# Section 1. The Sociological Perspective

## Concepts of Health and Illness: Section 1. The Sociological Perspective

This section covers:

(a) Key concerns
(b) Theoretical perspectives
(c) Defining the field of medical sociology

1. ### What are the concerns of Sociology?

The simplest view of the academic discipline of sociology is that it is somehow concerned with the understanding of human societies. However, this does not take us very far as most people feel they know a good deal about the society in which they live because they experience it everyday; this can be described as 'common-sense' knowledge. Another approach would be to define sociology as a research-based study of society. However, there are other academic disciplines such as history, politics, economics, anthropology and social psychology that also have human society as the object of study. Probably the best way of defining the contribution of sociology is by looking at the key questions that originally stimulated the development of the academic discipline and which continue to underpin sociological research today:

• What gives social life a sense of stability & order?
• How does social change & development come about?
• What is the nature of the relationship between the individual and the society in which they live?
• To what extent does the society into which people are born shape their beliefs, behaviour, & life chances (including health outcomes)?

Understanding and explaining social phenomena

• Sociology, in pursuing an objective scientific approach to answering the questions posed above, attempts to explain why social life is not a random series of events, but is structured and shaped by particular sets of rules (both obvious & hidden). This is not to say that social structures determine human behaviour, rather that social structure is both the ever-present condition for, and reproduced outcome of, intentional human agency or actions.
• Sociology, like any other academic discipline, is theory-based. That is, in order to understand how societies work (or why particular bio-chemical processes occur), we must go beyond a simplistic description of the phenomenon under investigation.
• Sociology, also like any other academic discipline which has as its object of study the human and social world, consists of a range of competing explanatory paradigms. Empirical research necessarily involves making assumptions about the nature of social reality.
• Sociology challenges both naturalistic and individualistic explanations of social phenomena (see Activity 1). These understandings arise as a consequence of growing up (being socialised') within a particular culture and set of social structures, and can result in people seeing their everyday roles and behaviour as being somehow natural'. Equally, when looking at other peoples behaviour i.e. unhealthy lifestyles' or lack of motivation; for example, the focus is all too often on particular individual characteristics ignoring the social factors that influence such behaviour and beliefs.

2. ### Theoretical approaches within Sociology

A single unified sociological perspective concerning the nature of social reality does not exist. In this respect sociology is no different to any other academic discipline, for all embrace competing perspectives or paradigms - this is how subject knowledge is advanced.

The major long-standing epistemological divide that exists within sociological theory is that between those sociologists who argue that society can be studied in an objective way through identifying and examining the structures of society, and those who argue for an interpretative or subjective approach to social phenomena more focused on social actors. Structuralist approaches often tend to focus on the macro level while subjectivist approaches tend to focus on the micro level of interaction. However, in more recent time's a third position has developed which attempts to breakdown this duality between the relative importance attached to social actors versus social structures. These three approaches are explored below.

1. Social structural approaches: Societies as objective realities

Social structural approaches to exploring social reality include those empiricist sociologists who believe that an objective 'science of society' is possible in much the same way as a physical science such as biology or physics. This empirical sociology seeks to explain the norms of social life in terms of various identifiable linear causal influences. Social structural approaches would also include those sociologists who see human society as being shaped by an underlying material social and economic structure. These are structures that may not always be visible, but nevertheless are fundamental in explaining social and individual processes.

In relation to health, a predominantly social structural approach would draw upon quantitative data derived from social surveys, epidemiological studies and comparative studies in order to point to the relative influence of societal structures and processes in determining health outcomes for social groups.

Within the academic discipline of sociology, two major theoretical perspectives exist which seek to analyse human societies utilising a social structural or systems approach. These perspectives are structural functionalism and Marxism, and their very different organising principles are described in relation to the social determination of health outcomes below. As a brief illustration of the two approaches to structural analysis we will briefly examine the issue of poverty. The functionalist explanation would set poverty in the context of social stratification and the unequal distribution of rewards associated with complex economies where different tasks are performed by different groups within society. Some groups are relatively less well off than others because they have less skills and knowledge and so their contribution to the functioning of society is not as extensive as other groups. Whilst the Marxist explanation would set poverty in the context of the class structure, specifically the relationship of social groups within an capitalist system of economic production in which there are the exploited and the exploiters (with some intermediate groups of managers and supervisors).

The functionalist perspective of health and illness

This theoretical perspective stresses the essential stability and cooperation within modern societies. Social events are explained by reference to the functions they perform in enabling continuity within society. Society itself is likened to a biological organism in that the whole is seen to be made up of interconnected and integrated parts; this integration is the result of a general consensus on core values and norms. Through the process of socialisation we learn these rules of society which are translated into roles. Thus, consensus is apparently achieved through the structuring of human behaviour. Within medical sociology, this approach is essentially concerned with the theme of the 'sick role', and the associated issue of illness behaviour. Talcott Parsons, the leading figure within this sociological tradition, identified illness as a social phenomenon rather than as a purely physical condition. Health, as against illness, being defined as:

'The state of optimum capacity of an individual for the effective performance of the roles and tasks for which s/he has been socialised.' Parsons, 1951

Health within the Functionalist perspective thus becomes a prerequisite for the smooth functioning of society. To be sick is to fail in terms of fulfilling one's role in society; illness is thus seen as 'unmotivated deviance'. The regulation of this sickness/deviance comes about through the mechanism of the 'sick role' concept and the associated 'social control' role of doctors in allowing an individual to take on a sick status.

The Marxist perspective of health and illness

A key assertion of the Marxist perspective is that material production is the most fundamental of all human activities - from the production of the most basic of human necessities such as food, shelter and clothing in a subsistence economy, to the mass production of commodities in modern capitalist societies. Whether this production takes place within a modern or a subsistence economy, it involves some sort of organisation and the use of appropriate tools; this is termed the 'forces of production'. Production of any type was recognised by Marx as also involving social relations. In modern capitalist societies these 'relations of production' lead to the development of a division of labour reflecting in the existence of different social classes. For Marx, it is these forces and relations of production together that constitute the economic base (infrastructure) of society. The superstructure of a society - the political, legal, educational, and health systems and so on, are shaped and determined by this economic base.

The orientation of this approach as applied within medical sociology is towards the social origins of disease. Health outcomes for the population are seen as being influenced by the operation of the capitalist economic system at two levels.

First, at the level of the production process itself, health is affected either directly in terms of industrial diseases and injuries, stress-related ill health, or indirectly through the wider effects of the process of commodity production within modern societies. The production processes produce environmental pollution, whilst the process of consuming the commodities themselves have long-term health consequences such as eating processed foods, chemical additives, car accidents and so on. Second, health is influenced at the level of distribution. Income and wealth are major determinants of people's standard of living - where they live, their access to educational opportunities, their access to health care, their diet, and their recreational opportunities. All of these factors are significant in the social patterning of health.

2. Interpretative approaches: Societies as subjective realities

Sociologists within this wide tradition would argue that the social world cannot be studied in the same way as the physical world because people:

'Engage in conscious intentional activity and, through language, attach meanings to their actions... [therefore] sociologists should be less concerned to explain behaviour than to understand how people come to interpret the world in the way they do.' Taylor and Field, 1993:15

In attempting to achieve this goal of interpretative understanding, reliance is placed on essentially qualitative research methodologies in order to get as close as possible to the world of the subjects or social actors being studied. In terms of health and illness, this interpretative approach focuses upon the (symbolic) meanings of what it is to be ill in our society, and would not confine its interest in health to what would be perceived as the closed world of clinical biomedicine (this would not rule out the study of the interactions of clinicians themselves both with patients and with colleagues). The following issues in health and illness are examples of the research focus of interpretative sociology:
Within this interpretative sociological tradition two distinct perspectives stand out; symbolic interactionism and social constructionism. These approaches will be outlined below in relation to health and illness.

The Symbolic Interactionist perspective of health and illness

This perspective developed from a concern with language and the ways in which it enables us to become self-conscious beings. The basis of any language is the use of symbols that reflect the meanings that we endow physical and social objects with. In any social setting in which communication takes place, there is an exchange of these symbols: that is, we look for clues in interpreting the behaviour and intentions of others. Communication being a two-way process, this interpretative process involves a negotiation between the parties concerned. The negotiated order that develops therefore involves:

'People construct[ing] understandings of themselves and of others out of experiences they have and the situations they find themselves in. These understandings have consequences in turn for the way in which people act, and the manner in which others react to them.' Aggleton, 1990:91

Interactionist sociology asserts that the social identities we possess are influenced by the reactions of others. So if we demonstrate some abnormal or 'deviant' behaviour it is likely that the particular label that is attached within a society at a particular time to this behaviour will then become attached to us as individuals. This can bring about important changes in our self-identity. A disease diagnosis could be one such label: for example, clinical depression and the assumptions about the person so labelled that then follow; here Goffman's (1968) work on this form of social stigma is particularly influential and will be discussed in detail in Section 3 of this module.

Within this perspective medicine too would be viewed as a social practice, and its claims to be an objective science would be disputed. In the doctor-patient interaction, patient dissatisfaction can result if the doctor too rigidly superimposes a pre-existing framework (disease categories) upon the subjective illness experience of the patient. For example, by presuming that they can understand what that individual is suffering because of an interpretation of their signs and symptoms without reference their health beliefs (explored in Section 4).

See Activity 2

The Social Constructionist perspective of health and illness - The relativity of social reality

This sociological perspective derives from the phenomenological approach of Berger and Luckmann (1967), who argue that everyday knowledge is creatively produced by individuals and is directed towards practical problems. 'Facts' are therefore created through social interactions and people's interpretations of these 'facts'. This essentially subjectivist approach embraces a number of very different sociological paradigms, but what such paradigms do have in common in relation to health and illness is a focus on the way we make sense of our bodies and bodily disturbances. Social constructionism refuses to draw a distinction between scientific (medical) and social knowledge. Nor would it ignore disease in favour of examining the illness experience; unlike the interactionist perspective. Rather, it maintains that all knowledge is socially constructed. We are seen to come to know the world through the ideas and beliefs we hold about it, so that it is our concepts and categories which are the realities of the world (For further reading see Bury:1986 - a sociological paper which focuses on social constructionism in relation to biomedicine).

Foucault (1973,1980,1985,1986) and the work of so-called post-structural social theorists are included within this perspective, though their concerns are frequently different from those researching within the tradition of phenomenology. Foucault is interested in power in itself, not as reduced to an expression of some other conceptual starting point such as class, the state, gender or ethnicity. He seeks to approach the relationship between agency and structure not through an essentialist analysis but by using an 'interpretative analytics' of practices and discourses, discerning the workings of power and knowledge in social relations.

In terms of health and illness, this Foucauldian approach to cultural constructionism draws attention to the ways in which we experience ourselves and our bodies not in some naturalistic way, but in what is termed a 'symbolically mediated fashion' - the body as a 'field of discourse'. As David Armstrong put it, in describing the development of medical knowledge in the latter half of the nineteenth century:

'The fact that the body became legible does not imply that some invariant biological reality was finally revealed to medical enquiry. The body was only legible in that there existed in the new clinical techniques a language by which it could be read.' Armstrong, 1983

3. Societies as a synthesis of agency and structure

Anthony Giddens' work (1979,1984) is concerned with attempting to overcome the traditional sociological dualities between agency and structure, and between the ideal and the material, which are discussed above. According to May (1996), Giddens seeks to examine the structural reproduction of social practices, whilst also insisting upon the opportunities which exist for individual innovation in social conduct:

'Structure enters into the constitution of the agent and social practices and 'exists' in the generating moments of this constitution.' Giddens, 1979:5

Here Giddens is referring to what he describes as the 'duality of structure'. This is the idea that while social structures are themselves produced by men and women, at the same time these structures act as mediators to constrain and influence this very productive process. In the context of health and illness, Giddens argues (following Durkheim) that for a society to function effectively requires that people have a sense of order and continuity - the social rules that people draw upon in their social practices. The existence of this structural continuity within society requires that people find intellectual and emotional meaning within their own personal lives - what he terms 'ontological security'. However, when we assess the meanings of illness or death and dying, for example, we recognise that these essentially individual experiences cannot simply be denied or disregarded by social structures. Our mortality is something we all have to face individually, and this calls into question many of the assumptions we might hold about the structures that appear to shape our lives. Equally, our self-identity is not simply provided for us by the social system we live within: it is something we have to search for ourselves. 'Praxis' is the name Giddens gives to this link between practical consciousness which informs our actions and behaviours, and the social conditions in which this action takes place.

3. ### The Sociology of health and illness: Defining the field

Sociology brings two distinct focuses of analysis to the study of health and illness:

• At one level it tries to 'make sense of illness', by applying sociological perspectives both to an analysis of the experience of illness, and to the social structuring of health and disease. At this level, sociology makes an important contribution to multi-disciplinary research into issues of interest to clinicians and other health professionals, the development of health policy, and epidemiological studies.
• At a second level, sociological enquiry can open doors to an understanding of the impact of wider social processes upon the health of individuals and social groups. Such processes include social inequalities, professional relationships, change and self-identity, knowledge and power, and consumption and risk.

See Glossary for Section 1