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Introduction to the Sociology of Health and Illness

MEDICAL SOCIOLOGY LECTURES (PART A)

by Dr PHUA Kai Lit
School of Medicine and Health Sciences
Monash University Sunway Campus
Bandar Sunway, Malaysia


BECOMING ILL/ILLNESS BEHAVIOUR

"DISEASE" VERSUS "ILLNESS": "Disease" is physical malfunctioning of the body. "Illness" is subjective perception of whether one is sick or not. Possible to have a disease and not feel sick, e.g., undetected diabetes. Also possible to feel sick without any detectable disease, e.g., hypochondriasis.

CULTURE-BOUND ILLNESSES: Illnesses found in some cultures but not in others, e.g., anorexia nervosa (not found in poor countries where people may not even have enough to eat!), Chinese restaurant syndrome, latah, koro.

MEDICALISATION OF SOCIAL PROBLEMS: A social problem becomes regarded as a medical problem for doctors to "treat" or "cure", e.g., alcoholism, ADHD (Attention Deficit and Hyperactivity Disorder), gambling addiction, sexual addiction. See articles on ADHD and Sexual Addiction.

LA Times article

DEMEDICALISATION OF MEDICAL PROBLEMS: Something once regarded as a medical problem is no longer regarded as a medical problem today, e.g., homosexuality is no longer regarded as a mental illness by the American Psychiatric Association (since the early 1970s)

ICEBERG MODEL OF DISEASE: Doctors see only the "tip of the iceberg" of diseases present in the community. Many people have episodes of disease but don't see the doctor for treatment.

REASONS FOR DELAY IN SEEING THE DOCTOR: You should "put yourself in the patient's shoes" (i.e. imagine you are the patient) and think of reasons why you are reluctant to see the doctor. Examples: fear of being diagnosed as being HIV positive, ignorance of symptoms, religious beliefs, embarrassment, cannot afford to pay the medical bills, etc.

THE "SICK ROLE": Know what it is and especially, the criticisms of this concept. According to this concept, the patient should (1) seek care when sick (2) cooperate with the doctor (3)want to get well quickly. (4) In return, the patient is excused from normal responsibilities

In reality, people may not seek care even when they are quite sick or experiencing moderate pain (you should think of reasons for this seemingly "irrational" behaviour), they often do not take their medicine properly, some people are malingerers (who claim to be "sick" so as to be excused from work). Also, patients who are sick may have no choice but to continue with their normal responsibilities e.g. a sick single mother with young children.


HEALTH AND FAMILY DYNAMICS

Dr Phua's paper on the family and medicine
Lost Children of Rockdale County (Transcript)
Lost Children of Rockdale County (Opinions of Experts)

Living and dying alone in Singapore

THE TYPICAL VIEW OF THE FAMILY VERSUS NEW FORMS: The "family" is a major social institution found in all human societies. The stereotyped view of the family is that it consists of a working father, a housewife mother and dependent children. This is getting less common. Newer forms of the "family" have appeared e.g. single parent family, "blended" family resulting from divorce and remarriage, even homosexual couples (with or without children). With globalisation, there is also the "transnational family" where the father/mother has to travel frequently (to foreign countries) on business and the sons/daughters are scattered across many countries.

FUNCTIONS OF THE FAMILY: Companionship. Sex and reproduction. Socialisation of children. Social support (especially in crises). Economic cooperation. Supermom Syndrome

THE FAMILY LIFE CYCLE: This refers to family formation (when one person marries another), family changes (birth of first child, birth of subsequent children)("empty nest syndrome" after the children grow up and leave the home), family dissolution (due to divorce or death of a spouse).

FAMILY IMPACT ON ILLNESS BEHAVIOUR: Family upbringing and family members can influence a patient's illness behaviour e.g. being stoic (such as putting up with pain and discomfort), decision to self-medicate or seek professional help. Whether to see a doctor or traditional healer (bomoh, herbalist etc)

FAMILY MEMBERS AND CARE OF THOSE WITH LONG TERM ILLNESS: Female family members are especially important in providing care to sick children, husbands, inlaws, elderly parents. See article on Eldercare

DYSFUNCTIONAL FAMILIES: Dysfunctional familes are troubled families that have a negative impact on the physical and psychological well-being of its members. Abuse of children - neglect, verbal abuse, physical abuse or even sexual abuse. Wife-beating and domestic violence. Alcoholism or drug abuse in the family.

Please note that a divorced family is NOT NECESSARILY a dysfunctional family!

FAMILY IMPACT ON HEALTH-RELATED BEHAVIOUR: Dietary preferences, smoking (including "passive smoking" or second hand smoke) , alcohol consumption (children of alcoholics are more likely to become alcoholics themselves), aggressive or risk-taking behaviour, values and sexual behaviour.

IMPACT OF FAMILY CHANGES ON HEALTH: How "stressful life events" affect other family members. People are more likely to fall sick when they experience "stressful life events" such as death of a spouse, death of a child, divorce, serious marital problems, etc. (Definition of "stressful life event" - a life event that results in high psychological stress and increases the risk of sickness). Large families may exert a negative impact on welfare and health of kids e.g. some kids may be neglected, less resources to go round, boys may be favoured over girls etc.

IMPACT OF BAD HEALTH ON OTHER FAMILY MEMBERS: Financial - medical bills to pay. Sick person may not be able to work. A relative may have to stop working in order to care for a sick person. Mental stress - taking care of a relative with schizophrenia, Alzheimer's Disease, incontinence, HIV positive, bed-ridden etc. Role changes e.g. if a wife is seriously sick or dies, the husband will have to take care of the kids, cook, clean etc. In parts of Africa today, many children have become orphans because their parents have died of AIDS.


SOCIAL CLASS AND OTHER INEQUALITIES IN HEALTH

Read about Poverty & Hunger in a "Rich" Country
Click for Interview with Prof Michael Marmot on social determinants of bad health

EPIDEMIOLOGY: Scientific study of the determinants ("causes") and distribution of disease in human populations. Epidemiologists look at relationships between "risk factors" such as ethnicity, social class, gender, age, place of residence, educational level, marital status etc" and the occurrence of disease.

UNEQUAL BURDEN OF DISEASE: The burden of disease is unequally distributed. Some social groups suffer from higher rates of disease, have more disabilities and die younger e.g. Orang Asli, the poor, rural people, urban slum dwellers, illegal migrant workers.

UNEQUAL ACCESS TO HEALTH SERVICES: Julian Tudor Hart's "Inverse Care Law" i.e. people who need health services the most are least likely to get them. Barriers to access: financial (unable to pay the doctor's fees, unable to pay for drugs and medical procedures, having to choose between paying for health care and paying for other necessities of life, time spent seeing the doctor means lost wages etc), geographic (clinics and hospitals are far away), cultural (lack of knowledge of seriousness of signs & symptoms of disease, theories of disease causation that influence the patient not to see a doctor). In contrast, rich people or people in rich countries may make use of health services "unnecessarily". Read article on "Necessary versus Unnecessary plastic surgery" For example, people in Asia pay for plastic surgery to make their eyes rounder, women in USA go for plastic surgery to make their breasts look bigger. Some men in the USA even go for "pectoral implants" to make their chest and shoulders broader and more muscular-looking!

WAYS TO GROUP PEOPLE: Ethnicity ("race"), social class (upper class, middle class, working class, "underclass"), gender ("sex"), age, region (rural, urban and suburban)(low income country, middle income country, high income country).

SOCIAL CLASS GRADIENT IN HEALTH: The lower the social class, the poorer the health. People from lower social classes experience higher disability rates, higher morbidity rates, higher mortality rates and have lower life expectancy.

REASONS FOR THE SOCIAL CLASS GRADIENT: The gradient is real and not an artifact of measurement. No matter how "social class" is measured (whether by INCOME or OCCUPATION), the relationship between class and health persists. Due to poverty, differences in health-related behaviour (partly because of ignorance), poor quality housing in unhealthy or high crime environments , more physically demanding or dangerous jobs of lower class people. Also, constant stress because of worries about money and unemployment (in industrialised countries, unskilled workers are more likely to experience bouts of unemployment than skilled workers).

Thus, a low social class position can result in poor health. On the other hand, poor health can also lead to a fall in social class position (the "Downward Drift" hypothesis e.g. people who become alcoholics or drug addicts, people who become unemployed because of physical disability caused by workplace or traffic injuries etc can fall into poverty).

THE BRITISH "BLACK REPORT": The Black Report concluded that equalisation of access to medical services through the British National Health Service (NHS) has not eliminated the social class gradient in health. GOOD HEALTH DEPENDS ON MORE THAN ACCESS TO MEDICAL SERVICES .

Note: In West Malaysia, the poverty line is RM529 per month
In Sarawak, it is RM600 per month
In Sabah, it is RM690 per month

No money to see the doctor in China

No money to see the doctor in the USA

Investigating the lives of the Working Poor in America

Ethnicity, class, migrants, work and health in USA

Heatwave Deaths

The People's Charter for Health (from the People's Health Movement)

Report on the People's Health Assembly held in Dec 2000 in Bangladesh


REFERENCES

Wallace, R.B. ed. 1998 "Maxcy-Rosenau-Last Public Health and Preventive Medicine" 14th ed. Stamford, Connecticut: Prentice-Hall International Inc.

Cassens, B.J. 1992 "Preventive Medicine and Public Health" 2nd. ed. Philadelphia: Harwal Publishing

Lucas, A.O. and H.M. Gilles 1990 "A New Short Textbook of Preventive Medicine for the Tropics" 3rd. ed. Sevenoaks, Kent: ELBS with Edward Arnold

McWhinney, I.R. 1997 "A Textbook of Family Medicine" 2nd. ed. New York: Oxford University Press

Patrick, D.L. and G. Scrambler 1982 "Sociology as Applied to Medicine" London:Bailliere Tindall

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