You will complete 3 Discussion Board Forums throughout this course. Each thread must be at least 350 words, and you must support your assertions with at least 1 citation in current APA format.  In Ch

Chapter 10 Reading

Social Problems

James M. Henslin

Chapter 10 Medical Care: Physical and Mental Illness

Learning Objectives

After reading this chapter, you should be able to:

1. 10.1 Explain what is social about illness. Include lifestyle, iatrogenesis, changing ideas, and the environment.

2. 10.2 Explain why the social organization of medicine is part of a social problem.

3. 10.3 Summarize some of the aspects of physical illness that make it a social problem.

4. 10.4 Summarize some of the aspects of mental illness that make it a social problem.

5. 10.5 Discuss the perspectives that emerge when you apply symbolic interactionism, functionalism, and conflict theory to health, illness, and the practice of medicine.

6. 10.6 Summarize changes in health problems and infectious diseases, the relationship of the environment and disease, and social inequalities in physical and mental illness.

7. 10.7 Summarize social policy regarding medical care.

8. 10.8 Discuss the likely future of medical care as a social problem.

To prepare for the birth of their first child, Kathie Persall and her husband, Hank, read books and articles about childbirth and took childbirth classes together. At 5 o’clock one morning, as Kathie woke from a fitful sleep, the protective “bag of waters” that surrounded her fetus broke.

By 10 a.m., Kathie was in the maternity ward, hooked up to an electronic fetal monitor and an intravenous feeding tube. She was informed of the hospital’s rule that to prevent infection, delivery must take place within 24 hours after the waters break. At 11 a.m., the resident physician (not her own doctor) said that they would speed up Kathie’s labor by using Pitocin, a powerful drug.

The nurse wiggled the bottle, and a large dose of Pitocin sped through Kathie’s veins. Kathie writhed in pain as a massive contraction took over her body.

Kathie’s sister, Carol, knew that inducing labor could lead to cesarean section. She urged Hank to get Kathie off Pitocin, but Kathie and Hank felt that they couldn’t tell the doctor what to do. By evening, the doctor decided that Kathie’s cervix wasn’t dilating rapidly enough, and he increased the Pitocin. A nurse, thinking that the flow of Pitocin looked blocked, wiggled the bottle. A large dose sped through Kathie’s veins. Kathie writhed in pain as a massive contraction took over her body. The fetal monitor set off an alarm, indicating that the baby’s heartbeat had dropped from 160 to 40 beats per minute. The doctor rushed in, cut off the Pitocin, and gave Kathie another drug to stop the contraction. He told Kathie and Hank that a cesarean might be necessary. Hank, who had been trying to comfort Kathie, protested. The doctor told them that they needed to sign a consent form, that they could face an emergency at any time. On the form, Hank and Kathie read a long list of things that could go wrong. They didn’t want to sign the form, but how could they resist? Kathie was in pain and exhausted.

At midnight, the doctor told Kathie that a cesarean was necessary because she had dilated only 5 centimeters in 13 hours of labor. At 1:10 a.m., Kathie went into surgery. When the baby was born, Kathie was vomiting severely from the anesthetic, and she could not even look at her new son. It took Kathie 7 weeks to recover physically from the cesarean surgery. She was left with a disfiguring scar, but this was nothing compared with her anger at the doctors, the hospital, and the medical procedures that had created the need for surgery, denying her and her husband the kind of delivery they had looked forward to.

Earlier we focused on the twin problems of crime and the criminal justice system. As we consider medical care in this chapter, we again need to focus on twin problems, in this case, illness and the medical care system. Our focus will be on how social factors affect health.

The Problem in Sociological Perspective: The Social Nature of Health and Illness

1. 10.1 Explain what is social about illness. Include lifestyle, iatrogenesis, changing ideas, and the environment.

In this chapter, we will focus on the social nature of health and illness and on the medical system as a social problem.

Not Just Biology

Most of us think of illness in biological terms, but there are significant social components as well. For example, what it means to be sick differs from one culture to another, and in a large, pluralistic society like ours, even from one group to another. This may seem strange—isn’t a fever always a sign of illness? Not always. While some take a low-grade fever as a sign of illness, others dismiss it as “just a little temperature.”

Industrialization and Lifestyle

The social nature of health and illness becomes apparent when we consider industrialization and lifestyle. When the United States changed from a farming nation to one where people worked in factories and offices, heart disease became the number one killer. The reason? As industrialization brought higher incomes, people changed their lifestyle. They ate richer foods and weren’t as physically active, which led to more heart attacks. As you know, the pursuit of pleasure is also often a cause of disease. Consider some consequences of unprotected sex—gonorrhea, herpes, syphilis, chlamydia, HIV, and genital warts. Then, too, there are the many diseases that come from smoking, drinking, and doing drugs. The social causes of illness and disease, then, take us far beyond biology.

We define health and illness according to our culture. If almost everyone in a village had this skin disease, the villagers might consider it normal—and those without it the unhealthy ones. I photographed this infant in a jungle village in Orissa, India, so remote that it could be reached only by following a foot path.

Iatrogenesis

I remember a doctor who presented a mistake so reckless and uncaring that I wanted to stand up and throttle him. I didn’t have to. One of my colleagues doled out a much more appropriate punishment: He pulled a newspaper out of his pocket, and began reading the obituary of the recently deceased patient. She was somebody’s mother, she was somebody’s daughter (Gupta 2012). (Used with permission of CBS News Copyright © 2012. All rights reserved.)

This statement was made by a doctor who was upset about iatrogenesis, medical errors that harm patients. You saw a minor example in our opening vignette. When the nurse jiggled Kathie’s bottle of Pitocin, the baby’s heartbeat plummeted, and Kathie and the baby needed emergency care.

You might think that iatrogenesis would be rare. It is not. It is stunningly common—and in many instances it is fatal. Each year, about 400,000 Americans die needlessly at the hands of doctors and nurses (Makary and Daniel 2016). If the number of Americans killed by medical errors were an official classification of death, it would rank as the third leading cause of death (Statistical Abstract 2016:Table 128). In Thinking Critically about Social Problems: How Incompetent Can a Doctor Be?, we examine medial incompetence, another aspect of iatrogenesis.

THINKING CRITICALLY ABOUT SOCIAL PROBLEMS

How Incompetent Can a Doctor Be?

When ultrasound showed that one of the twins had defects, the woman asked her doctor to abort it. He removed the healthy fetus.

Another woman went into the hospital with a problem with her lungs. Her surgeon did a hysterectomy.

Tests showed that a man had a cancerous kidney. The surgeon removed the healthy one.

A man was supposed to have a circumcision. The surgeon removed both of his testicles.

Someone hung the scan backward. The surgeon operated on the wrong side of the patient’s brain.

And then there’s the Oops! moment: In the midst of surgery, the doctor realized that he was removing the wrong leg. But it was too late. He had to complete the amputation.

No, I’m not making these up. These are actual cases (Steinhauer and Fessenden 2001; Seiden and Barach 2006; Childs 2007; Puzic 2010; Gupta 2012). There is also the woman who had the wrong foot amputated, the man who . . . . In fact, some physicians operate on the wrong patient altogether.

To prevent these mistakes, maybe surgeons should put a mark on the patient’s body where the incision is to be made. Using indelible ink, both patient and doctor could sign their names at that spot. Before the surgeon makes an incision, he or she can check the signatures.

This suggestion may sound facetious, but you should know that it isn’t. Nor is it just an idea. Mistakes are so flagrant that some hospitals have the doctor and patient mark the spot and sign it.

I once had such confidence in the medical profession (the tough entrance requirements for medical school, the years of study, the supervision and evaluations) that I didn’t think there were incompetent doctors. Some weren’t as good as others, to be sure, but they weren’t incompetent. Then on a postdoctoral fellowship I studied suicide in Missouri. As I pored over the coroner’s records, I was awestruck when I saw a doctor’s decision that a person who had been shot several times might have committed suicide. Later, I read about a father in Warren, Ohio, who was convinced that his 20-year-old daughter, who was found dead in a field, had not committed suicide. For 17 years, this man kept the case alive. As he doggedly pursued the issue, it eventually became apparent that the coroner had missed “obvious” clues—like “suspicious marks” on her neck. The woman’s former boyfriend was charged with strangling her.

When this case became public, the sheriff investigated the coroner. Over the years, the coroner had made these strange decisions:

• Suicide—the man had been run over with a bulldozer and shot

• Suicide—an inmate was found hanged on his knees with toilet paper stuffed in his mouth

• Death by carbon monoxide from a lawn mower—the lawn mower didn’t work

• Death by carbon monoxide—no carbon monoxide was found in the person’s blood

This coroner had served as president of the Ohio State Medical Association three years before his exposure.

Makes you wonder, doesn’t it?

Changing Ideas about Health and Illness

Physicians’ involvement in pregnancy also highlights the social nature of health and illness. Physicians have defined a natural process (pregnancy and birth) as a medical problem, one that requires fetal monitors, powerful drugs, and medical supervision. As in our opening vignette, many doctors define a woman as “ill” if she does not deliver a baby within 24 hours after her water breaks. This is an arbitrary definition of “illness.” It has been imposed on a natural process in which some women deliver a baby an hour after their water breaks, but others not for 48 hours or longer.

That the meaning of “symptoms” can change is another indication of the social nature of “disease.” Coal mining provides an excellent example. Longtime miners used to complain to doctors that they were short of breath and that they were coughing up blood. The doctors said that these weren’t signs of a disease. They were things that “just happened” to coal workers. To get their definition accepted, the miners had to fight the medical establishment. They did succeed, and the miners’ struggle to get their disease recognized led to a new understanding of how the environment can cause ­illness (Smith 1987).

The “new” disease, progressive massive fibrosis (black lung disease), turned out to be preventable. Safety measures were put into effect, and this disease among coal miners became uncommon. Now, however, with more powerful machines churning up more coal dust, the rate of disease is again increasing (Gibson 2016).

Environment and Disease on a Global Level

Medical researchers investigate how the environment affects disease. They look at how human activities reshape the environment, which in turn has profound effects on the diseases that humans experience. We explore this topic in A Global Glimpse: Solving Medical Mysteries: Cholera, Bats, and Ticks.

A Global Glimpse

Solving Medical Mysteries: Cholera, Bats, and Ticks

Back in the 1800s, fear stalked the city of London. An outbreak of deadly cholera had hit the city. There was no cure, and no one knew where this silent killer would strike next. Londoners, healthy one day, were dead a day or two later. The disease hit men and women, the elderly and the young. The public and authorities were alarmed, and London physicians were left perplexed. Nothing made sense.

John Snow, a physician, came up with a new idea. Taking a city map, he marked where each victim had lived. He saw that the marks were clustered around certain city wells. Snow speculated that some wells were contaminated, and that if they were shut down, the epidemic would end. To find out, he removed the pump handle from one well in an area where 500 people had died in just the previous 10 days (Cooper 2002; Lloyd 2006). The cholera was stopped in its tracks, defeated not by medicine but by medical investigation.

You can see how tracking the social causes of disease can be significant for human health and why it is an essential aspect of medicine. Medical mysteries like the cholera epidemic of London reappear. For example, asthma has doubled among preschoolers in the United States. Also, many U.S. campers come down with Lyme disease, but a few years back they didn’t. Surprising changes in disease also occur in other parts of the world. Malaysia has experienced the Nipah virus and an increase in malaria.

Let’s look at these health problems and see how researchers are tracing their changing patterns to changes in the environment. Let’s start with the Nipah virus.

In the 1990s, Malaysians cleared a lot of forests. At the same time, there were extensive forest fires in nearby Sumatra. In these forests lived fruit bats, which carry the Nipah virus. With much of their natural habitat destroyed, the bats migrated. In their search for food, they moved closer to where humans lived, some even settling in backyard fruit trees. The Nipah virus also migrated—from the fruit bats to pigs and then to people.

Clearing the forests also brought an unexpected increase in malaria. The clearing left countless holes where the trees had been. When it rains, these holes filled with water, turning the holes into breeding grounds for malaria-carrying mosquitoes. The millions of plastic bags that people discard around the world are doing the same thing. Crumpled, they, too, collect water, becoming breeding sites for mosquitoes and contributing to an increase in malaria.

But why has asthma more than doubled among U.S. preschool children? It can’t be because of clearing forests or discarding plastic bags. Researchers are narrowing the cause. The major suspect turns out to be air pollution, including diesel exhaust, that triggers asthma and magnifies its problems (Guidry 2016).

And the increase in Lyme disease? Researchers are pointing to global warming. There are more ticks because the warmer earth provides a more hospitable environment. With more ticks, more humans are bitten, leading to an increase in Lyme disease. As global warming continues, the ticks that carry Lyme disease have migrated northward. But the disease is also migrating southward, which confused researchers. The culprit appears to be the expansion of suburbia into the edge of forests, producing thin forest cover, favored by deer and the white-footed mouse, hosts and transporters of the tick that passes on Lyme disease (Lavelle 2014).

Medical researchers are trying to tease out more connections between human activities and disease. In Chapter 13, which ­focuses on the environment, I will be stressing that “everything is connected to everything else.” The relationship between human activities, the environment, and disease is an example of this principle.

In Sum 

We usually think of illness and disease as biological matters. Biology is certainly involved, but what is considered health and illness is also a social matter. At one point in time, a physical condition such as pregnancy can be considered as a natural event, and at another time, it can be considered a medical matter. What we think of as the causes of health problems also go beyond biology. Just as doctors once viewed “black lung problems” as “weakness” on the part of some coal miners, they now define this condition as a disease stemming from the miners’ environment.

he Problem in Sociological Perspective: The Social Organization of Medicine

1. 10.2 Explain why the social organization of medicine is part of a social problem.

When we look at issues of health as social problems, we look not only at illness and disease but also at the systemof health care. To make this clearer, let’s consider medical costs, cesarean births, and the quality of medical care.

An Explosion in Medical Costs

Figure 10.1 illustrates how medical costs have soared in the United States. In 1960, the nation’s medical bill ran $28 billion. By 2015, the cost had exploded past $3 trillion, more than 100 times higher. During this time, the cost of other goods increased eight times. If medical costs had increased at the same rate as average inflation and considering that the population had also increased by 75 percent, the nation’s annual medical bill would run about one-seventh to one-eighth of what it is now.

Figure 10.1

The Nation’s Medical Bill: Soaring Costs

Source: By the author. Based on Statistical Abstract of the United States 2011:Table 130; 2016:Table 148.

Figure 10.1 Full Alternative Text

Another way to illustrate the explosion in the costs of medical care is to see how little it used to cost to have a baby. Look at Figure 10.2. The 1962 bill of $113.85 included a three-day stay in the hospital for the mother, her anesthetic, lab fees, medicine, dressings, delivery room, nursery, her son’s circumcision, and even his bracelet. Today, an uncomplicated vaginal delivery with a three-day stay in the hospital runs about $16,889: $10,902 for the hospital, $1,947 for the anesthesiologist, and $4,040 for the attending physician (Healthcare Blue Book 2016). A circumcision will cost an additional $239, double the entire 1962 cost.

Why did the nation’s medical bill explode? There are three primary reasons: First, there are more elderly people in our population. (The standard of living increased during this time, and people now live longer. Overall, the ­elderly need considerably more medical treatment than the younger.) A second reason is that we have a lot of new technology, which is expensive. The third reason is that we ­approach medical care as a commodity to be sold for profit. Let’s look at this third reason.

Medicine for Profit: A Two-Tier System of Medical Care

Medicine for profit is also known as a fee-for-service medical system. Under this system, physicians are like mechanics and plumbers: They collect a fee for each service they perform. And like mechanics and plumbers, the more services they sell, the more money they make. In a fee-for-service system, health care is a commodity to be sold, not a citizen’s right.

Our fee-for-service system has led to a two-tier system of medical care: one for those who can afford good insurance, and another for those who cannot. Because our society treats health care as a commodity to be sold to the highest bidder, our medical care ranges from the finest in the world at major universities to that provided by an underground network of unlicensed, foreign-trained physicians who can barely understand their patients.

Medicine for Profit: Cesarean Delivery

Kathie, in our opening vignette, had an expensive cesarean section (C-section), her baby delivered through abdominal surgery. Although a mistake by a nurse triggered events that made her surgery necessary, the extra profits that come from cesarean deliveries motivate many doctors to prefer this method of delivering babies. As shown in Figure 10.3, in 1970 about one of 19 babies was delivered by cesarean section; now the total is one of every three (33 percent).

Why the Increase in Cesarean Births?

Do you think that women in the United States are becoming less healthy, so that more of them need this surgery?

To illustrate our two-tier medical system, I chose two photos of patients waiting for the doctor. I’m sure you have no problem telling which tiers the photos represent.

I’m sure you know the answer—that today’s women aren’t less healthy than women in the past. Actually, today’s women are healthier. How do we know? The best single indicator of health is longevity, how long people live. And women are living longer today. If it isn’t women’s health, then what is the answer? Could it be the medical system? It certainly is. We know this because some hospitals have much higher rates of cesarean delivery than other hospitals even though they are in the same city and serve patients from similar backgrounds. The doctors in some hospitals promote C-section births, while other doctors are less likely to do so (Park 2014).

In Figure 10.3, you saw how the rate of C-sections has risen—even though this type of delivery carries greater health risks for the mother: bleeding, blood clots, sterility, and ruptured uteruses (Kuklina et al. 2009; Offord 2016). Compared with women who give birth vaginally, women who have cesarean births also have to stay in the hospital longer. Their new babies are also more likely to have breathing problems, to require intensive care, and to have higher rates of asthma and diabetes (Rabin 2012; Blustein and Liu 2015).

And here is what many find shocking: Most cesarean deliveries are medically unnecessary. Then why are one-third of U.S. births by C-section? Let’s look at four main reasons.

• Profit: The major reason for the increase in Cesarean births seems to be more income for obstetricians—doctors who specialize in childbirth. Being able to charge much more for cesarean births motivates them to recommend the surgery. Obstetricians’ income has increased so much that, with the exception of other surgeons and anesthesiologists, it is higher than that of all other medical specialties (Bureau of Labor Statistics 2016).

• Convenience: Another reason for this increase is that cesarean births allow doctors to take control of the delivery process. Instead of having to come into the delivery room at 3 a.m.—something no one likes to do—the doctor can decide when the baby will be born. Both convenience and higher profits motivate doctors to do more C-sections. Now that births are scheduled around the physician’s preference, more births occur on Tuesday than on any other day of the week (“Births.” 2015:Table 1-3).

• Technology: Advanced technology is another reason. Almost all U.S. women who give birth do so in a hospital, and almost all of these women are attached to a fetal monitor during their labor. When the fetus is in distress, the monitor sets off an alarm, but many of these signals are false. With no standard way of interpreting the distress signals and doctors wanting to take the safest route, the use of fetal monitors increases the number of cesarean deliveries (American ­College . . . 2009).

• Preference: Finally, some women ask their doctors for a C-section because they fear the labor pains that come with vaginal childbirth or because they, too, want to control the time of delivery. It is difficult for doctors to refuse such requests—especially since a C-section means both convenience and profit (Nilstun et al. 2008; Kirkey 2016).

A Feminist Controversy

Cesarean births have become not only a social issue, but also cause for controversy among feminists. The central issue is the relative power of women (Sixkiller 2015). Some feminists say that cesarean delivery takes the power over childbirth away from women and puts it in the hands of doctors. Kathie, in our opening vignette, would agree. Others, in contrast, take the view that cesarean delivery can empower women. They point out that it isn’t always the physician who decides that a woman will have a cesarean delivery: As just mentioned, some women tell their doctors how and when they want to deliver their children.

The Scope of the Problem

To better understand the scope of medical problems, let’s look first at physical illness as a social problem.

Physical Illness as a Social Problem

1. 10.3 Summarize some of the aspects of physical illness that make it a social problem.

Two ways that social researchers evaluate the general health of a society are to analyze life expectancy and infant mortality.

Life Expectancy

In the United States, life expectancy has been rising for over a century. In 1900, the average person died before seeing the age of 50. In contrast, the average boy born today can expect to live to age 76, the average girl to age 81 (Statistical Abstract 2016:Table 115). These are national averages, and group averages never apply to individuals. Your particular life expectancy is not 76 or 81 or any other group average.

As with so many other conditions in society, life expectancy is related to income and education: Those who have higher incomes and education live longer. Life expectancy is also related to race–ethnicity: Whites live an average of 3.5 years longer than African Americans (Statistical Abstract 2016:Table 118); Asian Americans live the longest, while Native Americans have the shortest lives. If we could improve social conditions so that everyone has the same educational and environmental conditions as the wealthy, we would save five to eight lives for every one that is saved by advances in medicine (Woolf et al. 2010). Sociology contains a lot of practical lessons, as you’ve probably noticed by now. The practical lesson from this is that if your goal is to save lives, you might want to go into public health instead of medicine.

Infant Mortality

A primary reason that life expectancy has increased is that infant mortality has declined. The infant mortality rate (the number of babies who die before their first birthday, per 1,000 live births) is another way to measure a group’s well-being: It reflects the quality of nutrition, the health of mothers and babies, and the quality of health care. In 1960, the U.S. rate was 26 deaths per 1,000 births. Now it is just a fourth of that, six per 1,000 births (Statistical Abstract 1990:Table 110; 2016:Table 126). On the Social Map, you can see how infant deaths are distributed among the states. In general, the states with the highest rates of infant mortality cluster in the Southeast, and those with the lowest rate in the West. Here again we see social influences on health, illness, and even the death of babies.

Although our infant mortality rate has dropped, many still find it a cause for concern. To see why, look at Figure 10.5, where you can see that the U.S. rate is higher than that of several other nations. The cold numbers on this table translate into avoidable deaths. If our rate were the same as Japan’s, most of the 16,000 infants who die in the United States each year would live (Statistical Abstract 2016:Table 124).

Note: These are the countries listed in the source whose rates of infant mortality are less than that of the United States. Infant mortality is defined as the babies who die before their first birthday per 1,000 live births. Seven countries that were listed in earlier editions of the source as having rates of infant mortality lower than the United States no longer appear in the current source. These countries are Belgium, Cuba, Czech Republic, Greece, Portugal, Sweden, and Switzerland. It is likely that their rates are still lower.

Why is the infant mortality rate higher in the United States than in the other nations shown in Figure 10.5? The primary reason is the huge pockets of poverty in the United States. As you saw in Chapter 7, poverty is especially high among African Americans, Latinos, and Native Americans. Their higher rates of infant mortality reflect this poverty and increase the overall U.S. rate. To put the matter in the simplest terms: To live on the edge of survival is not good for pregnant women. They get sick more often, experience more stress, have more emotional problems, don’t eat as healthful foods, and receive less prenatal care.

Lifestyle

Although poverty is important, lifestyle may be even more significant. Sociologist Ruben Rumbaut and geographer John Weeks (1994) found that despite higher rates of poverty, Vietnamese and Cambodian refugees in California had lower rates of infant mortality than U.S.-born California women who were better off financially.

This puzzled the researchers, who expected that the higher poverty would lead to higher infant mortality rates. As they explored this puzzle, they found the answer not in biology but in social conditions: The U.S.-born women had gained more weight during pregnancy, were more likely to have abused drugs, and had “surgically scarred uteruses” from abortions. The immigrant women lived a more conservative lifestyle.

It is difficult to overstate the importance of lifestyle in determining health and illness, for lifestyle is the major cause of illness and death. To mention the most obvious: Overeating and lack of exercise lead to heart attacks and strokes, smoking causes cancer, and the abuse of alcohol harms essential body organs. These are all part of the socialnature of physical illness.

Sexually transmitted diseases (STDs) also illustrate how lifestyle is related to health. To again state the obvious: Singles who practice abstinence run zero risk of STDs. So do couples who never had sex before they marry, and then remained sexually faithful after marriage. All others are at risk, a risk that rises with the number of sexual partners and the amount of unprotected sex. Although people with more sexual partners and unprotected sex have a greater chance of acquiring an STD, it’s possible to become infected with gonorrhea, syphilis, and even HIV with just the first sexual encounter.

Heroic and Preventive Medicine

At the core of the social problem of medical care lies this contradiction: We live in an age of chronic illnesses (lingering and ongoing medical problems), while our medical services are geared for acute illnesses (those that have a sudden onset, a sharp rise, and a short duration). Our medical approach to cancer, heart disease, and other chronic disorders is heroic, hospital-based, and expensive. Intervening after a disease is advanced requires highly trained specialists, technical equipment, and expensive drugs. Patients who have serious illnesses want the best care, and the medical world has taught us that “the best” means complex, technical, and expensive.

Unlike heroic medicine, with doctors intervening in life–death situations— popularized by movies and television—preventive medicine is not dramatic. On the contrary, it consists of routine, day-to-day activities. Yet prevention, not heroic medicine, holds the key to limiting untold suffering and saving numerous lives. Public health measures can save millions of lives—but the means are not exciting. They center on such ­behaviors as promoting exercise and more healthful eating and reducing pollution, smoking, and alcohol and other drug abuse.

Quick Care: Emergency Rooms and Drugstores

The emphasis in U.S. medicine on specialists and hospital care has led to a shortage of primary care doctors who treat routine problems. Consequently, for basic medical care, many patients go to hospital emergency rooms. Because emergency rooms stay open day and night and do not require appointments, they are more convenient than visiting a doctor’s office. Emergency services, however, are more costly. Treating a splinter or fever in an emergency room runs several times more than treating it in a doctor’s office. In an effort to limit emergency rooms to emergency medical care, insurance companies refuse to pay for routine treatment given in emergency rooms.

Drugstores have entered the competition for patient dollars. Walk in without an appointment at an in-store clinic at CVS, Walgreens, or Walmart, and you can get a physical, flu shot, or vaccination from a nurse or physician’s assistant. The seven-days-a-week and no-appointment-approach is appealing, as is the lower cost.

Uneven Distribution of Doctors

Another problem with the medical delivery system is an uneven distribution of doctors. Some areas have an abundance of physicians, while others have few doctors. It is difficult for small towns, which offer few cultural attractions, to attract doctors, while large cities near major hospitals have doctors in abundance. As you can see from the Social Map, the states reflect this same unevenness. In the extreme, Massachusetts has 2.5 times more doctors per 100,000 people than Idaho.

Mental Illness as a Social Problem

1. 10.4 Summarize some of the aspects of mental illness that make it a social problem.

We should start by asking two basic questions: Has mental illness increased? and What is mental illness?

Measuring Mental Illness

Some experts argue that mental illness has increased because people today experience more stress while their social support systems (family, friends, and community) have become weaker. This sounds good and could be true, but, frankly, it is just as possible that there is less mental illness today than in past years. Then-and-now totals are impossible to compare because we don’t know how much mental illness there is today, much less how much mental illness there used to be. Any totals that any “expert” tells you are just fuzzy speculation. Experts don’t even agree on how to define various forms of mental illness—and the definitions they use keep changing. We can dispense, then, with the notion that mental illness is more common today, for there is no way of knowing one way or the other.

The Social Nature of Mental Illness

What exactly is mental illness? This question lands us in the midst of controversy. Some psychiatrists see mental illness behind each shadow, while others deny that mental illness exists (Szasz 1961; Doward 2013). Whatever mental illness is—if it exists, that is— has a strong social basis. That is, people who experience more stress are more likely to also experience what are known as mental problems.

Mental problems are assumed to be the primary reason for suicide, although the matter is not this simple. In Issues in Social Problems: Suicide: The Making and Unmaking of a Social Problem, you can see how suicide is related to social conditions and also how suicide changed from a personal problem to a social problem and then back again to a personal problem.

Issues in Social Problems

Suicide: The Making and Unmaking of a Social Problem

Deliberately drawing a razor blade across one’s wrist, putting a gun in one’s mouth and pulling the trigger, or taking poison—these chill the imagination. More than 100 years ago, sociologist Emile Durkheim (1897/1951) documented how suicide is more than an individual act, how it is related to social conditions.

Regularity of Rates 

When Durkheim analyzed the suicide rates of different countries, he noticed that year after year, each country’s rate remained about the same. Look at Figure 10.7. From one year to the next, these rates show little change. Ten years from now, Hungary and South Korea will have higher suicide rates than the United States, and Greece and Mexico will have lower rates. Suicide rates are so regular that you can expect about 35,000 to 36,000 Americans to kill themselves this year, and next year, and the year after that (Statistical Abstract 2016:Table 128).

Gender in Suicide 

From Figure 10.7, you can see that in each country men are more likely than women to kill themselves. In the United States, for every woman who kills herself, four men do the same. This ratio holds true year after year. Yet year after year women attempt suicide more often than men. This is interpreted as meaning that women’s suicide attempts are more likely to be “cries for help,” but men are more likely to mean it. This is true, but there is also the matter of gender in the choice of method: Women are more likely to take pills, men to use guns. Pills allow more time for discovery before death and lifesaving intervention, while a bullet does not.

I spent a (depressing) year studying suicide. As I reviewed my county’s coroner’s records, I was impressed by the role of gender in suicide. Before taking pills, women tended to “pretty” themselves with makeup and to smooth the bed cover. You could see that they had in mind an image of how they would look when they were discovered. And comfort in death: One woman turned on the gas and then rested her head on a pillow in the oven. Not all women commit suicide like this, of course. Some do blow their brains out, but this is more likely to be a man’s way of death.

The Making and Unmaking of a Social Problem 

In the 1960s, our suicide rates—just as they are now—were somewhere in the middle of those of the industrialized nations. But at that time, mental health professionals began to publicize the idea that suicide was a national problem. The objective conditions hadn’t changed; that is, there was no increase in suicide, but subjective concerns grew as mental health professionals and government officials used the mass media to arouse the public. The idea of swift intervention when people contemplate or attempt suicide was appealing, and across the nation the National Institute of Mental Health began to finance suicide prevention centers to conquer what had become a social problem.

Although the suicide prevention centers failed to reduce the suicide rate, subjective concerns gradually decreased. The funding dried up, and most centers closed their doors. From time to time, subjective concerns grow, such as after the suicide of a famous person or a series of suicides among the young. But subjective concerns have dropped to such an extent that suicide is again a personal problem, not a social problem. Note that during this social construction of a social problem the objective condition, the rate of suicide, did not change.

For Your Consideration

1. Can you explain why objective conditions are not sufficient to have a social problem?

2. Why did suicide change from a personal to a social problem? Why has it changed back to a personal problem?

3. Can you think of other examples of this process?

A Two-Tier System of Mental Health Delivery

Just as problems of physical illness have two parts—the illnesses and the medical delivery system—so do problems of mental illness. Let’s see how the medical delivery system is part of this problem. Here is something I observed when I did research on the homeless:

I watched as an elderly nude man, looking confused, struggled to put on his clothing. With his bare hands, the man had ripped the wires out of the homeless shelter’s electrical box and then, with the police in pursuit, had run from one darkened room to another.

I asked the officers where they were going to take the man, and they replied, “To Malcolm Bliss” (the state hospital). When I commented, “I guess he’ll be there for quite a while,” an officer replied, “Probably for just a day or two. We picked him up last week when he was crawling under cars at a traffic light—and they let him out after two days.”

The police explained that only people who are a danger to others or themselves are admitted as long-term psychiatric patients. Visualizing this old man crawling under cars in traffic and risking electrocution by ripping out electrical wires with his bare hands, I marveled at the definition of “danger” that the psychiatrists must be using. Here in front of me, the two-tiered medical system was stripped of its coverings. A middle-class or wealthy person would have received different treatment. Of course, such a person would not have been in a shelter for the homeless in the first place.

Here is a summary of our two-tier system of mental health care: People with more money are likely to receive individual counseling—some form of intensive, expensive “talk therapy” from a psychiatrist. People with little or no money are likely to be ignored or to be given some form of medication and told that “Everyone has problems, so do your best.”

The homeless are the castoffs of postindustrial society. Unwanted and unneeded, they are left to wander the city streets and countryside. Only grudgingly are their needs attended to. This photo was taken in Denver, Colorado.

Looking at the Problem Theoretically

1. 10.5 Discuss the perspectives that emerge when you apply symbolic interactionism, functionalism, and conflict theory to health, illness, and the practice of medicine.

Let’s look at how our theoretical perspectives apply to health, illness, and the practice of medicine.

Symbolic Interactionism

As we have reviewed, symbolic interactionists focus on how people determine meaning and how those meanings influence their behavior. Let’s look at how determining meaning (symbols) applies to health and illness.

The Meaning of Symptoms

If you feel something unusual, you will self-diagnose. That is, you will try to figure out what your out-of-the-ordinary feelings mean. Am I coming down with an illness? Should I go to bed? Call a doctor? Or just carry on with my everyday life?

How do you determine what your feelings mean? You use definitions that your culture provides. Because social classes and subcultures equip their members with distinctive ways of viewing life, you will interpret your experience differently than will someone from a different background. Back pain is an example. People from the lower classes are likely to regard back pain as part of life. “This is what happens to people when they get older.” People from the middle class, in contrast, are more likely to view back pain as a health problem that needs to be treated by a doctor. It is the same with cold or flu symptoms. For many people, these feelings indicate a need to go to a doctor and “get a shot.” To those who follow alternative medicine, these same symptoms indicate the need to drink more water or to take vitamin C or other antioxidants. In short, we use cultural and subcultural symbols to determine what our symptoms mean.

The Significance of Definitions

Just as social classes and subcultural groups perceive illness differently, so groups compete to get their views of health accepted. This, in turn, changes the way we view health, illness, and medicine. For example, the American Psychiatric Association (APA) used to list homosexuality as a mental illness and had therapists who treated it. Using conversion therapy (sometimes called reorientation or reparative therapy), psychiatrists would attempt to change a person’s sexual orientation. Homosexuals objected to being defined as mentally ill and having their sexual orientation treated as an illness. They lobbied for a change, and in 1973 the APA dropped homosexuality as a form of mental illness. Conversion therapy has fallen into such disfavor that some states are trying to make it illegal (Merritt 2015).

Just as medicine and psychiatry can decide that some behavior is no longer an illness, so they can declare that some other behavior is an illness. What had been called drunkenness, for example, was relabeled as the disease of alcoholism. As we reviewed in Chapter 4, through a similar process, unruly and inattentive children were reclassified as children suffering from attention-deficit disorder.

The labels we apply to health and illness become lenses through which we view the world. If we define alcohol abuse as a disease, we perceive an alcohol abuser as sick; if we define the abuse as drunkenness, we might think of the person as sinful or morally weak. Such contrasting views come with matching ideas of appropriate social policy: If we consider alcohol abuse to be a disease, we might think that sympathy and medical help are appropriate responses, but if we define alcohol abuse as a moral failing, we might think that shaming or punishment is more appropriate. Because our social groups provide the symbols or definitions that we use, sociologists say our ideas of health and illness are “socially constructed.”

Conflicting Referral Networks

As symbolic interactionists study how meaning is determined in the practice of medicine, they analyze interactions between doctors and patients. In classic research, Eliot Freidson (1961) examined how patients and doctors use different frames of reference. Patients use a lay referral network—family, friends, neighbors, and coworkers with whom they talk about their medical problems. This network helps the individual decide which doctor to see—or even whether to see a doctor at all. In this lay referral network, the perception of a physician’s knowledge and personality is important. So is the confidence that the doctor exhibits. Doctors who show uncertainty create fear, while those who appear confident instill trust. Patients also want to be sure they get a shot or a prescription, not just advice to go on a diet or to get more rest. That advice might be the most appropriate response the ­physician could give, but the patient expects something “more professional,” which translates into “medicine” that only a doctor can give.

The physician’s frame of reference, in contrast, is a professional referral network—made up of other physicians and medical professionals. In this network, the meaning of “doctoring” is different, for their training in medical schools has emphasized organs, symptoms, and diseases apart from the person. Sympathy for the patient is less important than determining why some organ is malfunctioning and prescribing appropriate treatment (Conrad 1995; O’Rourke 2014).

You can see, then, how the different referral networks of patients and physicians produce contrasting definitions. Because the expectations of patients and doctors are so different, their worlds can collide. Let’s look at such a collision of expectations.

Depersonalization

As Mary Duffy was lying in bed, still groggy on the morning after her breast surgery, a group of white-coated strangers filed into her hospital room. Without a word, one of them, a man, leaned over, pulled back her blanket, and stripped her nightgown from her shoulders. As the half-dozen medical students who had encircled her bed stared at Mary’s naked body with detached curiosity, the doctor talked about carcinomas. Abruptly, he said to her, “Have you passed gas yet?” (Carey 2005)

It’s difficult to imagine that doctors would treat a patient as an object to the extent that this surgeon did. But as you can see, some do. Sociologist call this depersonalization—treating a person as an inanimate object.

Depersonalization is common in some medical settings (Jauhar 2014). It is as though medical personnel think that people who check into a hospital have also checked their persona – their personal, intimate feelings and needs—into their medical folder. Sociologists who have studied depersonalization in public clinics note how the poor have to wait for hours, aren’t looked directly in the eyes when spoken to, and are addressed as numbers rather than by name. If they aren’t able to see a doctor that day, it’s just one of those things. After all, what do poor people have to do that’s important, anyway?

Patients who are depersonalized feel a gap between themselves and their doctors, and they have a greater tendency to sue their doctors. The threat of malpractice suits, in turn, produces defensive medicine; that is, doctors order lab tests and consultations that may not be needed in order to leave a “paper trail” to show they did everything reasonable. Preparing for possible lawsuits adds billions to the nation’s medical bill.

Physicians are often criticized for bad communications with patients.

10.5-7 Full Alternative Text

Functionalism

Functionalists assume that customs or social institutions persist because they fulfill social needs. This perspective raises interesting questions: Whose needs are met by a health care system that is hospital-based and oriented toward acute illnesses? What are the benefits of depersonalizing patients or of making childbirth a rigorous medical procedure?

Fee-for-Service Means Profits

Let’s start with the obvious: It is difficult for doctors to make money from people who are healthy. Sick people mean patients for doctors, and patients mean money for them. On top of this, patients who get well quickly bring less profit. But a high-profit-producing hospital-based system oriented toward acute illness—now that’s a dream come true. Everyone—doctors, nurses, hospitals, medical suppliers, and drug companies—makes money from patients who are given intensive care. Each year, about 35 ­million patients—one of every nine Americans—are admitted to a hospital and stay an average of five days (Statistical Abstract 2016:Tables 6, 1964). The average daily cost is shown in Figure 10.8. The shorter bars on this figure represent what a day’s stay in the hospital would cost if medical costs had risen at the same rate as inflation. Like the bill for delivering a baby in Figure 10.2, this figure illustrates the skyrocketing costs of medical care better than words can say.

Despite feeble denials from the medical profession, profits, not health care, are the engine that drives the U.S. health care system. Our fee-for-service system means that the more services doctors sell and the higher price they charge, the more they earn. One ­result is unnecessary surgery, such as most cesarean sections. Another example is hysterectomies, which we will review in the next section on conflict theory.

Physicians, nurses, and investors in the U.S. health care industry aren’t the only ones who benefit from our fee-for-service system. Patients also benefit, for this system lets them shop around. They can choose which doctor to see and what services to purchase. That this system is functional for patients is indicated by our rising life expectancy and decreasing infant mortality rates.

A Self-Correcting System

I have mentioned problems with our fee-for-service system, but functionalists reply that the system is self-correcting. For example, although the medical system is oriented to acute illnesses, after environmental health problems were recognized as serious, the government passed antipollution laws and formed the Environmental Protection Agency (EPA). Medical schools also responded, adding training programs in environmental medicine. Similarly, expensive insurance has led to the development of managed care (discussed later) and outpatient surgery. In short, functionalists view fee-for-service health care as a system that responds to shifting needs of the nation.

The Global Level

Functionalists also analyze functions and dysfunctions of medicine on a global level. Exporting Western medicine to the least industrialized nations provides an excellent example. The vaccines and medicines sent to these nations were functional because they reduced death rates on a global scale. But they were also dysfunctional because they set the conditions for the global population explosion that worries so many. We will discuss this topic in Chapter 12.

Conflict/Feminist Theory

As usual, conflict sociologists disagree with the functionalist view. In fact, they argue the opposite—that the U.S. medical system is not self-correcting. Conflict sociologists view patterns of illness and health care in the United States as the outcome of clashes between interest groups. They argue that the poor are sicker than others because they have lost the competition for high-quality education, food, housing, jobs, and medical care.

Medicaid

What about Medicaid, which benefits the poor? Conflict sociologists point out that this program developed in conflict. In the 1960s, resentment about the treatment of the poor in the medical system had grown so vocal that politicians were forced to take action. Congress saw Medicaid for the poor as the answer. However, the physicians’ union, the American Medical Association (AMA), viewed Medicaid as a first step to socialized medicine. This organization feared that Medicaid was an attack on its profitable fee-for-service system, and it spent millions of dollars lobbying to prevent Congress from approving Medicaid. Caught between the public’s demand for change and the intense lobbying of the AMA, Congress designed Medicaid to satisfy both—more medical coverage for the poor but retaining the doctor’s profitable fee-for-service system.

Colliding Interests of Doctors and Patients

Conflict theorists also have a different view of the doctor–patient relationship. Those adhering to the Marxist perspective emphasize that doctors and patients form two classes—those who control medicine and those who receive treatment. As the dominant class, physicians try to control the ­doctor–patient relationship. As you probably know, it is not unusual for doctors to say a few words to patients—often using foreign-sounding technical terms—and then send the patients on their way.

This is no accident, say conflict theorists. By not explaining their procedures and diagnoses in down-to-earth terms, physicians try to keep the oppressed class of patients ignorant and dependent (Waitzkin and Waterman 1974). As conflict sociologists put it: In a capitalist system of production for profit, the alienation of patient and physician is like that of owner and worker, inevitable when the interests of the one (making a profit from the illness) oppose those of the other (getting well at the least expense).

Women’s Reproductive Organs

Sociologists who have done participant observation of doctors have reported a bias against women’s reproductive organs. Sociologist Sue Fisher (1986) was surprised to hear surgeons recommend total hysterectomy (the removal of both the uterus and the ovaries) even when no cancer was present. She heard male doctors refer to the uterus and ovaries as “potentially disease-producing” organs— useless and unnecessary after childbearing age. Each year, about a half million American women have hysterectomies (Statistical Abstract 2016:Table 189). Physician researchers report that many of these surgeries are unnecessary (Corona et al. 2015).

To define the uterus and ovaries as “potentially disease-producing” organs—what money-making organs they become. The more surgery, the more profits. But women aren’t exactly pleased at having these organs cut out of their bodies, so surgeons drum up business by “selling” hysterectomies. Here is what one physician said to sociologist Diana Scully (1994):

You have to look for your surgical procedures; you have to go after patients. Because no one is crazy enough to come and say, “Hey, here I am. I want you to operate on me.” You have to sometimes convince the patient that she is really sick—if she is, of course [laughs], and that she is better off with a surgical procedure.

Some surgeons try to scare women into “buying” the operation. Look at this horrendous example:

When Mrs. J., a 47-year-old schoolteacher, was told in a routine examination that she had a “uterine fibroid” and needed a hysterectomy (removal of her uterus), the only thing she could think of was “tumor.” She asked the doctor if it was cancerous, and he frightened her more by saying, “Sometimes when we go in, we find them to be cancerous.” Fearing cancer of the uterus, she consulted two other physicians and learned that the fibroid was small, common in middle-aged women, and soon likely to shrink on its own as she went into menopause (Larned 1977:195–196).

Imagine this woman picturing herself lying in a casket, her tearful family inconsolable after the loss of their wife and mother. Why do you think that the surgeon did not tell her the rest of the truth—that fibroids are not likely to turn into cancer and that several nonsurgical treatments are available?

In Sum 

From a conflict/feminist perspective, profits, not health care, are the goal of the U.S. medical system. Physicians are businesspeople, patients are customers, and health care is the commodity for sale. Conflict theorists argue that their perspective best explains why medical care for the rich is better than that for the poor: The government pays an increasing proportion of the nation’s health care bill because it perpetuates and underwrites the interests of capitalist industries—including medicine. Conflict theorists argue that health care should be a right of all citizens and that people’s illnesses and diseases should not be exploited for profit.

Research Findings

1. 10.6 Summarize changes in health problems and infectious diseases, the relationship of the environment and disease, and social inequalities in physical and mental illness.

Sociologists do a lot of research on health problems and the medical system. In keeping with the theme of this book, our focus will be on social inequalities of health and health care. First, we will discuss physical health problems: age, race, and social class; our two-tier system of medicine; and how health insurance creates inequalities. We will then discuss social inequalities in mental illness.

Historical Changes in Health Problems

To examine the main causes of death in a society is to make the social nature of health, disease, and death even more apparent.

The Top 10 Killers

In Figure 10.9, you can compare today’s 10 leading causes of death with those of 1900. The changes over this time make the social nature of death evident. As you can see, only six of today’s 10 leading causes of death are the same as back then.

To see the social basis of even the cause of death, note that in 1900, “senility” was the ninth leading cause of death. This seems to have been a catch-all category for “old age,” which we don’t consider a cause of death today. When the elderly didn’t die from diarrhea, pneumonia, or something recognizable, doctors just said they died from “senility.” It is likely that the category included what we call Alzheimer’s disease today.

To emphasize even further the social nature of death, note how causes of death are related to lifestyle and environmental pollution. In 1900, lifestyle factors like smoking cigarettes and the intake of high amounts of sugar weren’t common, and lung diseases and diabetes didn’t make the top 10 list. With broad changes in lifestyle came changes in leading causes of death.

Infectious Diseases

Infectious diseases threaten us all, but not all of us are threatened in the same way.

A Decline in Infectious Diseases

From Figure 10.9, you can see how deadly infectious diseases used to be. In 1900, pneumonia was the number one killer, with tuberculosis (TB) close behind. Even diarrhea was a major killer. Every family feared polio, whooping cough, German measles, smallpox, and diphtheria. Then, during the first half of the 20th century, these diseases receded. As death rates dropped, life expectancy rose, going from 47 years to over 70. What happened?

The usual answer is that modern medicine wiped out these diseases. I don’t want to detract from the many accomplishments of modern medicine, for most of us know someone who would not be alive if it weren’t for coronary bypass surgery, cancer treatment, or some organ transplant. Prescription drugs and vaccinations certainly have been significant in prolonging life by preventing and treating diseases such as syphilis, bacterial pneumonia, and hypertension.

But most infectious killers of the 19th century were declining before antibiotics, immunizations, or specific drugs were developed (McKeown 1980). Although medical myth has it that new drugs and vaccinations conquered TB in the 1950s, you can see from Figure 10.10 that TB had been declining since the 1800s. If modern medicine didn’t conquer this infectious disease so feared by earlier generations, what did? The answer is that cleaner public water supplies and better living conditions improved overall health. Deaths from these infectious killers declined as people became healthier from cleaner water, better food, and better housing.

Tuberculosis used to be one of the greatest killers. Many people believe that modern medicine “conquered” TB with the discovery of streptomycin in 1947 and a vaccine in 1954. As you can see, the death rate for TB had been declining for almost 100 years before these discoveries. Many other infectious diseases “conquered” by modern medicine follow a similar pattern.

Source: McKeown 1980; Statistical Abstract of the United States 2016:Table 203.

Figure 10.10 Full Alternative Text

The Resurgence of Infectious Diseases

It started with a cough, an autumn hack that refused to go away.

Then came the fevers. They bathed and chilled the skinny frame of Oswaldo Juarez, a 19-year-old Peruvian visiting the United States to study English. His lungs clattered, his chest tightened, and he ached with every gasp. During a wheezing fit at 4 a.m., Juarez felt a warm knot rise from his throat. He ran to the bathroom sink and spewed a mouthful of blood.

“I’m dying,” he told himself, “because when you cough blood, it’s something really bad.”

Oswaldo Juarez had been infected with extremely drug-resistant (XXDR) TB, the first case in the United States (Mason and Mendoza 2009). Since then, a handful of XXDR cases have shown up (Lachatre et al. 2016).

Health officials around the world so fear a strain of TB that is resistant to all drugs, one that can spread wildly through a population, that in some countries officials arrest TB patients, keeping them locked up until their disease is cured (McNeil 2016).

Infectious diseases have surprised health experts by their way of fighting back by developing new strains that are resistant to drugs and vaccines. This may be happening not just with TB but with all the infectious diseases we thought our drugs had either cured or brought under control (Rohani and Drake 2011). The implications are severe on both a personal level, your own health, and on a global level. Let’s look at some aspects of this threat to our health in Technology and Social Problems: Superbugs in the Global Village.

How Disease is Related to Behavior and Environment: HIV/AIDS and other STDs

The most feared infectious disease today is not TB, but HIV/AIDS. Let’s look at how this disease is related to behavior and the environment.

Background

When HIV/AIDS first came to the public’s attention, almost all victims were men who had sex with men, intravenous drug users, and hemophiliacs. Hemophiliacs and intravenous drug users were exposed to the disease through contaminated blood. Drug-addicted prostitutes also spread the disease to heterosexual men. Today, the disease affects people from all walks of life. Behavior and environment remain important in the transmission of HIV, with men who have unprotected sex with men the most likely to get this disease. Today, women account for more than one-quarter of all new HIV cases.

Technology and Social Problems

Superbugs in the Global Village

Simon Sparrow, a 17-month-old toddler, was just learning to feed himself. His family was startled out of sleep early one morning when Simon let out a primal scream. They rushed Simon to the hospital, where he was diagnosed with a virus and asthma and sent home. Fifteen hours later, he was dead (Chase 2006).

What killed Simon? It was a new strain of staph infection. This germ can penetrate bones and lungs, leaving abscesses that require surgery. Simon died so quickly that he was spared this suffering.

This new form of staph (community- associated methicillin-resistant Staphy­lococcus aureus, which, fortunately has a shortened name—CA-MRSA) is blamed for 19,000 deaths in the United States a year (Lally 2016). Health authorities are alarmed. CA-MRSA and the other drug-resistant bacteria are appearing at various spots around the world. Their fear is that someone, somewhere, will come down with a germ that is resistant to every antibiotic—and that with global travel, in just a matter of days the new strain will spread throughout the global village.

Following the discovery of penicillin in the 1940s came a series of effective microbe killers. By the 1970s, more than 100 antibiotics sat on pharmacy shelves. The war against microbes had been won—or so the medical industry thought—and researchers stopped developing new antibiotics. Some promising new drugs, already in development, were canceled as superfluous (Chase 2006).

When hit with antibiotics, the weaker germs die off. The stronger ones, though, can mutate, survive, and multiply. This is especially likely to happen when people stop taking a drug because they feel better, instead of completing their full course of medical treatment. The more that antibiotics are used and misused, the more that drug-resistant bugs proliferate.

The misuse of antibiotics is common. One of the many reasons is that patients expect a prescription, and doctors comply. Researchers have found that 30 percent of oral antibiotics are unnecessary (Cara 2016).

We all carry staph germs on our skin and in our nose. They don’t lead to serious problems, as most of these staph germs are relatively mild. But when they are replaced by a mutant, virulent strain, even a simple cut or scrape can become a mortal wound. A patient who goes to the hospital for a sore throat or routine surgery can be carried out in a coffin.

Pharmaceutical firms are search­ing for the next generation of antibiotics to fight the next generation of microbes. Let’s suppose that we win this race and develop new antibiotics in time to ­prevent a global epidemic. Will we then repeat this process—overprescribing, not completing the course of treatments—with the microbes again mutating and developing resistance to the new drugs?

Granted the past, I am certain this will happen. We have a medical establishment eager for profits and the tendency of patients to quit taking medicine when they feel better, but before their invasive microbes are destroyed totally. A sage once said that those who do not learn from history are doomed to repeat it. I would add that although we study history, and even know its lessons, in some instances we set ourselves on a course destined to repeat it. This, I fear, is one such case.

American Red Cross in operation during the Spanish flu epidemic of 1918–1920. The flu killed 25 million people worldwide.

For Your Consideration

1. It is easy to stop taking medication when you feel better. It’s like, “I’m cured. Why take those last six pills in that bottle?” Do you know anyone who has not completed an entire course of treatment prescribed by a physician? Have you?

2. Do you realize the global health implications of not completing a prescribed course of antibiotics?

A Global Epidemic

HIV/AIDS is a global epidemic. Each year, about 2 million people are infected with HIV, and about 1 million people die from AIDS. The global death toll numbers 35 million. Hit the hardest is sub-Saharan Africa, where 70 percent of the world’s new infections occur (UNAIDS FactSheet 2014, 2016). HIV/AIDS is so common in this region that it has become the area’s leading cause of death. The main reasons for the prevalence of this disease in sub-Saharan Africa are a lack of sex education, unprotected sex, and prostitution.

Children are also victims, and about 3 million are living with this disease. Ninety percent of these children are in sub-Saharan Africa. Some are infected through sexual violence, but most get the disease from their mother, during pregnancy, birth, or breastfeeding (Avert 2016). Worldwide, 25 million children have been orphaned because of AIDS.

Orphans in Karonga, Malawi, whose parents died from AIDS are lined up at a feeding station, which they depend on for survival.

HIV/AIDS in the United States

Antiretroviral drugs (ARVs) can slow HIV infection, preventing full-blown AIDS from appearing for up to 20 years. When ARVs were first developed, they were expensive, costing $10,000–$15,000 per patient per year. With today’s generic versions, costs have dropped to as low as $210 to treat a patient for a year (World Health Organization 2016c). Although these drugs can hold back the symptoms of AIDS, they do not prevent people from infecting others with HIV. In the United States, the combination of antiretroviral drugs and education about unprotected sex has held this disease in check, with annual new HIV/AIDS cases dropping from 80,000 in 1992 to 44,000 now. Annual deaths from AIDS are now just one-seventh of what they were, dropping from 50,000 in 1995 to 7,700 now (Centers for Disease Control 2010, 2016c; Statistical Abstract 1998:Table 144; 2016:Table 130).

Figure 10.11 shows how HIV/AIDS is related to race–ethnicity. The reason that racial–ethnic groups have different rates of this disease is not genetic. No group is more or less susceptible to HIV/AIDS because of biological factors. The reasons are social: different rates of multiple sex partners, unprotected sex, and drug users sharing needles.

Ominous Changes

The HIV virus mutates rapidly (World Health Organization 2016d). Some medical researchers fear that strains of HIV might develop that are resistant to the drugs being used, making them only a temporary fix to a global epidemic. If drug-­resistant strains become widespread, the epidemic will surge again. Several new drugs, however, hold the promise of picking up where the current drugs leave off.

HIV is not the only sexually transmitted disease (STD), of course, and for all STDs social factors or behavior are important. You might be interested in following up this line of thought in Thinking Critically about Social Problems: “I Did Not Have Sexual Relations with That Woman”: What Is Sex, and So What?

Social Inequalities in Physical Illness

From your reading of earlier chapters and what I mentioned about pregnancy and poverty in this chapter, you should not be surprised to learn that social factors largely determine who will be healthy and who will be sick. Poor children, for example, are more likely to be undernourished or to lack a balanced diet. As a result, they are more vulnerable to disease. In general, the poorer people are, the sicker they are. Even their death rates are higher.

This takes us to the heart of the matter—social inequality—the essential factor that underlies our patterns of disease and death. Let’s look at social class.

Occupational Health Hazards

On September 12, 2001, Jimmy Willis, a former subway conductor, rushed to Ground Zero to volunteer alongside thousands of workers who had been sent by the city government. For about 10 days, they helped clear out a towering six-story mass of rubble known as “the Pile.” They carved a path “five feet at a time” through a morass of concrete and bodies, with little or no respiratory protection. Health problems have plagued these workers, and now 21,000 are being treated for asthma, breathing problems, blood disorders, and various forms of cancer (Chen 2007; Kim 2012; Pearson 2016)

THINKING CRITICALLY ABOUT SOCIAL PROBLEMS

“I Did Not Have Sexual Relations with That Woman”: What Is Sex, and So What?

In one of President Bill Clinton’s many public dramas, this one at a White House press conference televised to the nation, the then president said, “I did not have sexual relations with that woman.”

Some people believed him, and some did not. Almost all were disgusted, though, with the presidency degenerating to this point. But not as disgusted as they were when the transcripts of Clinton’s trials were published. And titillated, too, as they read accounts about oral-genital contact between Clinton and Monica Lewinsky, a White House intern.

Was Clinton lying at the televised press conference? At first blush, it seems so. There is no doubt that he was covering up, but was he lying? As Clinton emphasized with his famous “It depends on what ‘sex’ is” statement about his relationship with Lewinsky, it all depends on definitions. Just what do you mean by a particular word?

Or perhaps Clinton was simply ahead of his time. Only 20 percent of today’s college students consider oral-genital contact to be sex.

Or Clinton could have been the leader—showing a new generation a new way to define sex.

Regardless, what is significant about this?

Unprotected sex can lead to sexually transmitted diseases (STDs). Now everyone knows this, but those who don’t think that oral-genital contact is sex might think that they can’t get STDs from it.

And how wrong they would be! On the list of what someone can get from unprotected (no condom) oral-genital contact is a bunch of things that no one wants: herpes, syphilis, gonorrhea, human papillomavirus, hepatitis A, and HIV. They can also get little critters called intestinal parasites.

After the collapse of the World Trade Center on September 11, 2001, volunteers and city workers were exposed to severe environmental contamination at Ground Zero. During these initial recovery efforts, most of the volunteers and employees wore inadequate protection, or none at all.

Although this was an unusual event, it illustrates this principle: Health problems that are a result of employment hit the working class harder. The executive at headquarters is less likely than the worker at the manufacturing plant to be exposed to toxic chemicals—the carbon monoxide, mercury, and uranium that destroy the kidneys, and the heavy metals that invade the nervous system. It is the same for factory noise. It is the working-class ear that is likely to be damaged, not that of the executive.

Reducing Inequalities: Health Care Reform

In 2010, Congress passed the Patient Protection and Affordable Care Act. The intention of this law was to reduce the inequalities in health care by requiring all U.S. citizens and legal residents to have medical insurance. As I write this, the law is being modified. Whatever form this law may take, we can be certain that it will not eliminate the inequalities in health care. These are built into our social structure. People with higher incomes will always be able to afford higher-quality medical care. And, as with the example cited of Ground Zero, unless there is fundamental change—which there will not be—the poor will continue to be exposed to more harmful conditions at work. The poor will also continue to eat less healthy food, exercise less, and have a higher rate of obesity. The end result is that they will continue to suffer from more health problems and to die younger.

Social Class and Mental Illness

Do some social classes have more emotional problems than others? Sociologists have answered this intriguing question time and again. Since 1939, they have found that people’s emotional well-being gets worse the lower they are on the social class ladder. Those in the lower social classes are more likely to be depressed, anxious, nervous, and phobic (fearful). Numerous studies have confirmed this finding (Faris and Dunham 1939; Srole et al. 1978; Lundberg 1991; Sareen et al. 2011; Ross et al. 2016).

As I mentioned, the term mental illness is vague. To overcome this problem, sociologist Leo Srole and his colleagues at Columbia University defined their own set of symptoms and then interviewed a representative sample of New Yorkers. The results of this classic study, the Midtown Manhattan Project, are shown in Figure 10.12. Like researchers both before and after them, they found that the poor have considerably more emotional problems.

Results of the Srole study of mental health problems among adults. Number 1 is the wealthiest, number 6 the poorest.

Source: Srole 1978.

Figure 10.12 Full Alternative Text

Why do the poor suffer more mental disorders than people in other classes? Let’s compare two competing explanations.

The Drift Hypothesis

The first, the drift hypothesis, is based on the idea that people with emotional difficulties tend to be less successful in life. People from higher-income families who have mental problems tend to drift downward, landing in the lower classes (Fox 1990). One result is that those mental disorders thought to have a genetic base, such as schizophrenia and depression, have become concentrated among the poor. Even if these genetic predispositions once were distributed evenly among the social classes, the drift downward has redistributed them. Another result is that the poor have a larger percentage of mentally disturbed parents. Their children are more likely to learn pathological ways of coping with the world, making them less able to deal with the challenges of education and career. They, too, are more likely to end up living in poverty.

You can see how this explanation relates to the nature–nurture controversy we reviewed in the preceding chapter. There we saw how difficult it is to separate genetic ­influences from the effects of socialization. The many attempts to unravel this thorny problem regarding mental illness have also satisfied no one. With the decoding of the human genome system, researchers are attempting to match specific genes with mental illnesses (Network and Pathway Analysis 2015).

The Environmental Hypothesis

Most sociologists prefer the second explanation, the environmental hypothesis. To see how this works, let’s rephrase the basic finding that the lower classes have more mental illnesses this way: People in the lower social classes tend to be sadder, more anxious, and more fearful, while those in the higher social classes tend to be happier, less anxious, and less fearful. Sociologists regard these differences in emotions (or “feeling states”) as the product of different environments. In short, they see social class as producing “mental health” and “mental illness.”

Can social class really do this? Consider how social class sorts people into different kinds of lives. Because of social class, some people enjoy job security, solid finances, and good physical health, medical care, and marriages. Not only do these people have greater security at the present, but they also have greater hopes for the future. They realistically plan and look forward to larger houses, new cars, exotic vacations, college degrees for their children, and a relaxing, enjoyable retirement. You can see how this type of life can produce better mental health.

Compare this with the stress-filled lives of people who live in poverty. Their jobs don’t offer security. With low wages, they live from paycheck to paycheck. Unpaid bills pile up. They have high rates of divorce, alcoholism, violence, worse physical health, and less access to good medical care. The contrasting conditions of social class, then, either support people’s mental well-being or deal severe blows to it.

Social Class Differences in Mental Health Care

To better understand how mental health services are related to social inequality, let’s consider types of therapy. In individual psychotherapy, a therapist listens and tries to guide the patient toward a resolution of emotional problems. One type of psychotherapy is psychoanalysis, which Sigmund Freud pioneered as a way to uncover the subconscious motives, fantasies, and fears that shape people’s behavior. The patient meets an analyst several times a week and talks about whatever comes to mind, while the analyst listens for hidden patterns, particularly those that reveal unresolved conflicts from childhood. More common is short-term directive therapy, in which a counselor focuses on current situations to help clients understand their problems. In group therapy, several patients, with the guidance of a therapist, help each other cope with their problems.

Another treatment is drug therapy, the use of tranquilizers, antidepressants, and antipsychotic drugs to relieve people’s problems and help them cope with life. As discussed in Chapters 2 and 4, some of these drugs have serious side effects. Drug therapy is often criticized as treating symptoms without offering a cure.

For some illnesses, especially depression, doctors treat some patients with electroconvulsive therapy (ECT)(also called electroshock therapy). They attach wires to either side of a patient’s skull and send low-voltage electric shocks through the brain. Memory loss is a possible side effect.

The type of therapy that troubled people receive does not depend on what kind of problems they have, but on their ability to pay. People who have money and good insurance are more likely to be guided through their problems with talk therapy—psychotherapy, group therapy, and so on. “Talk” therapy is expensive, and few poor or uninsured people receive it. They are usually given drug therapy, sometimes derisively called pharmaceutical straitjackets—drugs that make patients drowsy, lethargic, and easier to handle.

Although the patterns of treatment differ by social class, we don’t know that this represents inequality. Despite the many years that these therapies have been used, we do not know which therapies work. Costly psychoanalysis could be less (or more) effective than drug therapy. It is even possible that no therapy is more effective than all of these. Since we don’t know which therapies are more (or less) effective, we don’t know whether the poor are receiving worse—or better—treatment for their emotional problems. We need rigorous studies to evaluate the effectiveness of therapy.

In every society, the poor have less access to the desirable things of their society. This includes medical care, both physical and mental. Shown here are mental patients chained to a rock in Mogadishu, Somalia.

In Sum 

Sociologists consider social inequality to be a root cause of mental problems. Social inequality is also related to the medical treatment people receive for both physical and mental problems. Health care reform is intended to address some of these inequalities in medical care. We won’t know the results of these changes in the medical delivery system for years, but we can be certain that laws will not eliminate inequality in health care. Let’s turn our focus on social policy.

Social Policy

1. 10.7 Summarize social policy regarding medical care.

Let’s review some of the major social policies that have been put into practice to improve the quality of medical care and to reduce its cost.

Prepaid Medical Care

To reduce the cost of providing health care for their workers, some employers buy prepaid or managed care. The best-known type is the health maintenance organization (HMO). A business pays a set fee to a medical corporation (the HMO), which covers the health needs of the company’s employees. If the health care of these employees costs less than the fee, the HMO makes money; if it costs more, the HMO loses money. Because the HMO receives no more than this fee, it is motivated to reduce costs. Doctors are paid salaries, but they can receive bonuses if they reduce patient costs.

The Positive Side: Healthier Lifestyles

Because doctors make more money when ­patients stay well, they are motivated to treat medical problems before they become serious and more expensive. They encourage preventive care, such as immunizations, well-baby checkups, mammograms, and physicals. They urge patients to adopt a lifestyle that improves health: better diet, exercise, rest, and avoiding the abuse of drugs, including alcohol. This lifestyle reduces medical tests, surgery, and hospital admissions. HMO doctors also lower costs by keeping the length of hospital stays to the bare minimum (Purcell 2016).

The Negative Side: Profits and a Conflict of Interest

A doctor noticed a lump in one of her own breasts. When she called the radiology department of the hospital where she worked to schedule a mammogram, she was told that she would have to wait six months. The hospital’s HMO allowed one mammogram every two years, and she had had a mammogram 18 months earlier. She had to appeal to the HMO’s board of directors, who agreed to let her be an exception to the rule. She had breast cancer (Gibbs and Bower 2006).

This event is a succinct summary of the negative side of HMOs. By cutting down on tests and hospitalization, HMO doctors sometimes withhold necessary treatments, tests, and hospitalizations. A woman I know was sent home from the hospital even though she was still bleeding from her surgery. If she had remained longer, she would have used up more than her “share” of allotted costs and eaten into the HMO’s profits. This would not have happened to a fee-for-service patient who could afford to pay for her health care.

Another negative is that physicians have to get permission to give certain treatments (Mathews 2012). Some administrators of HMOs, whose job is to produce profits, end up dictating to doctors what treatment they can give their patients. (“You can do that if you want to, but we won’t pay for it.”) Some HMOs even determine the number of patients the doctors must see each day. One HMO insisted that its physicians see eight patients an hour, limiting them to 7.5 minutes per visit. This did not leave the doctors enough time for completing paperwork, analyzing lab results, and, of course, calling HMO officials to get approval for treatment (Greenhouse 1999).

Being Paid to Stay Healthy

Another attempt to reduce costs is to give workers a rebate for staying healthy—or at least for staying away from doctors. In return for accepting a high annual insurance deductible, employees who spend less than the deductible are paid the difference between it and their insurance claims. If the deductible is, say, $1,500, workers who claim only $100 for medical care collect $1,400, a nice bonus. Where this program has been tried, employee health costs go down. As one employee said, “Now I feel I have an investment in my own health.”

Physician Assistants and Nurse Practitioners

Another strategy for controlling costs is to use lower-paid physician assistants and nurse practitioners, who work under the supervision of physicians. Half to three-fourths of all the problems that are dealt with in a typical doctor’s office are aches, sniffles, and other trivial matters. Physician assistants and nurse practitioners also manage routine tasks like giving school physicals and educating patients who have chronic disorders.

An in-house rivalry has developed. Physician assistants and nurse practitioners don’t like doctors breathing down their necks, and they want more independence in treating patients. Their efforts to attain greater autonomy are resisted by doctors, of course, who feel their turf is being invaded (Aston and Foubister 1998). In general, the attitude of the medical profession is, “If they want to do more, they can go to medical school.”

As physician assistants and nurse practitioners have pushed the boundaries, they have gained more autonomy. They now run the in-store clinics mentioned earlier, and in some states they can prescribe basic medications and work free of systematic observation of physicians (Japsen 2016). Nurses are earning “doctor of nursing” degrees and calling themselves “doctors.” Physicians are responding by trying to get state legislators to limit the title of doctor only to themselves (Harris 2011).

Training Physicians

Today there are 80 million more Americans than 25 years ago, yet our medical schools graduate only about 1,000 physicians a year more than they did 25 years ago (Statistical Abstract 2016:Tables 2, 316).

This startling statistic should give you insight into why some areas have the doctor shortage we discussed—and how limiting the number of new physicians drives up medical costs. Although the number of graduates has had only a small increase, as you can see from Figure 10.13, a fundamental change has occurred in the gender makeup of those graduates. I am not sure that this change in gender will have significant effects on how medicine is practiced. The medical delivery system is in place, with depersonalization and the profit motive built into it, which is likely to make gender irrelevant. Female doctors are as likely as male doctors to be generous or greedy, to be patient- or profit- oriented, and to favor heroic medicine or preventive medicine.

How to Solve the Doctor Shortage Here is a simple, direct, and far-reaching proposal for social policy: To reduce the costs of health care, overcome the doctor shortage, and provide more care for the poor, let’s train more physicians. The government could finance new medical schools. The schools could be tuition-free, and the students could be paid a monthly salary. In return, for each year the graduates were supported in medical school, they would spend one year in areas where there is a doctor shortage. These new physicians would not be given final certification until they completed their years of public service. During those years, the government would pay for their medical malpractice insurance and pay them a salary equal to what the average American earns. The United States already has the National Health Service Corps, which offers support for students in medical school, but this would be a much more extensive program.

A social policy to increase competition among doctors would be met with shrill protest from the American Medical Association. The AMA stifles competition by limiting the number of medical graduates. If medical schools graduated enough new physicians to produce strong competition among doctors, the cost of medical care would drop, threatening the power of this medical monopoly.

Home Health Care

In Figure 10.8, you saw how expensive hospitalization is. To help reduce medical costs, some doctors are substituting home health care (also called domiciliary care), treatment given in a patient’s home. Most elderly patients prefer home health care, not only because it is less expensive but also because they find it more humane to be treated at home than in an unfamiliar and often depersonalized nursing home or hospital.

We can extend this concept by establishing group homes and supervised apartments for the mentally disturbed and the chronically ill who have difficulty living in the community on their own. There, we can provide them home health care. Such programs would be costly, of course, and granted our ongoing, huge budget deficits, we can ill afford them. You can also anticipate the objection that we would be spending more money on the “unworthy.”

Preventive Medicine

Prevention—taking steps that preserve health or avoid illness and disease—can be highly effective. The most preventable cause of premature death is smoking. Each year, a half million (480,000) Americans die from nicotine in its various forms (Centers for Disease Control 2016b). Many other unhealthy lifestyle choices lead to deaths at early ages, especially obesity and lack of exercise. Let’s look at how we can improve health and avoid premature deaths.

Three Types of Preventive Medicine

There are three types of prevention. Primary prevention keeps a disease from occurring in the first place. Examples are improving nutrition and vaccinating children. Secondary prevention refers to detecting a disease before it comes to the attention of a physician. An example is self-examination for breast cancer. Tertiary prevention refers to preventing further damage from a disease that has been detected. This is often the same as regular medical care. Examples are maintaining a diabetic on insulin and controlling an infection so that it doesn’t lead to death.

Food and Health

Primary prevention has a huge payoff for improving health. Proper nutrition, exercise, rest, and avoiding tobacco and the abuse of alcohol and other drugs strengthen the immune system and help people avoid many diseases. Many cancers can be prevented by a diet rich in beta-carotene, raw fruits, vegetables, and nuts. Supplements of natural vitamin C and E also reduce the risk of cancer. So do wheat bran, canola oil, soy milk, cantaloupe, avocados, olive oil, red wine, and leafy green vegetables—cabbage, broccoli, brussels sprouts, and spinach (Kushi et al. 2012; Kohler et al. 2016).

Studies of the effects of milk on health are mixed (Tian 2014). Some research indicates that milk can reduce the risk of cancer (Cho et al. 2004; Nielsen et al. 2011), but other research indicates that milk might increase the risk of cancer (Mayne et al. 1995; Shaw 2007). If milk does increase the risk of cancer, this could be due not to the milk but to its contaminants—pesticides, herbicides, and bovine growth hormones. The growth hormones that are fed to cows may pave the way for cancer by inhibiting the body’s natural cancer fighters (Epstein 1999). Some accuse Monsanto, a global corporate giant that produces bovine growth hormones, of caring more about profits than people’s health. To this, conflict theorists would reply, “Big surprise!”

Immunizations

Immunizing children is effective primary prevention. Not only do immunizations save lives but also they save vast amounts of money that otherwise would be spent on medical treatment. Yet about 10 percent of U.S. children have not been immunized against measles, mumps, diphtheria, hepatitis, and polio (Statistical Abstract 2016:Table 235). This is the overall average. The rate of immunization is lower for children in poverty.

Preventing Drug Abuse

Although not usually thought of as preventive medicine, no program would be complete unless it also included preventing drug abuse. From what we learned in Chapter 4, to reduce drug abuse is to prevent many health problems. Drug abuse prevention programs that are directed against smoking and alcohol abuse could prevent the untimely deaths of hundreds of thousands of people each year. Drug abuse programs, then, are another way to improve the nation’s health.

Eating Ourselves to Death

Something disturbing is happening in the United States, and it does not bode well for health. Let me share these two events with you:

While waiting for a space shot at Cape Canaveral, Florida, I struck up a conversation with a British couple in their 20s. I asked about their impression of the United States. ­Hesitantly, they said that they had never seen so many fat people in their lives.

When a friend from Spain arrived, he asked me why there were so many fat Americans.

Are these valid perceptions or ethnocentric observations of foreigners? They seem to be valid. In 1980, one of four Americans was overweight. This was a huge number of people. But since then this already-large percentage has jumped to two of every three American adults (NIH 2016; Statistical Abstract 1998:Table 242; 2016:Table 225). In short, Americans eat too much and don’t get enough exercise.

Some will say, “So what?” Isn’t “fat” just an arbitrary idea of how much people should weigh? And maybe this idea came from a skinny person.

Obesity has become a major health problem in the United States. So far, attempts to solve it have failed. Over the coming years, these two high school students can expect to suffer from severe health problems because of their weight.

Unfortunately, we are talking about a great deal more than this. Obesity is more destructive to health than alcohol abuse, with one of five deaths due to excess weight (Olson 2016). Why so many deaths? Among other reasons, people who are overweight are more likely to suffer from diabetes and to have strokes and heart attacks. And compared with thinner people, when the obese come down with these health problems, they are more likely to die from them (Calle et al. 2003; Franks et al. 2010).

This unprecedented increase in the weight of Americans flies in the face of what we know about preventing health problems. But with cultural tastes for fattening, sweetened, processed foods, the pounds pile on. The cause is not biological, but social. With the onslaught of advertising, the average American drinks about 50 gallons of soft drinks a year (Statistical Abstract 2016:Table 240). To reduce the consumption of sugary soft drinks (and raise money), some cities have a “soda tax.” Within this cultural ­setting—and because fattening, sugary foods taste good—it is difficult to halt this growing problem.

It is also significant to note that prevention is not the primary emphasis in our culture. The primary cultural orientation is to visit a doctor when health problems arise, not to avoid health problems through healthier foods and lifestyles.

The Problem with Preventive Medicine

The problem with preventive medicine is that it isn’t appealing—it doesn’t taste good like all those sugary foods. It violates our desire to eat sweets and swill soft drinks and alcohol. And it goes against our pleasure of being lazy couch potatoes. But these things are killing us. If we want health, we have to work at it. This means eating healthfully, getting the sleep we need, and forcing ourselves to do the exercises that our bodies require to function well.

If the medical profession were to give preventive medicine the same priority it gives heroic medicine and the treatment of acute conditions, the nation’s health would improve. But preventive medicine is not only less appealing to people who have to exercise and watch their weight. It is also less appealing to medical people who have been trained for open-heart surgery, screaming ambulances, and rushing about in emergency rooms—or, if not that, at least prescribing pills. And a major problem for both the public and professionals is that, unlike antibiotics or surgery, prevention doesn’t show immediate results.

To see how lifestyle can affect people’s health on a national basis, read Spotlight on Social Research: Solving a Medical Mystery.

Spotlight on Social Research

Solving a Medical Mystery

William Cockerham, professor of sociology at the University of Alabama at Birmingham, studies international aspects of health. He has done research on health and lifestyles in Russia and Eastern Europe, and he is doing similar research in Japan.

In the mid-1990s, I attended a medical sociology conference in Vienna. Sociologists from the former socialist countries in Eastern Europe reported that their countries were in the midst of a health crisis. They said that men were dying prematurely and that the life expectancy for women had either declined or stagnated. What was striking about their presentations and in the discussions that followed was that no one could explain why this was occurring. That in peacetime an entire group of industrialized societies was experiencing a prolonged deterioration in the health of the population was unexpected.

The lack of an explanation for this crisis presented an intriguing research question. The killer turned out to be an increase in heart disease that had begun in the mid-1960s. A review of the evidence showed that infectious diseases, environmental pollution, and poor medical care were not enough to cause this surge in mortality. A clue that other social factors were important was the fact that the rise in death rates was not universal. Heart disease differed by gender, age, urban–rural locale, education, and region. Those most affected were middle-aged, urban men who did manual work.

We now knew the “what” and the “who,” but not the “why.” To discover the “why,” I traveled to Russia and Eastern Europe. There, I collected data from clinics, hospitals, and ministries of health. I also interviewed public health experts, physicians, and sociologists. In addition, I observed how the people lived.

I uncovered three reasons for the increase in premature deaths. The first was policy failures: the failure to address the increase in heart disease and to adopt measures to lower smoking and drinking. The second seemed to be stress, which had increased with the collapse of communism: Workers had lost jobs and state benefits, such as housing and food subsidies. In addition, inflation had made their money worth less, driving down the value of their pensions and salaries. The third—and the primary reason—turned out to be unhealthy lifestyles. Heavy drinking and smoking and lack of exercise characterized the people who died prematurely from heart disease. To say “heavy” drinking is an understatement: Adult Russian males, who comprise 25 percent of the population, drink 90 percent of the alcohol consumed in a country that averages 14 gallons per person annually.

I did not have enough data, however, to determine conclusively that stress—which has a well-established connection to heart disease—was especially important. A grant from the European Union provided funds to survey 18,000 people in eight countries of the former Soviet Union. This survey showed that women actually are more stressed than men. While stress undoubtedly makes the women’s lives less pleasant and has consequences for their health, it is not killing enough of them prematurely to come close to the mortality rates of the men. As bad as the situation may be for the women, the key to explaining the health crisis ultimately lies in the men’s behavior.

Humanizing Health Care

Jeanne Kennedy, the chief patient representative at Stanford Hospital in Palo Alto, California, broke her kneecap rushing to a meeting. A member of her staff wheeled her to the employee health department, where a nurse practitioner she had worked with for years began to arrange for her care. But the nurse spoke to the woman pushing the wheelchair and ignored Mrs. Kennedy.

“It was crazy,” she said, “Here I was in my own hospital, hurt but perfectly capable, and she’s being very professional, but she’s talking over my head as if I were a child. And we worked together. She knew me!” (Carey 2005)

Patients hate being depersonalized, but how can you overcome it? Even when medical students have a strong desire to treat patients as people, the pressures of their training, accompanied by the faculty’s stress on organs, disease, and dysfunctions, change the students’ attitude about patients. Listen to this medical student:

Somebody will say, “Listen to Mrs. Jones’s heart. It’s just a little thing flubbing on the table.” And you forget about the rest of her . . . and it helps in learning in the sense that you can go in to a patient, put your stethoscope on the heart, listen to it, and walk out . . . . The advantage is that you can go in a short time and see a patient, get the important things out of the patient, and leave (Haas and Shaffir 1993:437)

Ultimately, medical training needs to stress the inherent worth of patients—that each individual is valuable and deserves personal attention. Achieving this is certainly an uphill battle, because depersonalization has become instinctive to medical personnel. The best social policy, it seems, is the same as the one I proposed to overcome the doctor shortage. If we train enough doctors, we will produce strong competition for patients. Of necessity, doctors will have to treat patients as people. Those who don’t will have fewer patients—and less profit.

In Sum 

The aim of these policies is to reduce the cost of medical care, improve health by preventing disease, and humanize the treatment of patients. These simple, direct policies offer inexpensive alternatives to highly technological and costly medical care. But as we discuss in Issues in Social Problems: Doctors, Please Wash Your Hands!, for one problem there is an even simpler solution.

Issues in Social Problems

Doctors, Please Wash Your Hands!

Do you recall the statement I made at the beginning of this chapter, that each year about 400,000 Americans die needlessly at the hands of doctors and nurses? Many of these deaths are so easily preventable that it is infuriating to anyone who knows anything about them.

Let’s look at one type, deaths from catheterization. This term simply refers to inserting a little tube in a vein to deliver drugs or other liquids. This allows a nurse to make quick, easy connections to a tube that is attached to a bag of fluids. About 40,000 ­patients each year were getting blood stream infections from the catheters. About 5,000 to 10,000 of the patients died from the infections.

After new procedures were followed, the infections and deaths were cut almost in half.

What new procedures could have such dramatic results? Here are the main ones:

1. The doctors wash their hands.

2. The area where the needle is inserted is sterilized.

And there is a third. Nurses are given a checklist and—breaking with tradition—the nurse is authorized to tell the doctor that he or she must wash and must follow the checklist and to report the doctor if he or she does not do so (Mathews 2012). Medical researchers continue to remind doctors how important these basic procedures are (Band and Gaynes 2016).

The Future of the Problem

1. 10.8 Discuss the likely future of medical care as a social problem.

To try to catch a glimpse of the future, let’s look at trends in medical technology and in changing the direction of medicine.

Technological Advances

Both doctors and patients like new technology. They both derive satisfaction from technology that improves the diagnoses and treatment of medical problems. In the coming years, we can expect doctors to continue to adopt new medical technology and patients to expect their doctors and hospitals to have whatever technology is new. Within this context, the manufacturers of medical equipment will continue to develop and market cutting-edge technologies. You can expect, then, that medical costs will continue to escalate.

Advances in technology are changing the practice of medicine. Shown here is an ear grown in the laboratory, ready to be grafted onto a human.

Ethical Dilemmas from New Technology

Out of these technological advances have arisen ethical problems that plague medical professionals and laypeople alike. If people can be kept alive artificially, must doctors keep them alive? Does “brain dead” really mean “dead”? If so, should physicians be allowed to “harvest body parts” from people who (only because of machines) are still breathing? Should medical researchers be allowed to test dangerous drugs on these people, because, after all, they are “really” dead?

In Technology and Social Problems: “Need a New Body Part?” Turn on Your Printer,” we consider how technological advances hold both the potential for improving our lives and create further ethical dilemmas.

Technology and Social Problems

“Need a New Body Part? Turn on Your Printer”

The advances in technology are mind-boggling. Some are so astounding that it is difficult to grasp that what is being developed is even possible. Let’s explore one of these leap-frogging changes.

3-D printers are fascinating. Like the replicator of Star Trek, the technology allows us to print entire items. By laying down fine layers of whatever substance an item is made of, we can reproduce exact replicas of the item. This can be an item as simple as a cup or as complicated as a motorcycle. And you can drink from the replicated cup or ride the motorcycle, whose parts all work.

We have just begun to explore the implications of this fascinating achievement in technology. How will we apply it beyond making car parts on demand?

How about making human parts on demand? I’m talking about printing body parts such as working blood vessels, real veins and arteries that transport blood through the body. As the technology develops, we might be able to print livers and kidneys so good that we can transplant them into real people.

This isn’t just some futurist’s dream. 3-D bioprinters that can replicate body tissues and organs are now being developed. Their laser-guided nozzles extrude onto a mold “bio-inks” of human cells. After about 24 hours, the mold is removed, with a bioreactor keeping the tissue alive. As the tissue stitches itself together, it becomes the particular organ it was intended to be (Hotz 2012; Scott 2016).

There are no 3-D–printed kidneys or hearts yet, but they appear to be on the way. One of the problems to be overcome is developing a capillary system to feed the developing tissue. But if you look carefully at the gleams in the bioengineers’ eyes, you will see the reflection of patients’ X-rays and CT scans transformed into digital diagrams for printed body parts.

What a potential future. Absolutely mind-boggling.

This prosthetic hand was made entirely on a 3D printer. It is being fitted on a woman who lost her right hand at the age of four. We are still at the initial stages of 3D printing.

For Your Consideration

1. When the time comes that we can actually print replacement body parts—and this is likely to occur soon—do you think that we can continually replace our worn-out parts so we can live indefinitely, or at least for a couple of hundred years or so?

2. And if Mary Leticia, a star athlete, decides to enhance her running by printing out a new knee, one that improves her performance, should she be allowed to compete with people who are left with their old joints?

3. Then there is the matter of social equality. If a rich woman needs a new body part, should she be given preference over a poor woman?

4. How about a prisoner convicted of rape and murder? Should he be given the same consideration as your sociology instructor?

The Internet

The Internet has helped some patients regain control over their medical care. People who have rare diseases, for example, can participate in online discussion groups. Although people don’t meet personally, they share their experiences and knowledge with one another. Some doctors are surprised—and dismayed—when their patients know more than they do about a new treatment or some new research. Not only do physicians feel threatened because they no longer are the sole possessors of esoteric knowledge on rare diseases or even the treatment of common disorders, but they also fear that patients can be picking up misinformation on the Internet. Sharing information online can also contaminate medical experiments. Some patients are able to determine whether they are receiving an experimental drug or a placebo, an inert substance that is designed to look like the real medicine being given (Bulkeley 1995).

A Final Note

You have seen in this chapter how health and illness, disease and death, are much more than biological matters. Running through them all are social factors that affect who is sick and who is healthy, who gets what disease, and who dies and who lives. I have stressed the two-tier aspect of the medical delivery system, which might be tinkered with, but which I do not expect to fundamentally change. The rich will always receive better health care than the poor—and will also live healthier lifestyles.

You have seen how significant lifestyle is to health. I expect that the medical delivery system will gradually place more emphasis on “wellness,” and that the future will bring both heroic intervention and preventive medicine alongside one another.

If you take anything away from this chapter for your personal life, it should be how important lifestyle is, that you make your own lifestyle choices, which affect your health down the road. To make wise choices is up to you.

Summary and Review

1. What people consider to be health and illness varies with culture and social class. Physical and mental health problems are based on both biological and social factors.

2. Industrialization has brought better health, but with industrialization has come an increase in cancer, heart disease, drug addiction, and chronic illnesses caused by lifestyle, aging, and environmental pollution. HIV/AIDS illustrates the relationship among behavior, environment, and disease. Physical and emotional problems are more common among the poor. To explain the relationship between social class and mental illness, sociologists prefer environmental explanations rather than genetic ones.

3. The U.S. medical system is centered on specialized, hospital-based care and heroic intervention. A fee-for-service system increases medical costs. Preventive medicine redirects the emphasis to people’s lifestyles and environment.

4. Social inequalities plague physical and mental health care. In our fee-for-service system, health care is not a right but a commodity sold to the highest bidder. The United States has a two-tier system of medical care— public clinics and poorer treatment for the poor and private clinics and better treatment for the more affluent. Despite health care reform and universal insurance, the poor and affluent will not receive the same medical treatment.

5. Two policies designed to control medical costs are to pay patients to stay healthy and to pay doctors to reduce unnecessary medical care. HMOs are a form of managed care that provides a fixed amount of money to a medical corporation to attend to the health needs of a group of people. Medical services and tests come directly off the corporate bottom line, leading to a conflict of interest in treating patients. On the positive side, it costs the HMO less if providers catch problems early and if they practice preventive medicine.

6. The medical profession is experiencing a tension among its traditional focus on heroic intervention in acute problems, the need to treat chronic problems, and the emerging focus on preventing medical problems by changing lifestyles. Within this tension, there is likely to develop increased emphasis on preventive medicine—better health habits, a cleaner environment, and education designed to teach people how to take care of themselves and to manage their illnesses.