Learning Objectives
- Compare models of health that sociologists and health researchers use to explain inequality in health outcomes.
- Describe how various social groups and nations of the world differ in important indicators of health and illness.
- Summarize classical and other theoretical perspectives on problems of health and medicine.
- Explain how the social structure, systems of oppression, and patriarchy impact the experience of problems for people in marginalized groups.
- Describe differences in the healthcare model found in the US and in industrial nations.
- Describe health disparities and problems relating to healthcare and the institution of medicine.
- List strategies to reduce problems in medicine and health and provide effective health solutions, including those that expand social justice.
We probably can all tell a story about how COVID-19 impacted our lives. Some of us have had family members or friends pass away. Some of our kids just felt achy or tired for a day and then got better. Some of us wore masks, paused in-person socializing, and were anxious at the grocery store. Some of us are still experiencing lingering symptoms from a COVID-19 infection, called long COVID, as described in the videos below. Pause for a moment to think about your own COVID pandemic health story and consider the many ways that this disease has affected society in the United States and worldwide.
Common sense tells us that since COVID-19 is a disease, it should affect all people equally. You would think that a virus wouldn’t discriminate. However, we have learned that some social groups are more likely to be infected, hospitalized, and even die as a result of contracting COVID-19. The table below shows rates of cases, hospitalizations, and deaths due to COVID-19 by race/ethnicity from the first year of the pandemic, in summer 2020. As you can see, Black people died from COVID-19 at a rate twice that of white people during this time. Please take a moment to look at the other differences related to race/ethnicity in this table.
This table displays rates for COVID-19 Infection, Hospitalization, and Death by Race/Ethnicity, as of July 28, 2020. Race and ethnicity are risk markers for other underlying conditions that affect health, including socioeconomic status, access to health care, and exposure to related occupations, e.g. frontline, essential, and critical infrastructure workers.
“Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity” by the Centers for Disease Control (CDC) is in the Public Domain
Perhaps you noticed that the data show a gap between white non-Hispanic Americans and American Indian/Alaskan Native, Asian, Black people, and Latinx people. As you can see in the table, cases, hospitalizations, and deaths for all racial/ethnic groups except for Asians are substantially higher than for whites. This experience of inequality demonstrates that health and illness can be social problems.
This chapter will explore the social elements of health, and look deeply at why health is a social problem. We will also explore medicine, the social institution responsible for addressing health and healthcare. We will examine collective and individual models of the social determinants of health, as well as how sociologists make sense of health, illness, and the institution of medicine. We will look at differences in health systems internationally and decide if these systemic differences support health for everyone. We will also examine creative action from individuals, communities, and governments, responses that demonstrate our interdependence, and the need for the social justice of health.
Medicine and Health
The World Health Organization (1946) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. We usually think of health, illness, and medicine in individual terms. When a person becomes ill, we view the illness as a medical problem with biological causes. Doctors and medical professionals focus most on the health of an individual. However, health and illness in society go beyond individual experience.
Sociologists and public health professionals focus on the health of groups. This specialty is called epidemiology, the study of disease and health and their causes and distributions. Epidemiology can focus on the differences between neighborhoods, other communities, states, or countries. Unlike physicians, sociologists and other public health scholars do not try to understand why any one person becomes ill. Instead, we typically examine illness rates to explain why people from certain social backgrounds are likelier than others to become sick. Sociologists know that social location makes a critical difference. Epidemiologists also focus on social causes of differences in health outcomes.
As we look at health in the United States, we see a complex and often contradictory issue. On the one hand, as one of the wealthiest nations, the US fares well in health comparisons with the rest of the world. However, the US also lags behind almost every industrialized country in providing care to all its citizens. This gap between the shared value of health and unequal outcomes makes health and illness a social problem. Even with our brief explanation of COVID-19 above, we see that people experience unequal health outcomes based on their race. This is just one dimension of inequality in health outcomes.
Sociologists also examine medicine, the social institution that seeks to prevent, diagnose, and treat illness and to promote health in its various dimensions. In other words, it is the institution responsible for addressing health and healthcare. This institution is vast, to put it mildly, involving more than 11 million people such as physicians, nurses, dentists, therapists, medical records technicians, and many others, as well as everything else related to health and healthcare such as the pharmaceutical industry, hospitals and clinics, industries that profit from medical products such as eye glasses or walkers, insurance policies and companies, and more.
Medical sociology is the systematic study of how societies manage issues of health and illness, such as diseases and disorders, healthcare access, and the larger picture of physical, mental, and social components of health and illness. Major topics for medical sociologists include doctor/patient relationships, the structure and socioeconomics of healthcare, the causes of health disparities across social groups, the practices within the institution of medicine that perpetuate inequality, and even how culture impacts attitudes toward disease and wellness.
Our ideas about what is healthy, what is illness, and what actions we should take to be healthy and treat illness are socially constructed. A sociological approach emphasizes that a society’s culture shapes its understanding of health and illness and practices of medicine. In particular, culture shapes a society’s perceptions of what it means to be healthy or ill, the reasons to which it attributes illness, and the ways in which it tries to keep its members healthy and cure those who are sick (Hahn & Inborn 2009). Knowing about a society’s culture helps us to understand how it perceives health and healing. By the same token, knowing about a society’s health and medicine helps us to understand important aspects of its culture. We’ll look more deeply into cultural constructions of health and illness on Theoretical Perspectives page.
However, subculture can impact our understandings of health and medicine, such that we have competing understandings within one culture. For instance, during the COVID-19 pandemic, some people strongly believed that we should abide by scientific recommendations such as mask-wearing and social-distancing in order to protect each other and population health (the health of all people in the nation). Others strongly believed that the government regulating our behaviors in order to protect population health was a violation of individual freedom. These differences are illustrated in the images below.
As you think about your experience with COVID-19, have you changed how you think about your own health? Many people who became severely ill or died from COVID-19 had other health issues, such as hypertension and obesity. Do you know people whose attitudes about their general health have changed? Do you know people who are suspicious of the government’s intentions or less likely to listen to doctors or scientists? What do you think will be the best way to prevent illness and death should another pandemic strike? Each of these questions highlights a topic related to the social construction of the social problem of health and illness.
Additionally, how we get sick and how we stay healthy reveals both inequality and interdependence. For example, residents of Flint, Michigan experienced higher-than-normal levels of lead toxicity, hair loss, rash, and other health issues when the local municipal government changed the water supply in 2013. Although government officials knew that the Flint River was contaminated with pollution from manufacturing, they decided to use this water for city residents because it was cheaper. Decisions at several interdependent layers of government resulted in this harmful action. Local citizens connected with doctors, health officials, and journalists to tell the story of the contaminated water and support a change.
More than 60% of the residents of Flint are Black. Over 40% of Flint’s residents live below the poverty line. This combination of race and class influenced the original decision making and community response. Eventually, the Michigan Civil Rights Commission cited systemic racism as the fundamental cause for the questionable decisions. Recovery required both individual agency and collective action. If you’d like to learn more, Flint Water Crisis: Everything You Need to Know provides more details.
Mental Health
In addition to physical health, we discuss mental health in this chapter. Mental health is a state of mind characterized by emotional well-being, good behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stresses of life (American Psychological Association 2023). It includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.
Mental health includes subjective well-being, autonomy, and competence. It is the ability to fulfill your intellectual and emotional potential. Mental health is how you enjoy life and create a balance between activities. Cultural differences, your own evaluation of yourself, and competing professional theories all affect how one defines mental health. Mental health is important at every stage of life, from childhood and adolescence through adulthood.
Throughout your life, if you experience mental health problems, your thinking, mood, and behavior could be affected. Some early signs related to mental health problems are sleep difficulties, lack of energy, and thinking of harming yourself or others. All of us will experience mental health challenges throughout our lives – times when we’re not sleeping, eating, or socializing as well as we know we could be. We may have times when we feel mildly depressed for a matter of days or just don’t feel like doing much. These experiences are common and do not mean you have a mental illness.
Mental illness, also called mental health disorders, refers to a wide range of mental health conditions and disorders that affect your mood, thinking, and behavior. Examples of mental illness include depression and other mood disorders like bipolar disorder, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors (Mayo Clinic Staff 2022). When substance use disorders co-occur with other mental health disorders, it is known as dual diagnosis. Having a dual diagnosis increases symptoms and decreases responsiveness to treatment. Drug use can precipitate overdoses on drugs such as methamphetamines, cocaine, and cannabis and can also worsen diagnoses such as bipolar disorder and schizophrenia. We will discuss social problems of drugs including substance use disorder further in the following chapter.
Unlike mental health, mental illness has a very specific definition. Psychiatrists, psychologists, and even your primary care doctor use a manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which lists every recognized mental illness. The DSM-5 (the latest one published as of this writing) lays out 297 conditions that professionals recognize as a mental illness (American Psychiatric Association 2013).
Each mental illness listed in the DSM has a list of diagnostic criteria that a person must meet to be considered to have that particular mental illness. For example, to get an official diagnosis of major depressive disorder, a person must meet five out of eight symptoms, such as severe fatigue, feeling hopeless or worthless, or much less interest in activities they used to enjoy, for at least two weeks to be considered clinically depressed.
Mental illnesses are common in the US. Nearly one in five US adults (57.8 million) lived with a mental illness in 2021 (National Institute of Mental Health 2023). Mental illnesses include many different conditions that vary in degree of severity, ranging from mild to moderate to severe.
In addition to the definitions of mental health and mental illness that we commonly use to discuss diagnosis or lack thereof, some people are starting to use the description of mental well-being. Mental wellness is an internal resource that helps us think, feel, connect, and function. It is an active process that helps us to build resilience, grow, and flourish (McGroarty 2021). While people can support their own mental well-being with self-care activities and connecting with family and friends, the core concept is more profound. It comprises the activities and attitudes that all of us can cultivate to ensure our own resilience, whether we have a mental health diagnosis or not.
The community activists and researchers who created the phrase mental well-being use it for two reasons. First, by separating a mental health diagnosis from the quality of mental well-being, we have a model that helps us understand that mental illness can be similar to a chronic disease. You can see this model for yourself in the figure below.
Some days, weeks, or even years, the illness is very well managed, and the person leads a productive, happy, and fulfilling life. On other days, the illness is not well managed, and the person needs more support. On the other axis, some people may experience a life event that makes them deeply sad or feel powerless. They don’t have a mental health diagnosis but may need mental health treatment or support anyway. Watch Mental Health Continuum to see how the model works in real time.
Second, some people and communities stigmatize people who have mental illnesses or need mental health treatment. In those cases, using the language of mental wellbeing avoids stigma. The National Alliance on Mental Illness (NAMI) hosts these sites, which you can explore if it interests you: Sharing Hope: Mental Wellness in the Black Community and Compartiendo Esperanza: Mental Wellness in the Latinx Community. Both sites have excellent videos exploring issues relating to mental wellness and resilience, mental health, and mental illness in these specific communities.
In this chapter, we aim not only to understand the role of sociology in the study of mental health but to gain a deeper understanding of the effects of social life on our mental well-being. This discussion is interdisciplinary – it includes material from many fields. But there is a coherent organizing theme: The need to understand mental illness in a broad social context. Too often, scientists and psychologists study people who have diseases of the mind without regard to their social origins and to the workings of institutionalized social control involved in mental illness.
We will define more sociological concepts – stigma and total institutions – to understand why mental health is a sociological issue. This chapter critically examines how history, institutions, and culture shape our conceptions of mental illness and people with mental health challenges. We will consider the social factors contributing to the rates and the experiences of mental illness, including social location.
When sociologists study mental health, they look at trends across groups. They look at how mental health varies by race, class, gender, sexuality, and more. They also explore the factors that maintain or distract from mental health, such as stress, resilience, and coping factors, the social roles we hold, and the strength of our social networks as a source of support.
In addition to physical and mental health, sociologists are interested in health care programs and insurance, which vary dramatically around the world. The following brief section describes some of that variation.
Healthcare in Industrial Nations
Industrial nations throughout the world, with the notable exception of the US, provide their citizens with some form of national health care and national health insurance (Russell 2011). Although their healthcare systems differ in several respects, their governments pay all or most of the costs for health care, drugs, and other health needs. In Denmark, for example, the government provides free medical care and hospitalization for the entire population and pays for some medications and some dental care. In France, the government pays for some of the medical, hospitalization, and medication costs for most people and all these expenses for the poor, unemployed, and children under the age of 10. In Great Britain, the National Health Service pays most medical costs for the population, including medical care, hospitalization, prescriptions, dental care, and eyeglasses. In Canada, the National Health Insurance system also pays for most medical costs. Patients do not even receive bills from their physicians, who instead are paid by the government.
Although these national health insurance programs are not perfect – for example, people sometimes must wait for elective surgery and some other procedures – they are commonly credited with reducing infant mortality, extending life expectancy, and, more generally, for enabling their citizenries to have relatively good health. Their populations are generally healthier than Americans, even though healthcare spending is much higher per capita in the US than in these other nations. In all these respects, these national health insurance systems offer several advantages over the US healthcare model (Reid 2010). We will discuss this issue further in subsequent pages.
Lessons from Other Societies
National Health Care in Wealthy Democracies
As the text discusses, industrial nations other than the United States provide free or low-cost health care to their citizens in what is known as national (or universal) health insurance and national health care. Although the US spends more per capita than these nations on health care, it generally ranks much lower than they do on important health indicators. In the first decade of the twentieth century, 24 wealthy democracies from North America, Western Europe, and certain other parts of the world (Australia, Japan, New Zealand; the exact number of nations varies slightly by indicator), the US had the lowest life expectancy, the highest infant mortality, and the highest rates of obesity, adult diabetes, and HIV and AIDS. It ranked 21st in mortality from heart disease and only tenth in breast cancer mortality rate. The US also ranked 22nd for annual doctor consultations per capita and among the highest for hospital admissions for various conditions, such as respiratory disease, that are avoidable with adequate primary and outpatient care. According to policy analyst Lawrence Mishel and colleagues, the conclusion from these international comparisons is inescapable:
"Although the United States spends more on health care than other countries with similar per capita income and populations, it has worse health outcomes, on average… Compared to the United States, other countries are more committed to the health and well-being of their citizens through more-universal coverage and more-comprehensive health care systems."
Because of Canada’s proximity, many studies compare health and health-care indicators between the US and Canada. A recent review summarized the evidence: "Although studies’ findings go in both directions, the bulk of the research finds higher quality of care in Canada."
Surveys of random samples of citizens in several nations provide additional evidence of the advantages of the type of health care found outside the US and the disadvantages of the US system. In surveys of US residents and those of six other nations (Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom), Americans ranked highest in the percentage uninsured (16% in the United States compared to 0-2% elsewhere; though that figure was nearly cut in half with the Affordable Care Act), highest in the percentage that did not receive needed medical care during the last year because of costs, and highest by far in the percentage that had 'serious problems' in paying medical bills in the past year.
A fair conclusion from all the evidence is that US health lags behind that found in other wealthy nations because the latter provide free or low-cost national healthcare to their citizens and the US does not. As such, the US has much to learn from their example. Because the healthcare reform achieved in the US in 2009-2010 did not include a national healthcare model, the US will likely continue to lag behind other democracies in the quality of health and healthcare. At the same time, the cost of health care will certainly continue to be much higher in the US than in other Western nations, in part because the US uses a fee-for-service model in which many physicians are paid for every procedure they do rather than the set salary that some other nations feature.
Sources: Docteur & Berenson 2009; Mishel, Bernstein, & Shierholz 2009; Organisation for Economic Cooperation and Development (OECD) 2011; Schoen et al. 2007
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In this chapter we will cover social problems related to physical and mental health, including health disparities between various social groups, as well as other problems within the institution of medicine such as medicalization and the cost and quality of healthcare. First, we summarize how sociological and other perspectives frame medicine and health problems.
