Models of Health, Illness and Diseases
The ways in which health, disease and illness were defined depended upon a number of different factors. For example, the ways in which professionals define health and illness are different from the ways in which other members of society conceive of them. Within our Western culture there has always been great diversity in the conceptualizing of health and illness. Though the models of health and illness may vary, these concepts play a defining role, indicating what should, and what should not be, the objects of public health concern.
According to (1981), the concepts are ambiguous, operating both as explanatory and as evolutionary notions. Health and disease are normative as well as descriptive terms. For example, they describe states of affairs, factual conditions, while at the same time presenting them as good or bad (2001). At a cultural level what constitutes health has become a central plank of contemporary consumer culture as images of youthfulness, vitality, energy and so on have become key articulating principles of a range of contemporary popular discourses. For this paper, medical and social models of health, disease, and illness will be discussed.
According to (1980), health is the optimum level of independence in each activity of living which enables the individual to function at his or her maximum capacity. Orem (1995) defined health as a state of wholeness or integrity of the individual, his or her parts and modes of functioning. (1986), states that health is a relatively stable state of maximum wellness which equates with independence. (1980) pointed out that health is defined by cultures and individuals to denote behaviors that are of high value and low value. (1966) defined health as the ability to function independently regarding fourteen fundamental activities of daily living. According to (1982), health is a varying state of wellness and illness which is influenced by physiological, psychological, socio-cultural and developmental factors. These are just a few of the meanings of health as described by some authors.
As societies increasingly come to expect their citizens to manage their own health and take responsibility for their own illnesses, the individual is required to 'police their body'. In the sociology of health, a sociology of the body has emerged as a rapidly expanding area following the impact of post-modernist theory. In the present collection, two readings focus on 'the body'. In the first it examines the significance of the body to consumerism, and emphasizes the important role that consumerist notions of the body have in 'health maintenance' and ‘disease prevention' strategies and discourses.
In the field of medical sociology, empirical research has continually provided evidence of the way social and material circumstances influence the pattern of health and illness, apart from the undoubted influence of medical concepts and knowledge. The popular notion that 'knowledge is power' is often taken to mean the reverse: that under postmodern conditions power is little more than knowledge and 'truth claims'. However, the idea that we live in a period of 'post-scarcity values' where such discursive processes hold sway, flies in the face of the continuing effects of economic deprivation in contemporary societies-as reflected in the continuing debates about income differentials and social status and their impact on health, even where absolute poverty is less evident. Unless such sources of power are recognized postmodern ideas threaten to become little more than a gloss on the continuing trend of widening social inequalities (1998).
Within consumer culture the emphasis on 'appearance' and 'bodily presentation' has become paramount. The individual is encouraged to 'adopt instrumental strategies to combat deterioration and decay' with 'body work' being supported and structured through the production of 'stylized images of the body' in the advertising and entertainment media. In the context of consumer culture the prime purpose of individuals' maintaining their 'inner body' through control of their diet, exercise and unhealthy behaviors 'becomes the enhancement of the appearance of the outer body'. Clearly, consumer culture is incapable of generating satisfactory strategies and solutions to the inevitable deterioration and decay which accompany ageing and death insofar as its logic is to avoid these realities and instead sell us the illusion of a forever happy, disease and pain-free life which we can achieve by buying into regimes of body maintenance (2001).
A dichotomy has traditionally been seen between the biomedical or scientific model of health and a looser, more holistic model. These are sometimes falsely regarded as 'medical' and 'non-medical' ways of looking at health. Crudely, medical knowledge is seen as based on universal, generalizable science, and lay knowledge as unscientific, based on folk knowledge or individual experience. The lay concepts discussed in this chapter are not, however, being presented as necessarily or essentially different from medical concepts. In western societies, an intermixing is inevitable: lay people have been taught to think, at least in part, in bio-medical terms. Nor is modern medicine entirely wedded, in practice, to a narrowly-defined biomedical science: holistic concepts are also part of medical philosophy. The lay concepts which were expressed in this survey are, of course, sometimes less informed or expert than those of medical professionals. In other ways, however - since health must in part be subjectively experienced - they may be better informed. As other studies have found, they are often complex, subtle, and sophisticated ( 2001).
In considering the social and environmental forces affecting health, access to health care, disease and illness, the significance of various dimensions and aspects of social stratification has been well documented, including 'ethnicity', 'gender' and 'social exclusion'. In the present collection a short extract from (1995) describes the 'picture of health’ experienced by women in both the developed and poorer countries of the world.
Despite cultural variations in the concepts of sickness and health, and in the subjective experience of illness, women's physical and mental health is harmed in broadly similar ways. Inequalities in mortality and morbidity rates are shown to exist between women from different social groups and in the life expectancy of women in rich and poor nations. (1995) argues that Western medicine is limited in its ability to deal with many health problems experienced by women due to its separation of individuals from the 'social and cultural contexts of their lives' in which these health problems arise and develop.
In the field of health, social inequalities expressed themselves in many ways including unequal access to health care resources and facilities. 'inverse care law' (1971) suggested that those with the greatest need for health care actually received least. The inverse care law has persisted and, with it, growing inequalities in health have been well documented.
It has been argued that the new victim blaming ideology of 'individual responsibility for health’ which emerged in the United States in the 1970s served both to challenge and reorder the public's expectations regarding their right for access to medical services, and diverted attention from the social and economic causes of disease and ill- health in favor of emphasizing the role of individual lifestyle choices. By encouraging individuals to avoid 'at risk' behaviors and change their lifestyles accordingly, the ideology of individual responsibility meets the demands of an economic imperative of cost curtailment by justifying reductions in entitlement to health services and by shifting the burden of medical costs onto users themselves. Such a strategy of victim blaming can only exacerbate existing inequalities in health and in access to health services ( 2001).
Conflicting explanations for health inequalities can be usefully situated in relation to an ideology and politics of victim blaming. These include: (1) 'social selection' accounts which emphasize the importance of processes of social mobility in accounting for the social class gradient in health. The higher and more affluent social classes are seen to collect the healthier members of each generation of the population and the poorer and lower social classes the least healthy members; (2) 'cultural/ behavioral' approaches which consider poor health to be largely the outcome of individuals engaging in unhealthy behavior due to either ignorance or irrational/irresponsible choices, and which may suggest that certain communities are characterized by more unhealthy 'lifestyles' relative to others due to cultural or sub-cultural influences; and (3) 'materialist' or 'structural' explanations which emphasize the role of social and economic forces, and conditions such as poverty, unemployment, housing and environmental pollution in generating poor health (2001).
The increasing emphasis on the label of illness, then, has been at the expense of the labels of both crime and sin and has been narrowing the limits if not weakening the jurisdiction of the traditional control institutions of religion and law. The medical mode of response to deviance is thus being applied to more and more behavior in our society, much of which has been responded to in quite different ways in the past (2002). In our day, what has been called crime, lunacy, degeneracy, sin, and even poverty in the past is now being called illness, and social policy has been moving toward adopting a perspective appropriate to the imputation of illness. Chains have been struck off and everywhere health professionalism has been raised to legitimate the claim that the proper management of deviance is "treatment" in the hands of a responsible and skilled profession. The labels of sin and crime being removed, what is done to the deviant is likely to be said to be done for his own good, done to help him rather than punish him, even though the treatment itself may constitute a deprivation under ordinary circumstances. His own opinions about his treatment are discounted because he is said to be a layman who lacks the special knowledge and detachment that would qualify him to have his voice heard ( 2001).
Medicine, then, is oriented to seeking out and finding illness, which is to say that it seeks to create social meanings of illness where that meaning or interpretation was lacking before. And insofar as illness is defined as something bad - to be eradicated or contained - medicine plays the role of what Becker called the 'moral entrepreneur'. Medical activity leads to the creation of new rules defining deviance; medical practice seeks to enforce those rules by attracting and treating the newly defined deviant sick ( 2001).
However, while the label of illness does seem to function to discourage punitive reactions, it does not discourage condemnatory reactions. The "illness" is condemned rather than the person, but it is condemned nonetheless. The person is treated with sympathy rather than punishment, but he is expected to rid himself of the condemned attribute or behavior. Thus, while (ideally) the person may not be judged, his "disease" certainly is judged and his "disease" is part of him. Moral neutrality exists only when a person is allowed to be or do what he will, without remark or question. Positive moral approval, of course, exists where a person is urged to be what he may not wish to be. Clearly, the physician neither approves of disease nor is neutral to it. When he claims alcoholism is a disease, he is as much a moral entrepreneur as a fundamentalist who claims it is a sin. His mission is to impute social and therefore moral meaning to physical and other signs that are, but for such meaning, fit only for the licking and biting by which animals treat themselves ( 2001).
The existence of a wide variety of lay beliefs about health and illness, including lay theories of disease causation, has been shown to exist and is illustrated here by a short extract from (1985) major study of 'health and lifestyles', in which four views of health are identified from a number of previous studies on lay concepts of health. These are health as absence of disease or illness, as the ability to function and perform one's social roles, as fitness, and finally as a reserve. (1985) emphasizes the complexity of lay concepts, that they often incorporate elements drawn from biomedicine as we have been encouraged to think in biomedical terms, and that 'people cannot always be expected to be consistent' in their view of health.
Variations in health belief influence the 'illness behavior' which individuals engage in once they perceive that they have a health problem. The fact that health professionals only come into contact with the tip of an 'illness iceberg' is now well established (2002). Consequently, seeking 'professional' advice or assistance is by no means a simple clear-cut process. Unlike the assumptions of functionalists who consider that, faced with illness, the (socially responsible) individual can be expected to consult medical opinion, sociologists working from an interactionist standpoint suggest that going to the doctor may well be a last resort once other avenues of advice and assistance have been exhausted.
Gender related health inequality also has its role. Higher morbidity rates for women have been associated with cultural norms of 'nurturant role demands' ( 1984). Expectations that women should be the principal caregivers for their children, spouses and elderly parents, that they are responsible for maintaining the household and should provide for the social and medical health of family members, regardless of employment status, can create chronic stress and strain. It also makes it difficult for women to care for their own physical, social and psychological needs (1998).
It has also been emphasized that the health-related behaviors of some women have to be understood in the context of the limited material and health resources with which they seek to care for their children. The health-damaging behaviors they engage in are then seen to be less of a lifestyle 'choice' than a 'compromise', a strategy to sustain the women in the face of daily routines which are heavily and unremittingly stressful. Cigarette smoking in particular is seen to provide these mothers with a rare break from their routines of caring and thereby exists as a means for both managing and defusing stress. In this respect it is experienced as 'a deeply contradictory habit' by these women, being both health-damaging in its consequences for the health of themselves and their children and existing as 'a child protective strategy, a resource which helped mothers cope with the demands of caring'. This work offers a strong challenge to contemporary health policies which persist through their emphasis on individuals' managing their own lifestyles in focusing on individual behavior removed from the social, cultural and material context which gives it sense.
(1997) also point to the importance of understanding the effect of inequalities over the course of individuals' lives and in particular at 'socially critical periods' such as the transition to parenthood or job loss. By paying particular attention to these, policy-makers might be able to ameliorate some of the negative effects on health created by inequalities in income but even with this in mind they are left discussing the importance of the welfare state as a safety net for the poorest, rather than explicitly discussing how these critical periods are linked to class.
The health status of a population is also affected by the country's position in the world economic system. (1990), in a study of sixty-three underdeveloped countries, found that greater multinational corporate penetration, associated with increased income inequality, resulted in increased rates of infant mortality over time. Among the reasons why multinational corporate investment may distort development in the Third World, and thus undermine the health of populations, is that it tends to displace domestic firms, obstructs progressive domestic political processes contrary to core economic interests and sometimes results in the diversion of land from food production for domestic use while displacing poor farmers ( 1998).
The interrelationship between the world economy, local labor markets and the health of populations may also be reflected in AIDS and its transmission in central and southern Africa (1989). The pattern of industrialization during and since colonization was based largely on a migrant labor system for males working in mines, railroads, primary production and on plantations. This led to prolonged family separations and, with the depletion of males in rural areas, some deterioration in rural agriculture and subsequent migration of unmarried women to urban areas. With limited employment opportunities for women in urban settings, many were attracted to prostitution. The migration to urban slums escalated with large-scale takeovers of fertile land to produce foods for export and a push toward mechanization and monoculture (1988).
An urban labor force of men long separated from families and numbers of single women available as prostitutes, contributed to an explosion of sexually transmitted diseases in the years before AIDS was recognized. As men periodically returned to families that remained in rural villages, they brought with them the diseases so prevalent in urban environments such as tuberculosis and STDs (1995). The labor patterns, reflecting in part the position of those nations in a world economic system, provided the social conditions for the rapid transmission of HIV virus and AIDS epidemic. Thus, the socioeconomic conditions of populations within and between nations, with their related economic inequities, are reflected in health status.
Certainly, it is possible to define health as co-existing with quite severe illness, disease or incapacity. Increasingly, individuals' and communities' 'health-related behavior' is attracting social responses as cultural expectations of 'healthy lifestyles' and making 'healthy choices' become established as significant social norms within different societies. The response to 'unhealthy behavior' is largely to regard it as socially deviant and a result of inequalities.
Identifying inequalities in health has proved easier and more straight-forward than explaining their existence. Explanations of inequality can be found in the ideological agendas which have informed health policy and public provision of services, agendas which have either chosen to ignore or address such inequalities (2001). A significant example of the former has been the persistence of an 'ideology and politics of victim blaming' in which those sections of the population experiencing the poorest health and the greatest inequalities are effectively held to be responsible for their own poor health.
The sociology of health and illness is proving a particularly fertile terrain upon which evolving debates have been fashioned, both theoretically and empirically (1998). From the social construction of biomedical knowledge to the phenomenological experience of pain, illness, disability and death, sociological approaches to health and disease throw into critical relief deep ontological questions concerning the nature and status of human embodiment.
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