reversing the nation’s declining relative position in the world in terms of population health indicators such as life expectancy and infant mortality.

Understanding the processes and mechanisms that generate socioeconomic and racial/ ethnic health disparities and social and economic policy, as much or more than health policy, will be central to alleviating such disparities. The increased focus on such disparities is also essential to developing a more integrative causal theory of the determinants and consequences of psychosocial risk factors for health. Major challenges at this point, both theoretically and methodologically, are (1) to better under stand the causal priorities and interconnections of socioeconomic position (SEP), race/ethnicity, and other major sociodemographic factors such as gender and age, with respect to each other and to health (e.g., how much of the cause flow is from SEP to health or vice versa, or how much of racial/ethnic and differences in health are a function of differences of SEP); (2) to delineate the social, psychological, behavioral, and biomedical processes and pathways linking SEP and race/ethnicity (and also gender and age) to health; and (3) understanding how all these factors and processes are influenced by broader social contexts, forces, and policies. Multilevel, life course, longitudinal studies and methods will be central to all of these goals.

Thus, only a half century from its inception, social epidemiology has become increasingly central to broader health research and policy. All of this represents in many ways merely a reaffirmation, though on a much firmer conceptual, theoretical, and empirical base, of Rudolf Virchow’s mid nineteenth century insight that ‘‘Medicine is a social science, and politics nothing but medicine on a grand scale.’’ Social epidemiological research and theory have come a long way since Virchow, and even from their more modern roots in the mid twentieth century. They will be essential to twenty first century efforts toward understanding and improving individual and population health and reducing social disparities in health.

SEE ALSO: Biosociological Theories; Disease, Social Causation; Health and Social Class; Mental Disorder

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Open Education Sociology Dictionary

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