Chapter 18 Health and Medicine

The Functionalist Approach

As conceived by Talcott Parsons (1951),Parsons, T. (1951). The social system. New York, NY: Free Press. the functionalist perspective on health and medicine emphasizes that good health and effective medical care are essential for a society’s ability to function. Ill health impairs our ability to perform our roles in society, and if too many people are unhealthy, society’s functioning and stability suffer. This was especially true for premature death, said Parsons, because it prevents individuals from fully carrying out all their social roles and thus represents a “poor return” to society for the various costs of pregnancy, birth, child care, and socialization of the individual who ends up dying early. Poor medical care is likewise dysfunctional for society, as people who are ill face greater difficulty in becoming healthy and people who are healthy are more likely to become ill.

For a person to be considered legitimately sick, said Parsons, several expectations must be met. He referred to these expectations as the sick roleExpectations of how people are supposed to think and act when they are ill.. First, sick people should not be perceived as having caused their own health problem. If we eat high-fat food, become obese, and have a heart attack, we evoke less sympathy than if we had practiced good nutrition and maintained a proper weight. If someone is driving drunk and smashes into a tree, there is much less sympathy than if the driver had been sober and skidded off the road in icy weather.

Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as faking their illness or malingering after becoming healthier, they are no longer considered legitimately ill by the people who know them or, more generally, by society itself.

Third, sick people are expected to have their illness confirmed by a physician or other health-care professional and to follow the professional’s advice and instructions in order to become well. If a sick person fails to do so, she or he again loses the right to perform the sick role.

If all of these expectations are met, said Parsons, sick people are treated as sick by their family, their friends, and other people they know, and they become exempt from their normal obligations to all these people. Sometimes they are even told to stay in bed when they want to remain active.

Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the person’s illness, decide how to treat it, and help the person become well. To do so, they need the cooperation of the patient, who must answer the physician’s questions accurately and follow the physician’s instructions. Parsons thus viewed the physician-patient relationship as hierarchical: the physician gives the orders (or, more accurately, provides advice and instructions), and the patient follows them.

Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s health, but his perspective has been criticized for several reasons. First, his idea of the sick role applies more to acute (short-term) illness than to chronic (long-term) illness. Although much of his discussion implies a person temporarily enters a sick role and leaves it soon after following adequate medical care, people with chronic illnesses can be locked into a sick role for a very long time or even permanently. Second, Parsons’s discussion ignores the fact, mentioned earlier, that our social location in society in the form of social class, race and ethnicity, and gender affects both the likelihood of becoming ill and the quality of medical care we receive. Third, Parsons wrote approvingly of the hierarchy implicit in the physician-patient relationship. Many experts say today that patients need to reduce this hierarchy by asking more questions of their physicians and by taking a more active role in maintaining their health. To the extent that physicians do not always provide the best medical care, the hierarchy that Parsons favored is at least partly to blame.

The Conflict Approach

The conflict approach emphasizes inequality in the quality of health and of health-care delivery (Conrad, 2009).Conrad, P. (Ed.). (2009). Sociology of health and illness: Critical perspectives (8th ed.). New York, NY: Worth. As noted earlier, the quality of health and health care differ greatly around the world and within the United States. Society’s inequities along social class, race and ethnicity, and gender lines are reproduced in our health and health care. People from disadvantaged social backgrounds are more likely to become ill, and once they do become ill, inadequate health care makes it more difficult for them to become well. As we will see, the evidence of inequities in health and health care is vast and dramatic.

The conflict approach also critiques the degree to which physicians over the decades have tried to control the practice of medicine and to define various social problems as medical ones. Their motivation for doing so has been both good and bad. On the good side, they have believed that they are the most qualified professionals to diagnose problems and treat people who have these problems. On the negative side, they have also recognized that their financial status will improve if they succeed in characterizing social problems as medical problems and in monopolizing the treatment of these problems. Once these problems become “medicalized,” their possible social roots and thus potential solutions are neglected.

Several examples illustrate conflict theory’s criticism. Alternative medicine is becoming increasingly popular (see Chapter 18 "Health and Medicine", Section 18.4 "Medicine and Health Care in the United States"), but so has criticism of it by the medical establishment. Physicians may honestly feel that medical alternatives are inadequate, ineffective, or even dangerous, but they also recognize that the use of these alternatives is financially harmful to their own practices. Eating disorders also illustrate conflict theory’s criticism. Many of the women and girls who have eating disorders receive help from a physician, a psychiatrist, a psychologist, or another health-care professional. Although this care is often very helpful, the definition of eating disorders as a medical problem nonetheless provides a good source of income for the professionals who treat it and obscures its cultural roots in society’s standard of beauty for women (Whitehead & Kurz, 2008).Whitehead, K., & Kurz, T. (2008). Saints, sinners and standards of femininity: Discursive constructions of anorexia nervosa and obesity in women’s magazines. Journal of Gender Studies, 17, 345–358.

Obstetrical care provides another example. In most of human history, midwives or their equivalent were the people who helped pregnant women deliver their babies. In the 19th century, physicians claimed they were better trained than midwives and won legislation giving them authority to deliver babies. They may have honestly felt that midwives were inadequately trained, but they also fully recognized that obstetrical care would be quite lucrative (Ehrenreich & English, 2005).Ehrenreich, B., & English, D. (2005). For her own good: Two centuries of the experts’ advice to women (2nd ed.). New York, NY: Anchor Books. In a final example, many hyperactive children are now diagnosed with ADHD, or attention deficit/hyperactivity disorder. A generation or more ago, they would have been considered merely as overly active. After Ritalin, a drug that reduces hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD diagnosis was increasingly applied, and tens of thousands of children went to physicians’ offices and were given Ritalin or similar drugs. The definition of their behavior as a medical problem was very lucrative for physicians and for the company that developed Ritalin, and it also obscured the possible roots of their behavior in inadequate parenting, stultifying schools, or even gender socialization, as most hyperactive kids are boys (Conrad, 2008; Rao & Seaton, 2010).Conrad, P. (2008). The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore, MD: Johns Hopkins University Press; Rao, A., & Seaton, M. (2010). The way of boys: Promoting the social and emotional development of young boys. New York, NY: Harper Paperbacks.

Critics of the conflict approach say that its assessment of health and medicine is overly harsh and its criticism of physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of people in the industrial world; even in the poorer nations, moreover, health has improved from a century ago, however inadequate it remains today. Although physicians are certainly motivated, as many people are, by economic considerations, their efforts to extend their scope into previously nonmedical areas also stem from honest beliefs that people’s health and lives will improve if these efforts succeed. Certainly there is some truth in this criticism of the conflict approach, but the evidence of inequality in health and medicine and of the negative aspects of the medical establishment’s motivation for extending its reach remains compelling.

The Interactionist Approach

The interactionist approach emphasizes that health and illness are social constructions. This means that various physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members (Buckser, 2009; Lorber & Moore, 2002).Buckser, A. (2009). Institutions, agency, and illness in the making of Tourette syndrome. Human Organization, 68(3), 293–306; Lorber, J., & Moore, L. J. (2002). Gender and the social construction of illness (2nd ed.). Lanham, MD: Rowman & Littlefield. The ADHD example just discussed also illustrates interactionist theory’s concerns, as a behavior that was not previously considered an illness came to be defined as one after the development of Ritalin. In another example, in the late 1800s opium use was quite common in the United States, as opium derivatives were included in all sorts of over-the-counter products. Opium use was considered neither a major health nor legal problem. That changed by the end of the century, as prejudice against Chinese Americans led to the banning of the opium dens (similar to today’s bars) they frequented, and calls for the banning of opium led to federal legislation early in the 20th century that banned most opium products except by prescription (Musto, 2002).Musto, D. F. (Ed.). (2002). Drugs in America: A documentary history. New York, NY: New York University Press.

In a more current example, an attempt to redefine obesity is now under way in the United States. Obesity is a known health risk, but a “fat pride” movement composed mainly of heavy individuals is arguing that obesity’s health risks are exaggerated and calling attention to society’s discrimination against overweight people. Although such discrimination is certainly unfortunate, critics say the movement is going too far in trying to minimize obesity’s risks (Saulny, 2009).Saulny, S. (2009, November 7). Heavier Americans push back on health debate. The New York Times, p. A23.

The symbolic interactionist approach has also provided important studies of the interaction between patients and health-care professionals. Consciously or not, physicians “manage the situation” to display their authority and medical knowledge. Patients usually have to wait a long time for the physician to show up, and the physician is often in a white lab coat; the physician is also often addressed as “Doctor,” while patients are often called by their first name. Physicians typically use complex medical terms to describe a patient’s illness instead of the more simple terms used by laypeople and the patients themselves.

Management of the situation is perhaps especially important during a gynecological exam. When the physician is a man, this situation is fraught with potential embarrassment and uneasiness because a man is examining and touching a woman’s genital area. Under these circumstances, the physician must act in a purely professional manner. He must indicate no personal interest in the woman’s body and must instead treat the exam no differently from any other type of exam. To further “desex” the situation and reduce any potential uneasiness, a female nurse is often present during the exam (Cullum-Swan, 1992).Cullum-Swan, B. (1992). Behavior in public places: A frame analysis of gynecological exams. Paper presented at the American Sociological Association, Pittsburgh, PA.

Critics fault the symbolic interactionist approach for implying that no illnesses have objective reality. Many serious health conditions do exist and put people at risk for their health regardless of what they or their society thinks. Critics also say the approach neglects the effects of social inequality for health and illness. Despite these possible faults, the symbolic interactionist approach reminds us that health and illness do have a subjective as well as an objective reality.

Social Class

Not only do the poor have less money, but they also have much worse health. There is growing recognition in the government and in medical and academic communities that social class makes a huge difference when it comes to health and illness. A recent summary of the evidence concluded that social class inequalities in health are “pervasive” in the United States and other nations across the world (Elo, 2009, p. 553).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572.

Many types of health indicators illustrate the social class–health link in the United States. In an annual survey conducted by the government, people are asked to indicate the quality of their health. As Figure 18.5 "Family Income and Self-Reported Health (Percentage of People 18 or Over Saying Health Is Only Fair or Poor)" shows, poor people are much more likely than those with higher incomes to say their health is only fair or poor. These self-reports of health are subjective indicators, and it is possible that not everyone interprets “fair” or “poor” health in the same way. But objective indicators of actual health also indicate a strong social class–health link, with some of the most unsettling evidence involving children. As a recent report concluded,

The data illustrate a consistent and striking pattern of incremental improvements in health with increasing levels of family income and educational attainment: As family income and levels of education rise, health improves. In almost every state, shortfalls in health are greatest among children in the poorest or least educated households, but even middle-class children are less healthy than children with greater advantages. (Robert Wood Johnson Foundation, 2008, p. 2)Robert Wood Johnson Foundation. (2008). America’s health starts with healthy children: How do states compare? Princeton, NJ: Robert Wood Johnson Foundation.

For example, infant mortality is 86% higher among infants born to mothers without a high school degree than those with a college degree, and low birth weight is 29% higher. According to their parents, one-third of children in poor families are in less than very good health, compared to only 7% of children in wealthy families (at least 4 times the poverty level). In many other health indicators, as the news story that began this chapter indicated, children in low-income families are more likely than children in wealthier families to have various kinds of health problems, many of which endure into adolescence and adulthood.

Poor adults are also at much greater risk for many health problems, including heart disease, diabetes, arthritis, and some types of cancer (National Center for Health Statistics, 2009).National Center for Health Statistics. (2009). Health, United States, 2009. Hyattsville, MD: Centers for Disease Control and Prevention. Rates of high blood pressure, serious heart conditions, and diabetes are at least twice as high for middle-aged adults with family incomes below the poverty level than for those with incomes at least twice the poverty level. All of these social class differences in health contribute to a striking difference in life expectancy, with the wealthiest Americans expected to live four and a half years longer on average than the poorest Americans (Pear, 2008).Pear, R. (2008, March 23). Gap in life expectancy widens for the nation. The New York Times. Retrieved from http://www.nytimes.com/2008/03/23/us/23health.html?scp= 1&sq=Gap%20in%20life%20expectancy%20widens%20for%20the%20nation&st=cse

Several reasons account for the social class–health link (Elo, 2009; Pampel, Krueger, & Denney, 2010).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572; Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010, June). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36, 349–370. doi:10.1146/annurev.soc.012809.102529 One reason is stress, which is higher for people with low incomes because of unemployment, problems in paying for the necessities of life, and a sense of little control over what happens to them. Stress in turn damages health because it impairs the immune system and other bodily processes (Lantz, House, Mero, & Williams, 2005).Lantz, P. M., House, J. S., Mero, R. P., & Williams, D. R. (2005). Stress, life events, and socioeconomic disparities in health: Results from the Americans’ Changing Lives Study. Journal of Health and Social Behavior, 3, 274–288. A second reason is that poor people live in conditions, including crowded, dilapidated housing with poor sanitation, that are bad for their health and especially that of their children (Stewart & Rhoden, 2006).Stewart, J., & Rhoden, M. (2006). Children, housing and health. International Journal of Sociology and Social Policy, 26, 7–8. Although these conditions have improved markedly in the United States over the last few decades, they continue for many of the poor.

Another reason is the lack of access to adequate health care. As is well known, many poor people lack medical insurance and in other respects have inadequate health care. These problems make it more likely they will become ill in the first place and more difficult for them to become well because they cannot afford to visit a physician or to receive other health care. Still, social class disparities in health exist even in countries that provide free national health care, a fact that underscores the importance of the other reasons discussed here for the social class–health link (Elo, 2009).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572.

A fourth reason is a lack of education, which, in ways not yet well understood, leads poor people to be unaware of risk factors for health and to have a fatalistic attitude that promotes unhealthy behaviors and reluctance to heed medical advice (Elo, 2009).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572. In one study of whether smokers quit smoking after a heart attack, only 10% of heart attack patients without a high school degree quit smoking, compared to almost 90% of those with a college degree (Wray, Herzog, Willis, & Wallace, 1998).Wray, L. A., Herzog, A. R., Willis, R. J., & Wallace, R. B. (1998). The impact of education and heart attack on smoking cessation among middle-aged adults. Journal of Health and Social Behavior, 39, 271–294.

A final and related reason for the poor health of poor people is unhealthy lifestyles, as just implied. Although it might sound like a stereotype, poor people are more likely to smoke, to eat high-fat food, to avoid exercise, to be overweight, and, more generally, not to do what they need to do (or to do what they should not be doing) to be healthy (Pampel, Krueger, & Denney, 2010; Cubbins & Buchanan, 2009).Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010, June). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36, 349–370. doi:10.1146/annurev.soc.012809.102529; Cubbins, L. A., & Buchanan, T. (2009). Racial/ethnic disparities in health: The role of lifestyle, education, income, and wealth. Sociological Focus, 42(2), 172–191. Scholars continue to debate whether unhealthy lifestyles are more important in explaining poor people’s poor health than factors such as lack of access to health care, stress, and other negative aspects of the social and physical environments in which poor people live. Regardless of the proper mix of reasons, the fact remains that the poor have worse health.

In assessing the social class–health link, we have been assuming that poverty leads to poor health. Yet it is also possible that poor health leads to poverty or near-poverty because of high health-care expenses and decreased work hours. Recent evidence supports this causal linkage, as serious health problems in adulthood often do force people to reduce their work hours or even to retire altogether (J. P. Smith, 2005).Smith, J. P. (2005). Unraveling the SES-health connection [Supplemental material]. Population and Development Review, 30, 108–132. Although this linkage accounts for some of the social class–health relationship that is so noticeable, evidence of the large impact of low income on poor health remains compelling.

Race and Ethnicity

Health differences also exist when we examine the effects of race and ethnicity (Barr, 2008),Barr, D. A. (2008). Health disparities in the United States: Social class, race, and health. Baltimore, MD: Johns Hopkins University Press. and they are literally a matter of life and death. We can see this when we compare life expectancies for whites and African Americans born in 2006 (Table 18.2 "U.S. Life Expectancy at Birth for People Born in 2006"). When we do not take gender into account, African Americans can expect to live 5 fewer years than whites. Among men, they can expect to live 6 fewer years, and among women, 4.1 fewer years.

At the beginning of the life course, infant mortality also varies by race and ethnicity (Table 18.3 "Mother’s Race/Ethnicity and U.S. Infant Mortality, 2003–2005 (Average Annual Number of Infant Deaths per 1,000 Live Births)"), with African American infants more than twice as likely as white infants to die before their first birthday. Infant mortality among Native Americans is almost 1.5 times the white rate, while that for Latinos is about the same (although the Puerto Rican rate is also higher, at 8.1), and Asians a bit lower. In a related indicator, maternal mortality (from complications of pregnancy or childbirth) stands at 8.0 maternal deaths for every 100,000 live births for non-Latina white women, 8.8 for Latina women, and a troubling 28.7 for African American women. Maternal mortality for African American women is thus 3.5 times greater than that for non-Latina white women. In other indicators, African Americans are more likely than whites to die from heart disease, although the white rate of such deaths is higher than the rates of Asians, Latinos, and Native Americans. African Americans are also more likely than whites to be overweight and to suffer from asthma, diabetes, high blood pressure, and several types of cancer. Latinos and Native Americans have higher rates than whites of several illnesses and conditions, including diabetes.

Commenting on all of these disparities in health, a former head of the U.S. Department of Health and Human Services said a decade ago, “We have been—and remain—two nations: one majority, one minority—separated by the quality of our health” (Penn et al., 2000, p. 102).Penn, N. E., Kramer, J., Skinner, J. F., Velasquez, R. J., Yee, B. W. K., Arellano, L. M., & Williams, J. P. (2000). Health practices and health-care systems among cultural groups. In R. M. Eisler & M. Hersen (Eds.), Handbook of gender, culture, and health (pp. 101–132). New York, NY: Routledge. The examples just discussed certainly indicate that her statement is still true today.

Why do such large racial and ethnic disparities in health exist? To a large degree, they reflect the high poverty rates for African Americans, Latinos, and Native Americans compared to those for whites (Cubbins & Buchanan, 2009).Cubbins, L. A., & Buchanan, T. (2009). Racial/ethnic disparities in health: The role of lifestyle, education, income, and wealth. Sociological Focus, 42(2), 172–191. In addition, inadequate medical care is perhaps a special problem for people of color, thanks to unconscious racial bias among health-care professionals that affects the quality of care that people of color receive (see discussion later in this chapter).

An additional reason for racial disparities in health is diet. Many of the foods that have long been part of African American culture are high in fat. Partly as a result, African Americans are much more likely than whites to have heart disease and high blood pressure and to die from these conditions (Lewis-Moss, Paschal, Redmond, Green, & Carmack, 2008).Lewis-Moss, R. K., Paschal, A., Redmond, M., Green, B. L., & Carmack, C. (2008). Health attitudes and behaviors of African American adolescents. Journal of Community Health, 33(5), 351–356. In contrast, first-generation Latinos tend to have diets consisting of beans, grains, and other low-fat foods, preventing health problems stemming from their poverty from being even worse. But as the years go by and they adopt the typical American’s eating habits, their diets tend to worsen, and their health worsens as well (Pérez-Escamilla, 2009).Pérez-Escamilla, R. (2009). Dietary quality among Latinos: Is acculturation making us sick? Journal of the American Dietetic Association, 109(6), 988–991.

In a significant finding, African Americans have worse health than whites even among those with the same incomes. This racial gap is thought to stem from several reasons. One is the extra stress that African Americans of all incomes face because they live in a society that is still racially prejudiced and discriminatory (Williams, Neighbors, & Jackson, J., 2008).Williams, D. R., Neighbors, H. W., & James S. Jackson, P. (2008). Racial/ethnic discrimination and health: Findings from community studies [Supplemental material]. American Journal of Public Health, 98, S29–S37. In this regard, a growing amount of research finds that African Americans and Latinos who have experienced the most racial discrimination in their daily lives tend to have worse physical health (Lee & Ferraro, 2009; Gee & Walsemann, 2009).Lee, M.-A., & Ferraro, K. F. (2009). Perceived discrimination and health among Puerto Rican and Mexican Americans: Buffering effect of the lazo matrimonial? Social Science & Medicine, 68, 1966–1974; Gee, G., & Walsemann, K. (2009). Does health predict the reporting of racial discrimination or do reports of discrimination predict health? Findings from the National Longitudinal Study of Youth. Social Science & Medicine, 68(9), 1676–1684. Some middle-class African Americans may also have grown up in poor families and incurred health problems in childhood that still affect them. As a former U.S. surgeon general once explained, “You’re never dealing with a person just today. You’re dealing with everything they’ve been exposed to throughout their lives. Does it ever end? Our hypothesis is that it never ends” (Meckler, 1998, p. 4A).Meckler, L. (1998, November 27). Health gap between races persists. Ocala [FL] Star-Banner, p. 4A.

To some degree, racial differences in health may also have a biological basis. For example, African American men appear to have higher levels of a certain growth protein that may promote prostate cancer; African American smokers may absorb more nicotine than white smokers; and differences in the ways African Americans’ blood vessels react may render them more susceptible to hypertension and heart disease (Meckler, 1998).Meckler, L. (1998, November 27). Health gap between races persists. Ocala [FL] Star-Banner, p. 4A. Because alleged biological differences have been used as the basis for racism, and because race is best thought of as a social construction rather than a biological concept (see Chapter 10 "Race and Ethnicity"), we have to be very careful in acknowledging such differences (Frank, 2007).Frank, R. (2007). What to make of it? The (re)emergence of a biological conceptualization of race in health disparities research. Social Science & Medicine, 64(10), 1977–1983. However, if they do indeed exist, they may help explain at least some of the racial gap in health.

A final factor contributing to racial differences in health is physical location: poor people of color tend to live in areas that are unhealthy places because of air and water pollution, hazardous waste, and other environmental problems. This problem is termed environmental racism (King & McCarthy, 2009).King, L., & McCarthy, D. (Eds.). (2009). Environmental sociology: From analysis to action (2nd ed.). Lanham, MD: Rowman & Littlefield. One example of this problem is found in the so-called Cancer Alley on a long stretch of the Mississippi River in Louisiana populated mostly by African Americans; 80% of these residents live within 3 miles of a polluting industrial facility.

Gender

The evidence on gender and health is both complex and fascinating. Women outlive men by more than 6 years, and, as Table 18.2 "U.S. Life Expectancy at Birth for People Born in 2006" showed, the gender difference in longevity persists across racial categories. At the same time, women have worse health than men in many areas. For example, they are much more likely to suffer from migraine headaches, osteoporosis, and immune diseases such as lupus and rheumatoid arthritis. Women thus have more health problems than men even though they outlive men, a situation commonly known as the morbidity paradox (Gorman & Read, 2006).Gorman, B. K., & Read, J. G. (2006). Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior, 47(2), 95–110. Why, then, do women outlive men? Conversely, why do men die earlier than women? The obvious answer is that men have more life-threatening diseases, such as heart disease and emphysema, than women, but that raises the question of why this is so.

Several reasons explain the gender gap in longevity. One might be biological, as women’s estrogen and other sex-linked biological differences may make them less susceptible to heart disease and other life-threatening illnesses, even as they render them more vulnerable to some of the problems already listed (Kuller, 2010).Kuller, L. H. (2010). Cardiovascular disease is preventable among women. Expert Review of Cardiovascular Therapy, 8(2), 175–187. A second reason is that men lead more unhealthy lifestyles than women because of differences in gender socialization. For example, men are more likely than women to smoke, to drink heavily, and to drive recklessly. All such behaviors make men more vulnerable than women to life-threatening illnesses and injuries (Gorman & Read, 2006).Gorman, B. K., & Read, J. G. (2006). Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior, 47(2), 95–110. Men are also more likely than women to hold jobs in workplaces filled with environmental hazards and other problems that are thought to kill thousands of people—most of them men—annually (Simon, 2008).Simon, D. R. (2008). Elite deviance (9th ed.). Boston, MA: Allyn & Bacon.

A final reason is men’s reluctance to discuss medical problems they have and to seek help for them, owing to their masculine socialization into being “strong, silent types.” Just as men do not like to ask for directions, as the common wisdom goes, so do they not like to ask for medical help. As one physician put it, “I’ve often said men don’t come in for checkups because they have a big S tattooed on their chests; they think they’re Superman” (Guttman, 1999, p. 10).Guttman, M. (1999, June 11–13). Why more men are finally going to the doctor. USA Weekend, p. 10. Studies find that men are less likely than women to tell anyone when they have a health problem and to seek help from a health-care professional (Emmers-Sommer et al., 2009).Emmers-Sommer, T. M., Nebel, S., Allison, M.-L., Cannella, M. L., Cartmill, D., Ewing, S.,…Wojtaszek, B. (2009). Patient-provider communication about sexual health: The relationship with gender, age, gender-stereotypical beliefs, and perceptions of communication inappropriateness. Sex Roles: A Journal of Research, 60, 9–10. When both sexes do visit a physician, men ask fewer questions than women do. In one study, the average man asked no more than two questions, while the average woman asked at least six. Because patients who ask more questions get more information and recover their health more quickly, men’s silence in the exam room may contribute to their shorter longevity (Foreman, 1999).Foreman, J. (1999, June 14). A visit most men would rather not make. The Boston Globe, p. C1. Interestingly, the development of erectile dysfunction drugs like Viagra may have helped improve men’s health, as men have had to visit physician’s offices to obtain prescriptions for these drugs when otherwise they would not have made an appointment (Guttman, 1999).Guttman, M. (1999, June 11–13). Why more men are finally going to the doctor. USA Weekend, p. 10.

We have just discussed why men die sooner than women, which is one of the two gender differences that constitute the morbidity paradox. The other gender difference concerns why women have more nonfatal health problems than men. Several reasons seem to account for this difference (Read & Gorman, 2010).Read, J. G., & Gorman, B. K. (2010, June). Gender and health inequality. Annual Review of Sociology, 36, 371–386. doi:10.1146/annurev.soc.012809.102535

One reason arises from the fact that women outlive men. Because women are thus more likely than men to be in their senior years, they are also more likely to develop the many health problems associated with old age. This suggests that studies that control for age (by comparing older women with older men, middle-aged women with middle-aged men, and so forth) should report fewer gender differences in health than those that do not control for age, and this is indeed true.

However, women still tend to have worse health than men even when age is taken into account. Medical sociologists attribute this gender difference to the gender inequality in the larger society (see the “Sociology Making a Difference” box). For example, women are poorer overall than men, as they are more likely to work only part time and in low-paying jobs even if they work full time. As discussed earlier in this chapter, poverty is a risk factor for health problems. Women’s worse health, then, is partly due to their greater likelihood of living in poverty or near-poverty. Because of their gender, women also are more likely than men to experience stressful events in their everyday lives, such as caring for a child or an aging parent, and their increased stress is an important cause of their greater likelihood of depression and the various physical health problems (weakened immune systems, higher blood pressure, lack of exercise) that depression often causes. Finally, women experience discrimination in their everyday lives because of our society’s sexism, and (as is also true for people of color) this discrimination is thought to produce stress and thus poorer physical health (Landry & Mercurio, 2009).Landry, L. J., & Mercurio, A. E. (2009). Discrimination and women’s mental health: The mediating role of control. Sex Roles: A Journal of Research, 61, 3–4.

The U.S. Health-Care Model

As discussed earlier, other Western nations have national systems of health care and health insurance. In stark contrast to these nations, the United States relies on a direct-fee systemA system of medicine in which patients pay for health care, prescriptions, and other medical costs themselves., in which patients are expected to pay for medical costs themselves, aided by private health insurance, usually through one’s employer. Table 18.4 "Health Insurance Coverage in the United States, 2008" shows the percentages of Americans who have health insurance from different sources or who are not insured at all. (All figures are from the period before the major health-care reform package was passed by the federal government in early 2010.) Adding together the top two figures in the table, 57% of Americans have private insurance, either through their employers or from their own resources. Almost 28% have some form of public insurance (Medicaid, Medicare, other public), and 15.4% are uninsured. This final percentage amounts to about 46 million Americans, including 8 million children, who lack health insurance. Their lack of health insurance has deadly consequences because they are less likely to receive preventive health care and care for various conditions and illnesses. It is estimated that 45,000 people die each year because they do not have health insurance (Wilper et al., 2009).Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health, 99(12), 1–7.

Although almost 28% of Americans do have public insurance, this percentage and the coverage provided by this insurance do not begin to match the coverage enjoyed by the rest of the industrial world. Although Medicare pays some medical costs for the elderly, we saw in Chapter 12 "Aging and the Elderly" that its coverage is hardly adequate, as many people must pay hundreds or even thousands of dollars in premiums, deductibles, coinsurance, and copayments. The other government program, Medicaid, pays some health-care costs for the poor, but many low-income families are not poor enough to receive Medicaid. Eligibility standards for Medicaid vary from one state to another, and a family poor enough in one state to receive Medicaid might not be considered poor enough in another state. The State Children’s Health Insurance Program (SCHIP), begun in 1997 for children from low-income families, has helped somewhat, but it, too, fails to cover many low-income children. Largely for these reasons, about two-thirds of uninsured Americans come from low-income families.

Not surprisingly, the 15.4% uninsured rate varies by race and ethnicity (see Figure 18.7 "Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage With No Insurance)"). Among people under 65 and thus not eligible for Medicare, the uninsured rate rises to almost 21% of the African American population and 32% of the Latino population. Moreover, 45.3% of adults under 65 who live in official poverty lack health insurance, compared to only about 6% of high-income adults (those with incomes higher than 4 times the poverty level). Almost one-fifth of poor children have no health insurance, compared to only 3.5% of children in higher-income families (Kaiser Family Foundation, 2010).Kaiser Family Foundation. (2010). Kaiser state health facts. Retrieved from http://www.statehealthfacts.org As discussed earlier, the lack of health insurance among the poor and people of color is a significant reason for their poorer health.

Managed Care and HMOs

To many critics, a disturbing development in the U.S. health-care system has been the establishment of health maintenance organizationsPrepaid health plans with designated providers that typically enroll their subscribers through their workplaces., or HMOs, which typically enroll their subscribers through their workplaces. HMOs are prepaid health plans with designated providers, meaning that patients must visit a physician employed by the HMO or included on the HMO’s approved list of physicians. If their physician is not approved by the HMO, they either have to see an approved physician or see their own without insurance coverage. Popular with employers because they are less expensive than traditional private insurance, HMOs have grown rapidly in the last three decades and now enroll more than 70 million Americans (see Figure 18.8 "Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of Enrollees)").

Although HMOs have become popular, their managed care is also very controversial for at least two reasons (Kronick, 2009).Kronick, R. (2009). Medicare and HMOs—the search for accountability. New England Journal of Medicine, pp. 2048–2050. Retrieved from http://www.library.umaine.edu/auth/EZProxy/test/authej.asp?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=39651608&site=ehost-live The first is the HMOs’ restrictions just noted on the choice of physicians and other health-care providers. Families who have long seen a family physician but whose employer now enrolls them in an HMO sometimes find they have to see another physician or risk going without coverage. In some HMOs, patients have no guarantee that they can see the same physician at every visit. Instead, they see whichever physician is assigned to them at each visit. Critics of HMOs argue that this practice prevents physicians and patients from getting to know each other, reduces patients’ trust in their physician, and may for these reasons impair patient health.

The second reason for the managed-care controversy is perhaps more important. HMOs often restrict the types of medical exams and procedures patients may undergo, a problem called denial of care, and limit their choice of prescription drugs to those approved by the HMO, even if their physicians think that another, typically more expensive drug would be more effective. HMOs claim that these restrictions are necessary to keep medical costs down and do not harm patients.

Several examples of the impact of managed care’s denials of coverage and/or care exist. In one case, a woman with a bone spur on her hip had successful arthroscopic surgery instead of open hip surgery, the more common and far more expensive procedure for this condition. When her insurance company denied coverage for her arthroscopic surgery, the patient had to pay doctor and hospital fees of more than $21,000. After a lengthy appeal process, the insurance company finally agreed to pay for her procedure (Konrad, 2010).Konrad, W. (2010, February 5). Fighting denied claims requires perseverance. The New York Times, p. B6. In a more serious case a decade ago, a 22-year-old woman died after going to a physician several times in the preceding week with chest pain and shortness of breath. She was diagnosed with a respiratory infection and “panic attacks” but in fact had pneumonia and a blood clot in her left lung. Her physician wanted her to have lab tests that would have diagnosed these problems, but her HMO’s restrictions prevented her from getting the tests. A columnist who wrote about this case said that “an unconscionable obsession with the bottom line has resulted in widespread abuses in the managed-care industry. Simply stated, there is big money to be made by denying care” (Herbert, 1999, p. A25).Herbert, B. (1999, July 15). Money vs. reform. The New York Times, p. A25.

Racial and Gender Bias in Health Care

Another problem in the U.S. medical practice is apparent racial and gender bias in health care. Racial bias seems fairly common; as Chapter 10 "Race and Ethnicity" discussed, African Americans are less likely than whites with the same health problems to receive various medical procedures (Smedley, Stith, & Nelson, 2003).Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Gender bias also appears to affect the quality of health care (Read & Gorman, 2010).Read, J. G., & Gorman, B. K. (2010, June). Gender and health inequality. Annual Review of Sociology, 36, 371–386. doi:10.1146/annurev.soc.012809.102535 Research that examines either actual cases or hypothetical cases posed to physicians finds that women are less likely than men with similar health problems to be recommended for various procedures, medications, and diagnostic tests, including cardiac catheterization, lipid-lowering medication, kidney dialysis or transplant, and knee replacement for osteoarthritis (Borkhoff et al., 2008).Borkhoff, C. M., Hawker, G. A., Kreder, H. J., Glazier, R. H., Mahomed, N. N., & Wright, J. G. (2008). The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. Canadian Medical Association Journal, 178(6), 681–687.

Other Problems in the Quality of Care

Other problems in the quality of medical care also put patients unnecessarily at risk. These include:

• Sleep deprivation among health-care professionals. As you might know, many physicians get very little sleep. Studies have found that the performance of surgeons and medical residents who go without sleep is seriously impaired (Institute of Medicine, 2008).Institute of Medicine. (2008). Resident duty hours: Enhancing sleep, supervision, and safety. Washington, DC: National Academies Press. One study found that surgeons who go without sleep for 24 hours have their performance impaired as much as a drunk driver. Surgeons who stayed awake all night made 20% more errors in simulated surgery than those who slept normally and took 14% longer to complete the surgery (Wen, 1998).Wen, P. (1998, February 9). Tired surgeons perform as if drunk, study says. The Boston Globe, p. A9.

• Shortage of physicians and nurses. Another problem is a shortage of physicians and nurses (Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010; Fuhrmans, 2009).Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010). Understanding nurse manager stress and work complexity: Factors that make a difference. The Journal of Nursing Administration, 40(2), 82–91; Fuhrmans, V. (2009, January 13). Surgeon shortage pushes hospitals to hire temps. The Wall Street Journal, p. A1. This is a general problem around the country, but even more of a problem for two different settings. The first such setting is hospital emergency rooms, Because emergency room work is difficult and relatively low-paying, many specialist physicians do not volunteer for it. Many emergency rooms thus lack an adequate number of specialists, resulting in potentially inadequate emergency care for many patients.

  Rural areas are the second setting in which a shortage of physicians and nurses is a severe problem. The National Rural Health Association (2010)National Rural Health Association. (2010). What’s different about rural health care? Retrieved from http://www.ruralhealthweb.org/go/left/about-rural-health points out that although one-fourth of the U.S. population is rural, only one-tenth of physicians practice in rural areas. Compounding this shortage is the long distances that patients and emergency medical vehicles must travel and the general lack of high-quality care and equipment at small rural hospitals. Partly for these reasons, rural residents are more at risk than urban residents for health problems, including mortality. For example, only one-third of all motor vehicle accidents happen in rural areas, but two-thirds of all deaths from such accidents occur in rural areas. Rural areas are also much more likely than urban areas to lack mental health services.

• Mistakes by hospitals. Partly because of sleep deprivation and the shortage of health-care professionals, hundreds of thousands of hospital patients each year suffer from mistakes made by hospital personnel. They receive the wrong diagnosis, are given the wrong drug, have a procedure done on them that was really intended for someone else, or incur a bacterial infection. These and other mistakes are thought to kill almost 200,000 patients per year, or almost 2 million every decade (Crowley & Nalder, 2009).Crowley, C. F., & Nalder, E. (2009, August 9). Secrecy shields medical mishaps from public view. San Francisco Chronicle, p. A1.

Complementary and Alternative Medicine (CAM)

As the medical establishment grew in the 19th and 20th centuries, it helped formulate many standards for medical care and training, including licensing restrictions that prevent anyone without a degree from a recognized medical school from practicing medicine. As noted earlier, some of its effort stemmed from well-intentioned beliefs in the soundness of a scientific approach to medical care, but some of it also stemmed from physicians’ desire to “corner the market” on health care, and thus raise their profits, by keeping other health practitioners such as midwives out of the market.

There is increased recognition today that physical health depends at least partly on psychological well-being. As the old saying goes, your mind can play tricks on you, and a growing amount of evidence suggests the importance of a sound mind for a sound body. Many studies have found that stress reduction can improve many kinds of physical conditions and that high levels of stress can contribute to health problems (B. W. Smith et al., 2010).Smith, B. W., Papp, Z. Z., Tooley, E. M., Montague, E. Q., Robinson, A. E., & Cosper, C. J. (2010). Traumatic events, perceived stress and health in women with fibromyalgia and healthy controls. Stress & Health: Journal of the International Society for the Investigation of Stress, 26(1), 83–93.

Evidence of a mind-body connection has fueled the growing interest in complementary and alternative medicine (CAM) that takes into account a person’s emotional health and can often involve alternative treatments such as acupuncture and hypnosis. In the last two decades, several major medical centers at the nation’s top universities established alternative medicine clinics. Despite the growing popularity of alternative medicine, much of the medical establishment remains skeptical of its effectiveness. Even so, about 40% of Americans use an alternative medicine product or service each year, and they spend about $34 billion per year on the various kinds of products and services that constitute alternative medicine (Wilson, 2009)Wilson, P. (2009). Americans spend $33.9 billion a year on alternative medicine. Consumer Reports Health Blog. Retrieved from http://blogs.consumerreports.org/health/2009/08/information-on-natural-medicine-money-spent-on-alternative- medicine-alternative-treatments-vitamins.html (see Figure 18.9 "Use of Selected Forms of Complementary and Alternative Medicine (CAM), 2007 (Percentage of U.S. Adults Using Each Form During Past Year)").

Medical Ethics and Medical Fraud

A final set of issues in U.S. medicine concerns questions of medical ethics and outright medical fraud. Many types of health-care providers, including physicians, dentists, medical equipment companies, and nursing homes, engage in many types of health-care fraud. In a common type of fraud, they sometimes bill Medicare, Medicaid, and private insurance companies for exams or tests that were never done and even make up “ghost patients” who never existed or bill for patients who were dead by the time they were allegedly treated. In just one example, a group of New York physicians billed their state’s Medicaid program for over $1.3 million for 50,000 psychotherapy sessions that never occurred. All types of health-care fraud combined are estimated to cost about $100 billion per year (Kavilanz, 2010).Kavilanz, P. (2010). Health care: A “goldmine” for fraudsters. CNNMoney. Retrieved from http://money.cnn.com/2010/01/13/news/economy/health_care_fraud/index.htm?postversion=2010011315

Other practices are legal but ethically questionable. Sometimes physicians refer their patients for tests to a laboratory that they own or in which they have invested. They are more likely to refer patients for tests when they have a financial interest in the lab to which the patients are sent. This practice, called self-referral, is legal but does raise questions of whether the tests are in the patient’s best interests or instead in the physician’s best interests (Romano, 2009).Romano, D. H. (2009). Self-referral of imaging and increased utilization: Some practical perspectives on tackling the dilemma. Journal of the American College of Radiology, 6(11), 773–779.

In another practice, physicians are asking hundreds of thousands of their patients to take part in drug trials. The physicians may receive more than $1,000 for each patient they sign up, but the patients are not told about these payments. Characterizing these trials, two reporters said that “patients have become commodities, bought and traded by testing companies and physicians” and said that it “injects the interests of a giant industry into the delicate physician-patient relationship, usually without the patient realizing it” (Galewitz, 2009; Eichenwald and Kolata, 1999).Galewitz, P. (2009, February 22). Cutting-edge option: Doctors paid by drugmakers, but say trials not about money. Palm Beach Post. Retrieved from http://www.palmbeachpost.com/business/content/business/epaper/2009/02/22/a1f_drugtrials_0223.html; Eichenwald, K., & Kolata, G. (1999, May 16). Drug trials hide conflicts for doctors. The New York Times, p. A1. These trials raise obvious conflicts of interest for the physicians, who may recommend their patients do something that might not be good for them but would be good for the physicians’ finances.