The Sage Dictionary of Health and Society

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Kevin White

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      On Writing a Dictionary of Health Social Sciences

      If you open this book looking for Oxford English Dictionary type definitions you will be disappointed. Rather, in this dictionary I have attempted to show how critical medical anthropologists, sociologists, historians and philosophers of medicine use words to discuss healthcare and healing systems. Psychological and sociobiological concepts are also included, though usually contrasted with sociological accounts. This is because they make the same assumptions that medicine does about sickness, illness and disease: that they are a product of nature, existing independently of social life, and that they are essentially individual events, the product of the individual's biology or psychological characteristics. So the dictionary provides an account of how words are used in the social sciences when exploring the activities of professional medical workers, patients' experiences of disease, or alternative understandings of the causes of sickness, illness and disease. Thus many of these usages are at odds with both common-sense usage and medical usage. From a social sciences perspective, disease, for example, is not regarded as just the simple, or even complex, malfunctioning of the body. Rather, depending on the perspective of the social scientists under consideration, it is the product of what is defined as disease, its social distribution, and treatment processes, of the wider structures of power relationships in society. As an example, taking four major social science approaches to explaining disease will illustrate the point.

      Marxists argue that the cause of disease can be attributed to the alienating features of life in a capitalist society. Those among the unskilled and manual labouring sections of the workforce die earlier, and of more preventable conditions, than those in managerial and professional sectors. Those at the top also receive better and earlier treatment for their condition, thus enhancing their longevity. Feminist sociologists point to subordination of women in a patriarchal society, arguing that the focus on women's bodies by the medical profession, and especially the medicalization of their reproductive capacity, is in fact an exercise in social control. Foucauldian sociologists argue that medicine is part of a centralized administrative state apparatus which sorts and classifies the population to police deviance. Moreover, modern societies have been so successful in constructing an understanding of what is normal, based on medical and psychiatric definitions, that we have internalized these norms, and actively police ourselves. Thus in this analysis the focus on fitness, body weight, jogging and diet – healthism – are aspects of social control by the psy-professions, though we experience them as freely chosen pastimes or reasonable concerns about our physical and psychological well being. Even those sociologists who view medicine in a favourable light, for example Talcott Parsons, argue that despite its overt role of caring and curing, the fundamental role of the medical profession is to guard entry into the sick role and to maintain individuals at a level to competently perform their social roles. So something that is taken for granted by the medical sciences and in common usage, disease, as an objectively existing disorder, is for the health social sciences very problematic. Disease and how an individual experiences it, is the product of the organization of the economy, the gendered division of labour, the division between the private world of the home and the public world of work, the ranking of ethnic groups into status hierarchies and the impact of class membership on life chances. It is not an accident of biology or nature.

      This leads social scientists from a wide range of perspectives to argue that the problems of our society which are usually dealt with by medical practitioners should be seen as social issues. They argue that in contemporary society many conditions which have their origin in society – learning disabilities for example – are medicalized and turned into ‘natural’ conditions which obscure the social processes producing them. So while there is a wide range of social science perspectives on health and illness – the Parsonian, interactionist, social constructionist, Foucauldian and feminist – they all distance themselves from the medical model of disease. This is because of three central aspects of medical thought. First, it is biologically reductionist, reducing human action to its lowest common denominator, its claimed understanding of the body, and separating the experience of sickness, illness and disease from their social location. Second, the medical model, developing out of the Cartesian separation of mind and body, is mechanistic and behaviouristic, conceptualizing disease as an event that happens to parts of the body and not an experience that involves the whole person. Third, the medical model is scientistic, applying the methods of the natural sciences – designed to examine an inert nature – to human beings who actively and meaningfully construct their environment. The use of statistical definitions of disease, in particular, leads to definitions of disease as deviations from a norm that takes no account of the individual's experience of the condition. Thus in the medical approach sickness, illness and disease are things that happen to the body, independently of its social location and the subjectivity of the individual, to be treated using drugs and high cost technology.

      The development of the social science approach, in general, develops out of a long tradition of social medicine, derived from Frederick Engels and Rudolf Virchow, which takes as its premise that health and illness are the product of social, political and economic relationships. Rather than point to the individual's body, or to germs as the sole cause of disease they identified the social environment as the source of sickness and ill health. Along with others in the sanitary movement such as Booth, Snow, and the Webbs, the solution proposed for ameliorating disease was to clean up the slums, keep water fresh and uncontaminated by sewage, and enforcing the hygienic production of foodstuffs.

      These early social, political and economic analyses of the causes of disease are backed up by historical analyses of the negligible role of organized medicine in contributing to the health of the population in the nineteenth and twentieth centuries. Rather than the triumphal overcoming of diseases as a consequence of great men, having great breakthroughs, in great institutions, as Whig histories of medicine would have it, it was precisely urban reform and control over working conditions that transformed the health of the population. As the historical epidemiologist Thomas McKeown has demonstrated, environmental and social reforms counted for more in the development of contemporary health standards than any breakthroughs around the germ theory of disease, the formation of the medical profession, or developments in medical technology. The work of Archie Cochrane in Britain in post-World War II continued to testify to the limited or unknown utility of much medical practices and the need for the development of evidence-based medicine if medicine's claim to be a science was to have any basis. Coupled with Ivan Illich's analysis of modern medicine as iatrogenic there developed a powerful critique of claims of the medical profession to be the practitioners of the humane application of science in society. The medical profession and its activities came to be seen as part of the problem rather than a solution to the problems of sickness and disease in society. This orientation was given substantial impetus with the development of the antipsychiatry movement, which argued that the ‘diseases’ of psychiatry were in fact labels attached to deviant individuals for the purposes of social control; and that the treatment processes were there to ensure the smooth functioning of bureaucracies such as hospitals and asylums, rather than the cure of individuals. The publication of Eliot Freidson's Profession of Medicine: A Study of the Sociology of Applied Knowledge, and Professional Dominance, both in 1970 marks the consolidation of the sociology of medicine (the contrast is with sociology in medicine) into an examination of medicine, medical knowledge and medical practices. Freidson's argument is that the medical profession dominated the health sector, not because it was the humanitarian scientific elite it claimed to be, but because it was politically well organized. Consequently it has excluded competing medical knowledges and practitioners, obtained a monopoly of practice guaranteed by the state, has autonomy over its own work practices, and defines for the wider society the issues that it has control over. The achievements of the profession have little to do with its professionalism and more to do with its economic and political power.

      The key to this position, and to the development of the health social sciences by the early 1980s, is that it does not allow that medicine has a pure, scientific knowledge base. It calls into question medicine's claims to reflect an objective underlying reality, and argues that the conceptual categories of medicine, the diagnostic categories of disease and treatment patterns are themselves a product of social life. While this argument is often identified in the work of Foucault, and in social constructionist accounts of medical knowledge and technology, it has had a subterranean history in the sociology of health throughout the twentieth century, in the work Bernhard Stern in the United States, Ludwig Fleck in Germany, and Georges Canguihelm and Gaston Bachelard in France. In this perspective the point is not to counterpoise medicine as a natural science with contaminating social factors but to see them as mutually constitutive of each other.

      While the development of the sociology of medical knowledge, the historical sociology of health, and the development of a sceptical attitude to the claims of medicine were central to the development of a social science approach to medicine, there were also factors at work intrinsic to the social sciences. The dream of a scientific account of society – in the sense of being on par with the methods and findings of the natural sciences – had been central to Durkheim and Marx, albeit from different political perspectives. Coupled with the rise of statistics and the need for the welfare state to have access to information about large numbers of people, quantitative, large scale surveys became the dominant form of social science research in the post-World War II period. However from the 1970s onwards sociologists became more and more critical of the positivist tradition of quantitative research and more interested in the philosophy of the social sciences. Weber's work in particular, with its neo-Kantian epistemology (put crudely, that the mind shapes reality rather than reality shaping the mind) experienced a resurgence in Britain leading to an emphasis on interpretive, qualitative sociology, conducted with the aim of explaining not only the regularities of social life, but also understanding the subject's world view. This development resonated with the pragmatism of the American sociological tradition – from Peirce, Dewey and Mead – crystallizing in the Chicago school, and fed into the development of ethnomethodology and phenomenological sociology, through the work of Schutz in the United States. These developments echoed the demise of Parsons' structural functionalism and a rejection of grand theorizing in favour of grounded theory: exploring what actually was happening in various social sites and institutions.

      Health sociologists thus turned to studying the experience of illness and disease, the informal structures of hospitals and asylums, as in the work of Erving Goffman, of the experience of disease as stigma, or the social organization of dying. Social science enquiries into the working of society came to be based more on ethnographies, case studies and to use qualitative techniques of investigation such as participant observation, in-depth interviews, and focus groups. These types of studies often supply very rich empirical case studies which may not be generalizable, and may be vulnerable to the charge that they overlook the workings of powerful groups and institutions in society.

      Along with these intellectual developments, and central to compiling this dictionary has been the social and political changes in Western capitalist societies since the late 1970s. Political sociologists of health have demonstrated that with the winding back of the welfare state, more and more of the services that it used to provide – in shorthand, the social wage – have to be provided by individuals in the home, especially women, and by communities as they are exhorted to develop their social capital to make themselves healthy. The corporatization of health services, the privatization of state facilities, and the outsourcing of activities once supplied by the state have had a major impact on the structure of the medical profession, leading to deskilling and proletarianization, as well as restricting access to services to those in a position to take out private health insurance. The introduction of market principles – funder–provider splits, case mix and diagnostic related groups – into state institutions such as hospitals has led to degradation of nursing work and conditions, as patients, doctors and nurses meet production targets. Many sociologists argue that the ‘new public health’, with its emphasis on lifestyle factors and risks, feeds into this neoliberalism, individualizing and depoliticizing the political, environmental and economic causes of disease.

      There has been ongoing debate about the impact of these and other social changes – an increasingly educated public, scepticism about the appropriateness of much medical interventions based on drugs and technology, the rise of complementary and alternative medicines – on the medical profession. With changes in the economic environment, the rise of entrepreneurial medicine, and the ongoing commodification of healthcare, doctors perform more and more as employees than as freestanding professionals. This proletarianization, or alternatively, deprofessionalization, has suggested that the end of medical dominance is nigh. However the situation is not clear cut: doctors still retain considerable independence in their clinical work; and empowered patients do not seem to be fundamentally challenging medicine, but want more of it delivered on their terms. The rise in complementary medicine in part reflects this ambiguous relationship to the medical system. Users of complementary medicine are usually not rejecting orthodox medicine, but seeking supplementary treatments and therapies. The health consumer movement and the concept of the empowered patient have meant that there has been considerable research into the doctor-patient relationship, with Parsons' original model of the passive patient and the active doctor seriously questioned. Many current research projects into the doctor-patient relationship emphasize negotiation and interaction of the doctor and patient over treatment and therapies. This is especially the case in the context of the rise of chronic illness where patients may be on equal footing or have greater knowledge of their condition than their doctor.

      This dictionary is a product of these intellectual and social changes. It grows principally out of my parent discipline, sociology, and my experience as a sociologist of health over the better part of twenty years. In writing it I drew on my own work in political sociology, the sociology of the health professions, the sociology of medical knowledge, the historical sociology of healthcare and the medical profession and the medicalization of social problems. I also reviewed leading textbooks in the fields of anthropology of health, the social psychology of health, health administration, public health, the social history of health and medicine and epidemiology. From these, doing a rough and ready frequency count I identified words that cropped up across these different disciplines (for example, medicalization) as well as words specific to the discipline (say epidemiological polarization in epidemiology). This resulted in the over 900 head words in this dictionary. Wherever possible I tried to track a word to its original usage, often without success, sometimes with (for example, Jarvis' Law). Except where I have directly quoted an author, the text is my own, and I have not consulted other dictionaries of health sociology except fleetingly (for example, Cockerham, W. and Ritchey, F. (1997) Dictionary of Medical Sociology, Westport: Greenwood Press). This seemed to me to be the easiest way to avoid plagiarism. At one point I was bemoaning my fate in attempting this project and someone in a bar suggested using the web. While not a Luddite this had never occurred to me. However it was not particularly useful, since it constantly provided me with screeds of course outlines in which my word appeared. The only truly memorable event in using it was tracking down the entries for Kinsey, and Masters and Johnson, who do not rate a mention in any contemporary study of sexuality that I could find – it is remarkable how short lived fame is! So most of the research was done in the old fashioned way, trudging back and forth to the library and ransacking my office shelves for examples of the use of words.

      A good deal of the dictionary was written as ‘word trees’ that is, of interlinked words – for example, all the entries relating to profession were written in sequence, and most of the entries in the philosophy of social science, as were entries on the social construction of technology, the historical sociology of health and the sociology of scientific knowledge. Hence, following the links is a good way to pick up the full usage and complexity of a term. Because so many sociologists have contributed to the sub-discipline, I restricted entries for individuals to those who are dead. So to my professional colleagues, if you are disappointed not to have an entry under your own name, be grateful: at least you are alive.

      The writing of this dictionary has very much been the product of my own intellectual biography. My undergraduate career spanned the mid-1970s at the height of the debates around scientific and humanist Marxism, and the role of class analysis in the social sciences. I was fortunate at Flinders University in my lecturers Professors Ivan Szelenyi, Bob Holton, and Allan Patience. As I started my PhD Professor Bryan Turner was appointed and became my supervisor as I pursued research into the historical formation of the medical profession, using a sociology of knowledge framework to examine the ways in which the germ theory of disease was mobilized to consolidate the nascent professions' claim to be the arbiter of health and disease. My first appointment, to teach the history and philosophy of medicine at Wollongong University, in the then Department of the History and Philosophy of Science (now science and technology studies) immersed me in the sociology of scientific knowledge and the sociology of technology. I benefited enormously from working with John Schuster, Ev Richards, Brian Martin and Terry Stokes. I then moved to New Zealand to the Department of Sociology and Social Work at Victoria University of Wellington. New Zealand fully embraced the neoliberalist revival of the late 1970s and early 1980s and provided a microcosm of changes to the welfare state and the introduction of market principles to the healthcare sector. My political sociology of healthcare systems and an interest in comparative healthcare systems were fostered by interactions with Professor Peter Davis (now Christchurch), while my colleagues at VUW, Professor Mike Hill, Drs Claire Toynbee, David Pearson and Bob Tristram, along with Barry Doyle, provided a rich sociological environment in which to work. At the Australian National University I have enjoyed the colleagueship and friendship of Dr Owen Dent, Stephen Mugford, Jack Barbalet and Professor Frank Lewins (to whom I owe the opening line of this introduction). I would also like to sincerely thank Dr Thomas Mautner, Department of Philosophy, ANU who provided often very funny feedback on an early draft of parts of the dictionary. Thomas' sense of humour, as the only other person I have met who has taken on a dictionary (A Dictionary of Philosophy. Cambridge, MA: Blackwell, 1996) was far more important in keeping me going than he would realize. Dr Alison Rawling (whose PhD I supervised and who is now also a medical practitioner) tried to steer me in the direction of the interesting usages of some medical terminology.

      Academic writing by definition is a solitary exercise, but one's intellectual formation is the product of the intellectual communities that nourish and shape us and I sincerely thank the above institutions and colleagues, as well as my students, for their input and support. One way or another this dictionary would not have been written without the love and support of Dr Elizabeth Coleman. Elizabeth heard my first halting efforts at many of the definitions, talked through the logic of the dictionary with me, played tennis, shared beers, and by her own example as a scholar, kept me committed to doing my best in this book. She also had the good humour during my pensive silences, when she asked what I was thinking about, not to be offended by answers such as the entry on the body, or what to do about all the ‘s's that needed filling in! This dictionary is for her. And always there are my children: Claire, Michael and David. Hi guys.

      From the perspective of specialists in the wide range of health social sciences covered in this dictionary, the errors will be glaring. (I cannot repeat the description of my first attempts at critical medical anthropology provided by Professor Hans Baer!) I apologise in advance. However, I hope its failings are balanced by the effort to chart the dynamics of the health social sciences and that in the future updated versions will rectify the most immediate faults.

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