Key Concepts in Health Studies

Chris Yuill, Iain Crinson, Eilidh Duncan

• Publisher: SAGE Publications Ltd
• Year: 2010
• ISBN:
  9781473903319
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Key Concepts in Health Studies provides a much needed guide to the central concepts used across the subject, and offers the reader a comprehensive overview of the core topics, theories and debates. Drawing together the fundamentals within the disciplines of health, nursing, and social policy this book is an ideal text both for students studying health in a range of academic fields, and for health and social care practitioners. From ageism to public health, and gender to obesity, the book offers an exciting guide to the multidisciplinary field. Each entry features:

-A snapshot definition of the concept

-A wider discussion of the main issues

-Case studies illustrating the application of theory to practice

-Examples of further reading

Highly readable, with clear indexing, and cross-referencing between entries, this is not only a student-friendly textbook that will enable the reader to dip into and update their knowledge of a particular key concept, but a valuable resource to anyone practicing in the health care field.

Part 1

Defining Health

The biomedical model of health

The medical, or as it has more properly become known, the ‘biomedical’ or ‘scientific’ model, draws upon biochemical explanations of ill health as the basis for treatment and intervention, as opposed to the focus of other forms of non-allopathic medicine (see Alternative or complementary medicine).

Many sociologists and others have for sometime argued that despite the undoubted achievements of biomedical interventions in the management of particular forms of illness (but also see Medicalization), and the very real effects of biological mechanisms in illness, the practice of biomedicine remains rooted in a knowledge base that is not as empirically-bound as biomedical scientists would have us believe. However, to the extent that biomedical knowledge is concerned to categorize and manipulate an understanding of biological mechanisms in order to contextualize the reality of the human illness, it is a process of knowledge construction which implicitly involves cultural and social assumptions as well as drawing upon a biological base of understanding (Lock, 1988).

The continuing dominance of the biomedical model or paradigm within modern health care systems is reflected in the day-to-day rational–scientific practices associated with the work of doctors in the hospital or clinic. For Foucault (1973) and those influenced by a relational conceptualization of power, these everyday clinical practices have contributed to the (social) construction and reproduction of what is termed the ‘biomedical discourse’. A ‘discourse’ being the means through which we have come to know, understand and respond to aspects of our lives; in this case, our health and illness. Studies in the history of medicine have demonstrated the ways in which this biomedical discourse has been shaped not only by an emergent scientific understanding of the biological mechanisms of the human body, but also by other social, economic and cultural developments.

For example, Jewson’s (1976) classic work on the development and production of medical knowledge identified a series of what he termed ‘medical cosmologies’, or ways of seeing the contribution of medicine to the diagnosis and treatment of the sick. Jewson drew on these ‘cosmologies’ to describe the ways in which developments in medicine have historically been intimately linked with the sets of social relations and dominant ideas existing within society at the time. The person-orientated cosmology was seen as existing prior to industrialization and the ‘Age of Enlightenment’. This approach to the practice of medicine required the physician to recognize the patient as a holistic entity, and where medical judgement was to be made in terms of the personal attributes of the sick person (if they were not, then the physician would lose the business!).

The early development of hospital-based medicine in the late eighteenth century is seen as being associated with the broader social changes occurring within British society at that time. The rise, that is, of capitalist forms of production, industrialization, the growth of towns and cities, and the increasing dominance of scientific knowledge and explanation. The emergence of a specialist scientific medical knowledge reflects the historical period in which the doctor–patient balance of power begins to change, and is described as an object-orientated cosmology. At this time the medical profession was becoming less dependent upon patronage of rich patients, and the control of medical knowledge began to pass from the patient to the clinician. Hospitals now became training centres for the new profession of medicine and sites for scientific research. The late nineteenth century witnessed the emergence of Jewson’s third medical cosmology, that of laboratory medicine. Here, the patient as the object of medical practice moves out of the frame, and disease becomes a ‘physio-chemical process’. This practice is characterized by the emergence of what Foucault (1973) termed the new ‘clinical gaze’, reflecting the changing social relationship of power between doctors and their patients.

The main methodological and philosophical assumptions of some of the key components of the biomedical model or ‘discourse’ are set out and explored below:

• A knowledge base that draws in large part upon a positivist methodology. Positivism is the philosophical position that science can only examine what is observable and measurable. Knowledge of anything beyond that is deemed to be impossible. It follows then that only observable signs and symptoms can lead to a medical ‘diagnosis’, all ‘real’ disease has to have measurable biological causal mechanisms. This approach has, in the past, frequently led to the marginalization and neglect of social and psychological factors in ill health.
• Health defined as the absence of any biological abnormality or change. Therefore ‘disease’ as its obverse is conceived as predominantly a biological state associated with the malfunctioning of human biological systems. This is essentially a biologically reductionist view in that all forms of illness are seen as causally related to specific biochemical mechanisms.
• The (ontological) separation of the mind and body. This philosophical notion derives from the work of the seventeenth-century philosopher René Descartes, who distinguished between the res cogitans and the res extensa. The former referred to the soul or mind and was said to be essentially ‘a thing which thinks’, while the latter referred to the material stuff of the body. The latter is much more amenable to observation and measurement, and so enabled the emergence of modern bioscience and the practice of biomedicine (Bracken and Thomas, 2002). The legacy of this ‘Cartesian split’ within biomedicine has been a rejection of any possible connection between the mind or psyche and physicality. This distinction is now beginning to be addressed by more recent developments in neuroscience.
• The reification (i.e. to make an essentially abstract idea into something concrete or ‘natural’) of disease categories. The specific notion of disease that we all understand today (as a discrete set of pathological processes that can be isolated and located with body organs and tissues) first appeared with the emergence of modern medicine. The process of constructing diseases categories bundled together observed and measurable ‘deviations’ from the ‘normal’ functioning of the body (often distinguishing between those localized to specific organs and those deemed to be more general or systemic within the body), was crucial to the (social) construction of a body of clinical knowledge with which to train doctors and develop biomedical interventions. Drawing distinctions between the pathological effects of different diseases enabled a set of nosological (classificatory) tables to be drawn up. Yet, from the very beginning of modern medicine, the process of disease classification was not solely based on bioscientific knowledge of the ‘natural’ and the ‘pathological’. There is an extensive literature which has documented, for example, the ways in which women were frequently ‘diagnosed’ as suffering from ‘hysteria’ when their behaviour appeared to fall outside particular social norms. This example and many others reflect the social, political and cultural assumptions surrounding the process of disease classification. The process of disease classification is ongoing, with the International Classification of Diseases (ICD) now in its 10th edition (for a history of the development of the ICD, see WHO, 2008). This history demonstrates the contested and often uncertain nature of the practice of disease classification that the process of reifying disease would deny.
• The doctrine of specific aetiology. This is the oversimplified notion that draws on the positivist methodology (described above) that pathologies have single linear causality, i.e. a TB bacillus invades the ‘host’ (individual) bringing about the development of a particular form of tuberculosis (Comaroff, 1982). In practice, this doctrine has served to limit the understanding of the environmental factors that make individuals and social groups more susceptible to disease.

However, drawing attention to the biomedical ‘discourse’ does not constitute the case for arguing that the whole edifice of biomedicine is purely a social construction as some commentators would claim. What it does do is to question the claim to scientific rigour of all biomedical and clinical practice. Indeed, the practice of Medicine is sometime described as an ‘Art’ by clinicians themselves. What is being referred to here is the practice of making a diagnosis based on experience and the synthesis of a series of clinical ‘facts’ and ‘data’ about an individual patient from a variety of sources. The attempt is then made to connect this often incomplete and context-specific knowledge to a ‘textbook’ disease classification which is not always a systemic process; hence the notion of medical practice as an ‘art’ (Berg, 1992).

REFERENCES

Berg, M. (1992) ‘The construction of medical disposals’, Sociology of Health and Illness, 14(2): 151–81.

Bracken, P. and Thomas, P. (2002) ‘Time to move beyond the mind–body split’, British Medical Journal, 325: 1433–4.

Comaroff, J. (1982) ‘Medicine, symbol and ideology’, in P. Wright and A. Treacher (eds), The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh: University of Edinburgh Press.

Foucault, M. (1973) The Birth of the Clinic: An Archaeology of Medical Perception. London: Tavistock.

Jewson, N. (1976) ‘The disappearance of the sick man from medical cosmology 1770–1870’, Sociology, 10: 225–44.

Lock, M. (1988) Biomedicine Examined. London: Kluwer Academic Publishers.

WHO (World Health Organization) (2008) International Classification of Diseases: History of ICD. Available at: http://www.who.int/classifications/icd/en/HistoryOfICD.pdf (accessed April 2009).

The social model of health

The social model of health offers a distinctive and holistic definition and understanding of health that moves beyond the limitations and reductionism associated with the medical model of health. Health, according to the social model, is not a state of being solely under the domain of the medical profession, nor is health and disease only made intelligible by findings of medical science. Rather, a perspective of health is realized that embraces all aspects of human experience and places health fully in the dynamic interplay of social structures and embodied human agency. Such an approach in understanding health is crucial for Health Studies as it allows a wider understanding of health, one that accords with the multidisciplinary basis of the Health Studies approach and provides an excellent conceptual vantage point for the study of health.

The key elements of the social model of health are identified and outlined below. Many of the themes, such as the role of wider social and psychological elements, are encountered throughout this textbook and in many respects this entry provides a condensed overview of the ideas that animate Health Studies.

Individual health is enabled or inhibited by social context. A common lay perception of health, and one that is frequently found in media representations, is that what makes people healthy or ill is down to their own choices. People choose, for example, to eat the ‘wrong’ sort of high-fat sugary foods, or choose not to diet regularly or choose to engage in risk activities such as smoking. While the power and influence of human agency (ability to make decisions) cannot be ignored, only about a third of poor health can be explained by the choices people make. To further an understanding of health choices it is important to consider that people have to make sense of their lives as conditioned by the specific context in which they find themselves and in which they exercise that agency. Social distinctions such as class, gender and ethnicity also differentially shape the experience of these social contexts and it is to these that we must turn in order to have a fuller social conceptualization of health.

Where someone is socially ‘located’ allows (or denies) access to certain resources, such as the ability to participate in certain power relationships or to emotionally experience life in a certain way. Social class provides a useful example here. On average, both men and women from social class five live shorter lives than their counterparts in social class one (approximately, 7.5 years for men and 5 for women); they will also experience more life-limiting illness, be exposed to greater chances of disability and will age quicker overall. The reasons for the variance between social classes can be found in how class shapes people’s lives. Different social classes have access to better or worse material resources (good housing, for example) and to how much control and power they can exert over their lives. The work of Marmot (2005) indicates that those with more control over their lives tend to have healthier lives than those with low control. How much control one can effect is, in turn, strongly related to social class.

The body is simultaneously social, psychological and biological. The social model of health understands that the human body is much more than simply biology, physiology and anatomy. Instead, the human body is perceived as being bound up in and emerging from many different relationships involving biological, social, psychological, cultural and individual processes. One important process is that of identity. It is both through and with the body that self-identity is enacted and performed. Daily routines attest to this practice with the styling of hair, the selection of particular clothes or the pursuit of the ‘perfect’ toned gym body. The use of the body to display identity is heightened in consumer societies where appearance can be everything. That sense of identity can be challenged and questioned by the onset of chronic illness, for example. Bury (1991) in his sociological work on chronic illness identifies how chronic illness disrupts an individual’s biography triggering a re-evaluation of sense of self.

Health is cultural. The ways in which health is perceived and the experiences of disease and illness are expressed vary by culture. Health and healing have long been important aspects of human existence and all cultures have developed particular norms by which to express the changes that illness brings to their state of being. For example, South Asian people express mental distress using physical metaphors referring to pains in the body as opposed to deploying emotional metaphors (Fenton and Charlsey, 2000). As always when discussing culture, care must be taken not to imply that cultural differences in expressing and perceiving health and illness belong only to ‘ethnic minority’ groups. Within ‘ethnic majority’ groups too there are varied traditions of relating the experiences of being unwell. Williams’s (1983, 1990) research in the North-East of Scotland among older people illustrates this point. He found that the particularly strong variant of Protestantism that informs the local culture lead to a stoical approach to illness. People who were ill were expected to carry on without complaining or drawing attention to their discomfort.

Culture can also exist in the ‘sub-cultures’ of the office and sports team. Roderick’s (2006) research explored the contradictions found among professional footballers on experiencing pain. Given that they were injured, the next logical step would have been to report the injury, but that might have lost them their place on the squad. The players would consequently endure high levels of pain and injury. By doing so, this could exacerbate the injury, thus jeopardizing future performance and their place on the team. This mode of behaviour may seem illogical but is perfectly consistent with the (masculine) culture of the team in not admitting to pain.

Biomedicine and medical science is something – but not everything. There can be a temptation to ‘write off’ all that biomedicine and medical science purports to do given the criticisms that are levelled against it. Medical science can be upbraided for being biological reductionism, technological determinism and overstating its efficacy. Many of these criticisms are perfectly valid but one should avoid replacing a ‘medical imperialism’ with a ‘social science imperialism’. Simon J. Williams (2001) warns that sometimes social science perspectives can present a caricature of biomedicine to the extent that no medic would recognize the medical model that they are said to be practising. He also points out that medical science does exhibit many strengths, which are unfortunately often ignored by social scient...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Notes on the text
• Notes on the authors
• Introduction
• Part 1 Defining Health
• Part 2 The Human Life Course
• Part 3 Health Protection
• Part 4 Health Beliefs and Health Behaviour
• Part 5 The Lived Experience of Health and Illness
• Part 6 Health Care Provision