The Journal of Health and Social Behavior recently ran a supplemental issue dedicated to the 50th anniversary of the journal and of the Medical Sociology Section of the American Sociological Association. The issue is made up of a series of reviews about key issues in medical sociology written by some of the leading scholars in the sub-discipline. Aside from being an excellent—and completely open-access—resource on the current state of knowledge in medical sociology, this issue is interesting as an object of comparison with the 2009 meeting of the Society for Medical Anthropology, which was also framed as a 50th anniversary celebration. (What was it about 1959?) Here is how guest editors Janet Hankin and Eric Wright introduce the issue:
Since 1959—when the Medical Sociology Section of the American Sociological Association was founded and the first issue of JHSB (then called the Journal of Health and Human Behavior) was launched—health status and the delivery of health care have dramatically changed. Life expectancy at birth in the United States was about 70 years in 1959, with large gaps in life expectancy between whites and nonwhites. Fifty years ago, Medicare and Medicaid did not exist. There were no safety nets for the elderly, the poor, and the medically needy who required health care. The United States spent only 5.1 percent of its GDP on health. Treatments for cancer, heart disease, and stroke were limited. There were no warning labels on cigarette packages or alcoholic beverage containers. Fee-for-service payments for medical care prevailed. Doctors were the “captains of the team.” Medical technology and high power drugs were limited.
Fifty years later, life expectancy at birth in the United States exceeds 78 years. While the gaps in longevity for whites and nonwhites have narrowed, significant differences persist. Medicare covers over 45 million elderly and disabled persons, while Medicaid pays for the care of 46 million low-income children and parents. Nonetheless, an estimated 46 million Americans do not have health insurance. The United States spends more than 18 percent of its GDP on health. Cancer, heart disease, and stroke are no longer death sentences, but people are living longer with chronic, disabling diseases. Warning labels appear on cigarette packages and alcoholic beverage containers. Managed care and salary or capitation arrangements have supplanted fee-for-service. The professional dominance of physicians has eroded. Medical technology and high power drugs have exploded. There have been numerous incremental initiatives to improve our health care system over the years, but more fundamental changes are on the horizon with the passage of The Patient Protection and Affordable Care Act of 2010.
Given these dramatic changes in health status and the health care system over the past 50 years, what has medical sociology contributed to our understanding of illness, disease prevention, and the treatment process? The articles in this issue describe these contributions in eleven broad areas within medical sociology: (1) racial-ethnic disparities in health care, (2) fundamental causes of health inequalities, (3) stress and health, (4) social relationships and health, (5) the social construction of illness, (6) patient–provider relationships and help-seeking behaviors, (7) the social transformation of the medical profession, (8) health services research, (9) technology, (10) bioethics, and (11) health reform,” (Hankin and Wright 2010).
And here are the titles and abstracts. Again, the full length articles are all available free-of-charge to everyone.
What Do We Know? Key Findings from 50 Years of Medical Sociology
Edited by: Janet R. Hankin and Eric R. Wright
Katherine J. Rosich and Janet R. Hankin, Executive Summary: What Do We Know? Key Findings from 50 Years of Medical Sociology
For much of 2009 and early 2010, discussions of health care policies dominated national discourse in the United States. The prolonged and often acrimonious debates brought into sharp focus the enormous, complex, and highly fragmented system that provides health care in the United States. Considerable attention was also devoted to demonstrating the advanced state of this country’s medical knowledge, technology, and health services.
The debates also highlighted the great shortcomings and problematic nature of the American health care delivery system. While millions of Americans have little or no access to health care, millions of dollars are spent on the health care of a relatively few Americans. This unequal distribution raises moral and ethical questions about basic social justice and a misallocation of resources that is economically costly to society. There is ample evidence that these disparities cost American society billions of dollars in medical care and lost productivity.
The contentious debates over health care reform in the U.S. demonstrate the need for credible empirical research that is widely available to both the public and policy experts so that it can help frame the complex issues involved in policy discussions. For more than half a century, medical sociologists have provided such research insights into many of the great health policy challenges we have faced. This extra issue of the American Sociological Association’s premier Journal of Health and Social Behavior synthesizes many of the contributions from this community of scholars, summarized here by leading sociologists.
Janet R. Hankin and Eric R. Wright, Reflections on Fifty Years of Medical Sociology
In the past half-century, medical sociology has provided significant insights about the social dimensions of health and health care, ranging from causes and consequences of health disparities to the organization, delivery, and financing of health care. The purpose of this extra issue of the Journal of Health and Social Behavior is to review key findings over the past 50 years on eleven core topics, from sociological studies of health and illness to healing. The authors highlight policy implications of these key findings and discuss the future in each of these domains.
David R. Williams and Michelle Sternthal, Understanding Racial-ethnic Disparities in Health: Sociological Contributions
This article provides an overview of the contribution of sociologists to the study of racial and ethnic inequalities in health in the United States. It argues that sociologists have made four principal contributions. First, they have challenged and problematized the biological understanding of race. Second, they have emphasized the primacy of social structure and context as determinants of racial differences in disease. Third, they have contributed to our understanding of the multiple ways in which racism affects health. Finally, sociologists have enhanced our understanding of the ways in which migration history and status can affect health. Sociological insights on racial disparities in health have important implications for the development of effective approaches to improve health and reduce health inequities.
Jo C. Phelan, Bruce G. Link, and Parisa Tehranifar, Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Policy Implications
Link and Phelan (1995) developed the theory of fundamental causes to explain why the association between socioeconomic status (SES) and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. They proposed that the enduring association results because SES embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections that protect health no matter what mechanisms are relevant at any given time. In this article, we explicate the theory, review key findings, discuss refinements and limits to the theory, and discuss implications for health policies that might reduce health inequalities. We advocate policies that encourage medical and other health-promoting advances while at the same time breaking or weakening the link between these advances and socioeconomic resources. This can be accomplished either by reducing disparities in socioeconomic resources themselves or by developing interventions that, by their nature, are more equally distributed across SES groups.
Peggy A. Thoits, Stress and Health: Major Findings and Policy Implications
Four decades of sociological stress research offer five major findings. First, when stressors (negative events, chronic strains, and traumas) are measured comprehensively, their damaging impacts on physical and mental health are substantial. Second, differential exposure to stressful experiences is a primary way that gender, racial-ethnic, marital status, and social class inequalities in physical and mental health are produced. Third, minority group members are additionally harmed by discrimination stress. Fourth, stressors proliferate over the life course and across generations, widening health gaps between advantaged and disadvantaged group members. Fifth, the impacts of stressors on health and well-being are reduced when persons have high levels of mastery, self-esteem, and/or social support. With respect to policy, to help individuals cope with adversity, tried and true coping and support interventions should be more widely disseminated and employed. To address health inequalities, the structural conditions that put people at risk of stressors should be a focus of programs and policies at macro and meso levels of intervention. Programs and policies also should target children who are at lifetime risk of ill health and distress due to exposure to poverty and stressful family circumstances.
Debra Umberson and Jennifer Karas Montez, Social Relationships and Health: A Flashpoint for Health Policy
Social relationships—both quantity and quality—affect mental health, health behavior, physical health, and mortality risk. Sociologists have played a central role in establishing the link between social relationships and health outcomes, identifying explanations for this link, and discovering social variation (e.g., by gender and race) at the population level. Studies show that social relationships have short- and long-term effects on health, for better and for worse, and that these effects emerge in childhood and cascade throughout life to foster cumulative advantage or disadvantage in health. This article describes key research themes in the study of social relationships and health, and it highlights policy implications suggested by this research.
Peter Conrad and Kristin K. Barker, The Social Construction of Illness: Key Insights and Policy Implications
The social construction of illness is a major research perspective in medical sociology. This article traces the roots of this perspective and presents three overarching constructionist findings. First, some illnesses are particularly embedded with cultural meaning—which is not directly derived from the nature of the condition—that shapes how society responds to those afflicted and influences the experience of that illness. Second, all illnesses are socially constructed at the experiential level, based on how individuals come to understand and live with their illness. Third, medical knowledge about illness and disease is not necessarily given by nature but is constructed and developed by claims-makers and interested parties. We address central policy implications of each of these findings and discuss fruitful directions for policy-relevant research in a social constructionist tradition. Social constructionism provides an important counterpoint to medicine’s largely deterministic approaches to disease and illness, and it can help us broaden policy deliberations and decisions.
Carol A. Boyer and Karen E. Lutfey, Examining Critical Health Policy Issues within and beyond the Clinical Encounter: Patient–Provider Relationships and Help-seeking Behaviors
Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient–provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care. The challenge in trying to contain the growth of health care costs is two-fold: developing better ways of defining need for care and promoting better access for those who could benefit most from health care. Both of these strategies need to be considered in the context of addressing racial, ethnic, socioeconomic, and health status disparities. Rebuilding the primary care sector as a sociologically informed strategy and a key component of health care reform may optimize both health care delivery and patient outcomes.
Stefan Timmermans and Hyeyoung Oh, The Continued Social Transformation of the Medical Profession
A pressing concern in contemporary health policy is whether the medical profession’s mandate to take care of clients has been undermined by the influx of money into health care. We examine the medical profession’s transformation over the past decades. First, we review how sociologists have viewed the medical profession over the past half-century as one stakeholder among other stakeholders vying for market share and power in the health care field. We then examine three recent challenges to the profession that exemplify the tension between self-interest and collective altruism to act in the best interest of patients: (1) the rise of patient consumerism, (2) the advent of evidence-based medicine, and (3) the increasing power of the pharmaceutical industry. We show the resilience of the medical profession as it adapts and transforms in response to these challenges. We conclude with implications to help inform policy makers’ assessments of how the medical profession will react to policy initiatives.
Eric R. Wright and Brea L. Perry, Medical Sociology and Health Services Research: Past Accomplishments and Future Policy Challenges
The rising costs and inconsistent quality of health care in the United States have raised significant questions among professionals, policy makers, and the public about the way health services are being delivered. For the past 50 years, medical sociologists have made significant contributions in improving our understanding of the nature and impact of the organizations that constitute our health care system. In this article, we discuss three central findings in the sociology of health services: (1) health services in the U.S. are unequally distributed, contributing to health inequalities across status groups; (2) social institutions reproduce health care inequalities by constraining and enabling the actions of health service organizations, health care providers, and consumers; and (3) the structure and dynamics of health care organizations shape the quality, effectiveness, and outcomes of health services for different groups and communities. We conclude with a discussion of the policy implications of these findings for future health care reform efforts.
Monica J. Casper and Daniel R. Morrison, Medical Sociology and Technology: Critical Engagements
In this selective review of the literature on medical sociology’s engagement with technology, we outline the concurrent developments of the American Sociological Association section on medicine and advances in medical treatment. We then describe theoretical and epistemological issues with scholars’ treatment of technology in medicine. Using symbolic interactionist concepts, as well as work from the interdisciplinary field of science and technology studies, we review and synthesize critical connections in and across sociology’s intellectual relationship with medical technology. Next, we discuss key findings in these literatures, noting a shift from a focus on the effects of technology on practice to a reconfiguration of human bodies. We also look toward the future, focusing on connections between technoscientific identities and embodied health movements. Finally, we call for greater engagement by medical sociologists in studying medical technology and the process of policy-making—two areas central to debates in health economics and public policy.
This article explains the emergence, growth, and institutional anchoring of bioethics in both policy and clinical arenas. Under the heading of principlism, bioethics developed a public language for resolving disputes that allowed it to transform disputes involving sacred matters into profane work routines. At the same time, having principlism as a common language for solving practical disputes allowed “ethics work” in health care to be separated from moral theorizing as a practical activity. Two issues—the right to die and the protection of research subjects—serve to illustrate the process through which bioethics established a large institutional footprint in health care.
David Mechanic and Donna D. McAlpine, Sociology of Health Care Reform: Building on Research and Analysis to Improve Health Care
Health reform efforts in the United States have focused on resolving some of the fundamental irrationalities of the system whereby costs and services utilization are often not linked to improved patient outcomes. Sociologists have contributed to these efforts by documenting the extent of problems and by confronting central questions around issues of accountability, reimbursement, and rationing that must be addressed in order to achieve meaningful reform that controls costs, expands access, and improves quality. Major reform rarely occurs without “paying off” powerful interests, a particularly difficult challenge in the context of a large and growing deficit. Central to achieving increased coverage and access, high quality, and cost control is change in reimbursement arrangements, increased accountability for both costs and outcomes, and criteria for rationing based on the evidence and accepted as legitimate by all stakeholders. Consensus about health reform requires trust. The traditional trust patients have in physicians provides an important base on which to build.