William C Cockerham. The International Handbook of Sociology. Editor: Stella R Quah & Arnaud Sales. Sage Publications. 2000.
The purpose of this chapter is to examine the global state of medical or health sociology at the end of the 20th century. This is an especially important time for this field of specialization as major social, economic, and political transformations in the wider society are affecting health policy, social welfare systems, the health of populations, and the work of medical sociologists.
This transformation is caused by postmodern social change which is bringing about a new social order in the 21st century. While there is considerable debate in the literature about the nature of postmodernity and the degree to which its fundamental premise about the deconstruction of modern society can be supported, it is nonetheless clear that modern social conditions are changing. Postmodernity refers to the oncoming social and political era that is currently evolving, in a historical sense, out of the recent and current modern period; thus, the term “postmodern” represents what George Ritzer (1997: 6) conceptualizes as “a new historical epoch, new cultural products, and a new type of theorizing about the social world.” This perspective is based upon the observation that something new is indeed occurring in modern society and replacing or modifying the social realities created by the industrial age. As Barry Smart (1993: 39) explains: “The idea of postmodernity indicates a modification or change in the way(s) in which we experience and relate to modern thought, modern conditions, and modern forms of life, in short to modernity.”
Given the fact that we are experiencing the onset of new social conditions as society moves beyond the 20th century, the close relationship between health and society is likely to undergo change as well. Consequently, medical sociologists need to anticipate and adjust to the new realities associated with postmodern change. The focus of this chapter will be on tracing the historical development of medical sociology worldwide and assessing its position relative to changing social conditions in the final decade of the 20th century. Medical sociology is the study of the social causes and consequences of health and illness (Cockerham and Ritchey, 1997). Some practitioners prefer the use of the term “health sociology” since the field of specialization’s interests extend beyond the medical environment, but “medical sociology” will be used here since it is the traditional name of the field. Medical sociologists investigate the social aspects of health and disease, the social functions of health organizations and institutions, the relationship of health care delivery systems to other social systems, the social behavior of health care providers and people who are consumers of such care, and the patterns of health services established by society. Medical sociology has evolved into a mature subdiscipline; its practitioners now number in the thousands, have established teaching and research roles in academic and health institutions, find employment opportunities within and outside of academia, and conduct work supported by an extensive body of literature developed over the last fifty years.
Today, medical sociology comprises one of the largest and most active sociological specialties in the developed world and the subdiscipline is expanding in Asia, Africa, Latin America, and the formerly socialist countries of Europe (Cockerham and Ritchey, 1997; Ostrowska, 1996; Sonoda, 1988). This is an enviable position for a field which did not fully emerge until after World War II. However, as the 21st century approaches, there is both optimism and concern for its future. Optimism results from the subdiscipline’s growth, successes, quality of work, and capability to answer important questions about the powerful relationship between health and society. Overall, it can be concluded that medical sociology has become a global discipline and ranks high in popularity and usefulness at the turn-of-the-century. There are, however, important areas of concern related to funding, competition from other fields, and ties to general sociology (Pescosolido and Kronenfeld, 1995). Yet this paper will argue that the major challenge confronting medical sociology is the new reality of postmodern social change. In order to determine where medical sociology is today, it is useful to know where it has been. We will therefore begin with a review of the origins of the field of specialization (1897-1955), its golden age (1956-1970), and period of maturity (1971-1989). The challenges and advances of medical sociology in the 1990s will then be discussed and a determination made of the state of the field at the turn-of-the-century.
Origins of Medical Sociology (1897-1955)
A major factor in medical sociology’s development is that it began with a different orientation than many of sociology’s core specialities. Areas like theory, social stratification, urbanization, social change, and religion had direct roots in 19th century European social thought. Medical sociology, however, appeared in strength only in the mid-20th century as an applied field in which sociologists could produce knowledge useful in treating disease and developing public policy in health matters. Medical sociology evolved largely because of government efforts in Western countries to improve social conditions and promote health in the aftermath of World War II. Medical sociology was the prototype social science funded by governments for coping with the problems of the Welfare State and industrial society at mid-century (Cockerham, 1983). The intent was to use medical sociology as a tool for identifying and helping solve social problems causing poor health, and to improve patient care. Ample funding in both the United States and Western Europe not only encouraged such research but stimulated sociologists and health practitioners to change their fields and adopt medical sociology as their specialty (Johnson, 1975). Medical sociology thus came into existence because there was money and jobs. Some participants had no training in medical sociology or even a course in sociology (Claus, 1982; Illsley, 1975).
The earliest work and possibly the only one among the classical social theorists that can be linked to modern-day medical sociology is Emile Durkheim’s (1951) famous study of suicide in 1897. Durkheim’s notion of social integration anticipated current concepts of social support in stress research and his study established a precedent for sociological investigations of health problems (Pescosolido and Kronenfeld, 1995). Yet Durkheim’s interest was not in health or suicide per se, but in demonstrating that sociology was an independent science and capable of explaining such phenomenon as differences in suicide rates. Consequently, the work did not lead to the establishment of medical sociology.
Physicians, not sociologists, published the first two works entitled Medical Sociology. Both were collections of essays on medicine and society, one written by Elizabeth Blackwell in 1902 and the other by James Warbasse in 1909. Blackwell is perhaps better known as the first woman to graduate from an American medical school (Geneva Medical College in New York). A more influential treatise was the 1935 article by biologist-physician Lawrence Henderson of Harvard University on “The Physician and Patient as a Social System” which appeared in the New England Journal of Medicine. Henderson introduced a number of ideas, such as the doctor-patient role relationship and the notion of equilibrium in social relationships, which were major influences on Talcott Parson when he was a Harvard student (Gerhardt, 1989).
Although physicians were showing interest in medical sociology in the early 20th century, sociologists focused their attention elsewhere. Much of sociology had been developed in opposition to biological theories and social Darwinist concepts explaining differences in human behavior and group life on the basis of innate biological or genetic characteristics. Durkheim, in particular, rejected biology as the sole explanation of social interaction. Rather, he believed that social behavior had to be explained from the standpoint of factors that are distinctly sociological, namely, norms, values, and status differences. Medicine was also ignored by sociology’s founding fathers because it was not an institution shaping the structure and nature of society to the same extent as class distinctions, modes of economic production, religion, and other basic social processes. What motivated sociologists to recognize medical sociology as an “official” area of sociological inquiry was (1) the realization that medical practice represented a unique and interesting segment of society with its own institutions, roles, occupations, and behavioral settings which needed study and (2), as noted, the substantial financial support available after World War II to study the social causes of health and illness (Hollingshead, 1973; Johnson, 1975; Parsons, 1951). Medicine, in turn, was showing increasing interest in medical sociology because of the prevalence of chronic diseases in modern societies and their connection to social behavior, along with the link between social problems and poor health.
Particularly significant was the establishment of the National Institute of Mental Health in the United States in the late 1940s that was instrumental in encouraging and funding joint sociological and medical projects. Also, in 1949, the Russell Sage Foundation funded a new program to improve the utilization of social science research in medical practice. One result of this program was the publication of Social Science in Medicine (Simmons and Wolf, 1954), followed a few years later by Sociology and the Field of Public Health (Suchman, 1963). Both of these books discussed the practical aspects of medical sociology. At the point (late 1940s) that large-scale funding initially became available, medical sociology was an applied field.
However, a major event occurred in 1951 that oriented the subdiscipline in a theoretical direction as well. This was the publication of Parsons widely anticipated book The Social System. Included in his complex structural-functionalist model of society linking social systems to corresponding systems of culture and personality, this book contained Parsons concept of the sick role. This concept still provides the most systematic account of the behavior of sick persons in developed societies and ranks as one of the most important theoretical contributions to medical sociology. Having a theorist of Parsons stature render the first major theory in medical sociology brought intellectual recognition to the field of specialization that it needed in its early development (Cockerham, 1983, 1998; Pescosolido and Kronenfeld, 1995). By bringing a concept of health and medicine into his general scheme of society, Parsons was the first major theorist to demonstrate the role of medicine in macro-level social systems. And he did so within the parameters of classical social theory by drawing on the work of Durkheim and Max Weber to support his analysis. Although extensive criticism was to subsequently lessen the acceptance of his ideas generally, this outcome does not negate the significant impact Parsons had on helping medical sociology become academically respectable (Cockerham, 1998; Cockerham and Ritchey, 1997).
The Golden Age (1956-1970)
Beginning in the mid-1950s, medical sociology became a major area of sociological inquiry and research in the United States. Following Parsons, other leading scholars in American sociology, such as Robert Merton, Howard Becker, and Irving Goffman conducted studies in the field. Merton and his colleagues in The Student Physician (1957) extended the functionalist mode of analysis to the socialization of medical students, with Renée Fox’s paper on training for uncertainty ranking as a particularly important contribution. A highly significant book by August Hollingshead and Fredrick Redlich, entitled Social Class and Mental Illness: A Community Study, followed in 1958. This landmark research produced important evidence that social class could be correlated with different types of mental disorders and the psychiatric care people receive. This study attracted international attention and is the foundation for a considerable body of literature on the powerful relationship between class position and the extent and types of mental disorder in a population. The book was also important in influencing the establishment of community mental health centers in the United States in the 1960s.
A short time later, Howard Becker, Anselm Strauss, and their associates published Boys in White: Student Culture in Medical School (1961), a study of medical school socialization conducted from a symbolic interactionist perspective. This book, which became a sociological classic, was important for both its theoretical and methodological context. The techniques in participation observation employed in Boys in White proved to be the basis for subsequent innovations in theory and methods developed by Barney Glaser and Anselm Strauss in The Discovery of Grounded Theory (1967). These books and other significant work on death and dying, chronic illness, and health professions established Strauss as a major figure in medical sociology. In addition to Strauss, Hollingshead, and Fox, other American sociologists produced important work that established medical sociology as a respected field in the United States and elsewhere. Included amoung these scholars are Ronald Anderson, Odin Anderson, Samuel Bloom, John Clausen, Rodney Coe, Fred Davis, Howard Freeman, Eliot Freidson, Eugene Gallagher, James House, Sol Levine, John McKinley, David Mechanic, Virginia Olesen, Leonard Pearlin, Leo Reeder, Richard Scott, Stephen Shortell, Rosemary Stevens, Edward Suchman, Irving Zola, and others.
The introduction of symbolic interactionist research into a field of specialization previously dominated by functionalism caused medical sociology to become a battlefield between two of sociology’s major theoretical schools. A virtual flood of publications appeared in the 1960s with symbolic interaction dominating a significant portion of the literature. One feature of this domination was the numerous studies conducted with reference to labeling theory and the controversy it provoked. Although labeling theory pertained to deviant behavior generally, the focal point of discussion was the mental patient experience (Scheff, 1966). Other research focused on stigma, stress, and the ability of families to cope with mental disorder. For example, Goffman’s Asylums (1961), a study of life in a mental hospital, featured his concept of “total institutions” and the book as a whole was a major influence in the deinstitutionalization of mental patients in the 1960s. The numerous studies published during this period on mental health resulted in this research category becoming a major subfield within medical sociology with an extensive literature of its own (Cockerham, 1996).
Three other areas of research were also important at this time. First, was health services utilization involving comparisons of various social groups in the help-seeking process. Major studies included Freidson’s (1960) concept of the lay-referral system, Suchman’s study on beliefs and the acceptance of modern medicine among ethnic groups in New York City (1965a) and stages of the illness experience (1965b), and Zola’s (1966) research on ethnic differences in coping with illness among hospital patients. Second, was death and dying, where Glaser and Strauss (1965, 1968) produced significant studies of the dying process in hospitals. And third, was the study of medicine as a profession. The leading work was by Freidson, whose two books, Profession of Medicine (1970a) and Professional Dominance (1970b), set the standard for subsequent research on this topic. A related subject was doctor-patient relations with Bloom’s book, The Doctor and His Patient (1963), an important work.
Other developments included the appearance of the first textbook in the field, Medical Sociology, by Norman Hawkins, published in 1958. Freeman, Levine, and Reeder edited the first of four prominent editions of the Handbook of Medical Sociology in 1963, while Coe (1970) and Mechanic (1968) published major textbooks. Additionally, the Medical Sociology Section of the American Sociological Association was established in 1962 and grew to become one of the largest sections (Bloom, 1986). The Journal of Health and Social Behavior, founded in 1960, became an official publication of the American Sociological Association (ASA) in 1966, making medical sociology one of the few sociological subdisciplines to publish a journal under ASA sponsorship.
In the period under review (1956-1970), medical sociology had prospered in the United States. But Robert Straus (1957) observed a division in the field between sociologists working in medicine (who produced applied research primarily motivated by a medical problem) and sociologists of medicine (who studied the medical environment from a sociological perspective). The first group generally worked in medical schools and other health organizations, while the latter was typically employed in sociology departments in universities. A certain amount of tension developed between the two groups over whose work was the most important, with sociologists in medicine helping to solve medical problems and those in sociology departments conducting more theoretical studies within the context of mainstream sociology. Although the schism still exists, the tension has lessened as funding sources required applied work and studies in medical settings were increasingly guided by sociological perspectives, moreover, so many medical sociologists now perform their craft outside sociology departments that the distinction is further declining.
This situation has not evolved to any great degree outside of the United States because most medical sociologists in other countries are not found in sociology faculties but in medical and health organizations, and research institutes, or government agencies, performing teaching and/or research in applied settings. Great Britain was the first country after the United States to organize medical sociology as a specialty. Sociologists working in medicine held their first professional meeting in 1956 and formed the Medical Sociology Group of the British Sociological Association in 1964. The first British textbook was Sociology in Medicine (1962) by Mervyn Susser and William Watson. An important journal was founded in 1967, Social Science and Medicine, which serves a global audience of social scientists in several health fields and hosts a conference in Europe every two years. Among the British scholars who helped develop the field were Raymond Illsley, Mildred Blaxter, George Brown, Michael Bury, Anne Cartwright, Robert Dingwall, David Hughes, Margot Jefferys, and Graham Scambler.
In Germany, the beginning of medical sociology is often credited to a 1958 lecture given in Cologne by August Hollingshead at the invitation of René Knig (Claus, 1982; Siegrist and Rohde, 1976). Earlier, however, in 1953 and 1954, a set of studies in the journal Soziale Welt, addressed topics in medical sociology. Special supplements to the Klner Zeitschrift fr Soziologie und Sozial-psychologie, West Germany’s leading sociology journal, were published on medical sociology in 1958 and 1970. Other noteworthy publications were Jgen Rohde’s (1961) book on the sociology of the hospital and Manfred Pflanz’s (1962) monograph on the relationship between disease and social change. Prior to 1965 there were no full professor positions in medical sociology in West Germany. However, in 1970, a strong effort, completely unmatched in the development of any other West German academic discipline, was made to establish medical sociology. The impetus behind this action was a federal regulation that required medical sociology to be incorporated into the curriculum of medical schools, but courses were also added to the sociology curriculum in universities. In 1970 there were only six courses available in medical sociology in West Germany and West Berlin; by 1975, 80 courses had been established.
As 1970 drew to a close, medical sociology was more developed in the United States than elsewhere in the world. In many ways, especially in research and leading publications, the field was dominated by Americans. Yet a strong foundation existed in Great Britain and German medical sociology was very active. Medical sociology was also emerging in other countries and regions during this period, as seen in developments in Europe, Israel, Japan, and Latin America (Claus, 1982; Cockerham, 1983; Illsley, 1975; Johnson, 1975; Nunes, 1998; Ostrowska, 1996; Sonoda, 1988). Consequently, the International Sociological Association established Research Committee 15 on Medical Sociology in 1966 (renamed “Sociology of Health” in 1986).
Whereas the field in the United States was grounded in both academic and health centers, in Europe it was largely an applied field and connected more to social medicine and public health than general sociology. Links to the mother discipline in Europe were established only after medical sociology had developed in health institutions (Claus, 1982). The role of government funding, the growth of European universities, the development of general sociology, and a critical political climate in the late 1960s hoping to sensitize physicians to social problems favored the development of medical sociology in Western Europe. But barriers also existed—namely, the rigidity of many universities in accepting a new field of specialization, the characterization of the field by some in the medical profession as “radical” and “left wing” because of critical analyses, and the powers of rival disciplines like social medicine and public health in competing with medical sociology over professional boundaries and resources (Claus, 1982).
Period of Maturity (1971-1989)
During medical sociology’s next phase of maturity (1971-1989), it confronted a major crisis: the charge that the subdiscipline was handicapped as both a scholarly and a policy science by a subordinate relationship to medicine (Gold, 1977). Although the potential for medicine to dominate sociological work on health problems was a real possibility in the early years, this situation had become less of a reality over time and the notion of “crisis” was not sustained. The subdiscipline had not evolved as a field which merely provided technical skills and research services in support of medicine and topics physicians defined as important.
While some medical sociologists perform those tasks, others studied health problems sociologists define as important and were critical of the medical profession when warranted. This situation was seen in studies dealing with barriers to quality medical care faced by the poor (Dutton, 1978), the medical profession’s weak control over incompetent doctors and the correction of medical mistakes (Bosk, 1979; Freidson, 1975), opposition by the medical profession to health reform in the public interest (Starr, 1982), and inequalities associated with capitalist medicine (Navarro, 1976, 1986; Waitzkin, 1983). With maturity, medical sociology was establishing an independent professional position in relation to medicine with its own literature and scientific methods.
The 1980s were a period of tremendous activity and growth. Several textbooks were produced during this period with William Cockerham’s Medical Sociology appearing in 1978 and continuing today (1998) through seven editions. Another book which has stood the test of time is Peter Conrad and Rochelle Kern’s edited book of readings, The Sociology of Health and Illness: Critical Perspectives, which was first published in 1981 and is now in its fifth edition (1997). Research conducted in American medical sociology at this time tended to reflect changes in both the interests of medical sociologists and the delivery of health services in the United States. Some of this research centered on measuring the organizational characteristics and effectiveness of hospitals and clinics (Flood and Fennell, 1995). Studies dealing with stress, especially occupational stress and the impact of life events on physical and mental health, also attracted numerous researchers and became a major area of investigation (House, 1981; Lin and Ensel, 1989; Mirowsky and Ross, 1989; Pearlin, 1989; Thoits, 1995). Papers on stress-related topics, in fact, were often the principal subject of the majority of articles published in the Journal of Health and Social Behavior. Additionally, medical sociologists played key roles in the development of the Health Belief Model (Becker, 1974) and the Behavioral Model of Health Services Use (Andersen, 1995; Aday and Andersen, 1975).
Two important and relatively new areas of research that gained prominence during this period were (1) women’s health and (2) the deprofessionalization process affecting American physicians. Studies on women’s health not only detailed the health differences between men and women but the social causes of such differences (Lennon, 1987; Mirowsky, 1985; Rosenfield, 1989; Verbrugge, 1985, 1989). The inequality of women in patient relationships with male doctors, signifying a traditional pattern of social control by men over women, was investigated as well (Fisher, 1984). Growing numbers of women physicians also forecasted conflict in the medical profession over sexist barriers to career opportunities for women doctors (Lorber, 1984).
Perhaps the most significant publication in the 1980s was Paul Starr’s Pulitzer Prize winning book, The Social Transformation of American Medicine (1982). This book generated considerable publicity and influenced numerous studies on the changing professional status of physicians. Starr described how the rise of large corporate profit-making health care delivery systems and increasing government regulation of medical practice was undermining the professional autonomy and power of doctors. Starr’s book was followed by an important paper by George Ritzer and David Walczak (1988) on the deprofessionalization of physicians. Deprofessionalization was defined as a decline in a profession’s autonomy and control over clients. Analyzing this development in the context of Weberian theory, Ritzer and Walczak argued that government policies designed to regulate health care and the rise of the profit orientation in American medicine identified a trend in medical practice away from substantive rationality (stressing ideals like serving the patient) toward greater formal rationality (stressing rules, regulations, and efficiency). The result was increased government and corporate control of medical work. Other areas of research developing in the 1980s included studies of doctor-patient discourse, such as Howard Waitzkin’s (1989) finding that the personal problems patients bring to doctors are often shaped by macro-level social structures and the social aspects of AIDS, such as the manner in which AIDS functions as a “master status,” overriding the importance of other statuses in social interaction (Weitz, 1989).
In the meantime, in Europe, the European Society for Medical Sociology (ESMS) was formed in 1983. The ESMS changed its name to the European Society for Health and Medical Sociology in 1994 and hosts a conference biannually bringing together medical sociologists throughout Europe to present papers and discuss issues. In Great Britain, during the 1970s and 1980s, there was a tremendous increase in the number of medical sociologists and the extent of their activities. The Medical Sociology Group of the British Sociological Association (BSA) became the largest section and, in 1976, the annual meeting of the BSA was devoted to the sociology of health.
British medical sociologists particularly excelled in studies of (1) social inequality and health, (2) micro-level studies of medical care, (3) lay beliefs, (4) qualitative studies of the illness experience, and (5) feminist studies of reproductive health (Bury, 1997a). Prior to the 1980s, it was widely assumed in Britain that society was becoming more egalitarian and class difference were lessening because of the growth of welfare services (Wilkinson, 1986). But this assumption was shattered in 1980 with the publication of the Black Report which not only found large differences in mortality rates between social classes but also that these differences were not declining. British workers in lower status occupations were not living as long as those at the top of the occupational scale and this gap continued despite equal access to health care. Other research followed by medical sociologists which expanded knowledge about social inequality in health in Britain (Macintyre, 1986; Wilkinson, 1986) and elsewhere in Europe (Fox, 1989).
British medical sociologists were especially adept at micro-level studies of interaction in medical settings, especially analysis of everyday medical practice and the experience of illness. From this growing tradition in British medical sociology has emerged a series of studies analyzing clinical work from the viewpoints of the participants within a relatively broad symbolic interactionist and ethnomethodological framework (Calnan, 1987; Dingwall, 1976; Fitzpatrick et al., 1984). These studies provide accounts of day-to-day interaction between patients, practitioners, and others in the provision of health care, along with accounts of lay definitions of health and patterns of seeking care.
Among the new textbooks was Margaret Stacey’s The Sociology of Health and Healing (1988) and a selective view of medical sociology by Bryan Turner, Medical Power and Social Knowledge (1987) that utilized sociological theory in a critique of medicine. Turner, during an earlier stay in Australia, produced The Body and Society (1984), which initiated much of today’s sociological discussion on the topic. Turner based much of his insight on the earlier work of the French theorist Michel Foucalult (1973), who examined the ways in which medical knowledge was used to socially control the human body and repress sexuality and emotions. Scambler edited a groundbreaking book entitled Sociological Theory and Medical Sociology (1987) that brought together a number of theoretical perspectives in health and medicine. Additionally, a new journal, The Sociology of Health and Illness, was established in 1979.
In Germany, the first textbook written exclusively on medical sociology, Lehrbuch der Medizinischen Soziologie, was authored by Johannes Siegrist in 1974. The Medical Sociology Section of the German Sociological Association was formed in 1972 and shortly thereafter had the largest membership of any section. Also in 1972, the German Society for Medical Sociology was formed and its membership in the late 1980s was one-fifth that of the entire German Sociological Association (Gerhardt, 1989). Among the works attracting international attention were Alexander Schuller and American medical sociologist Donald Light’s edited book on Germany’s health care delivery system, Political Values and Health Care: The German Experience (1986) and Uta Gerhardt’s extensive theoretical discussion—taking a decade to complete—entitled Ideas about Illness: An Intellectual and Political History of Medical Sociology (1989). Two journals, Mensch Medizin Gesellschaft and Medizinische Soziologie, published medical sociological work.
Medical sociology, however, never really developed to any great extent in France, although three French sociologists, Alphonse d’Houtaud (d’Houtaud and Field, 1984), Claudine Herzlich, and Janine Pierret (Herzlich and Pierret, 1987) were prominent in the field. According to Herzlich (Claus, 1982), French sociologists were not especially interested in the subdiscipline, government funding for research was lacking, and few signs of dissatisfaction existed with the health care system. In Western Europe, outside of Britain and Germany, medical sociology’s development reached its highest levels in the Netherlands and the Scandinavian countries, especially Denmark and Finland. The Scandinavian Journal of Social Medicine is a major journal for medical sociologists in that region.
In Eastern Europe, a fledging medical sociology existed in the few countries (Hungary, Poland, Romania, and Yugoslavia) where the general discipline of sociology was allowed to exist by communist governments. The subdiscipline was most developed in Poland under the leadership of Magdalena Sokolowska (Ostrowska, 1996). Her accomplishments included numerous publications and conference activities, including organizing an important international meeting on the sociology of medicine in 1973 sponsored by the Polish Academy of Sciences. This conference helped establish future forms of cooperation between medical sociologists in the eastern and western countries of Europe and produced a book on social factors in health (Sokolowska, Holowka, and Ostrowska, 1976). Many publications in Eastern Europe during this period simply highlighted the achievement of communist health care; since Marxism with its emphasis on conflict, could not be applied to socialist countries, the most popular theoretical perspective was functionalism with its notions of consensus, cooperation, and functional processes (Ostrowska, 1996). Paradoxically, states Antonina Ostrowska (1996: 103), “in the East there were very few medical sociology studies, which could be derived from the traditions of Marxist sociological theory.”
In Japan, the Japanese Society for Medical Sociology was established in 1974 and sponsored Asian seminars on the field of specialization in 1980 and 1987, published a review of Japanese medical sociology in 1977, and translated an edition of the Freeman et al. Handbook of Medical Sociology into Japanese (Sonoda, 1988). In addition, a special issue of the Japanese Sociological Review was devoted to medical sociology in 1976 and Social Science and Medicine published papers in English on Japanese trends in the field in 1978. The best English-language book on medical sociology in this period was Kyoichi Sonoda’s Health and Illness in Changing Japanese Society (1988).
Interest, research, and publications on medical sociology were also appearing in developing countries, as seen, for example, in China (Cai, 1987), Hong Kong (Lee, 1975), India (Venkataratnam, 1979), Singapore (Quah, 1989), Thailand (Sermsri, 1989), and South Africa (Rensburg and Mans, 1982). In Israel, research by Aaron Antonovsky (1979) on stress and Judith Shuval (1970) on the medical profession were major contributions to the field. As the 1980s came to an end, medical sociology was a global field; however, its greatest presence was in developed countries having the financial resources, strong traditions in sociology, and advanced medical systems to sustain its growth. Since the origins of the field were in the United States and the language of the subdiscipline, as well as sociology in general, is English, it is not surprising the medical sociology’s development was greatest in Anglo-American countries (Claus, 1982).
The 1990s
As medical sociology entered the 1990s, it was subjected to currents of social change affecting all social sciences. First, was the emergence of a new world order brought about by the collapse of communism in the former Soviet Union and Eastern Europe during 1989-1991. Second, were other social processes like the multiculturalization of Europe and North America, cultural and sexual politics, changing patterns of social stratification and mobility, and the rise of ethnic nationalism. All of these developments were relevant for health. The collapse of communism accelerated the long-term process of health deterioration and rising adult mortality in the former Soviet bloc, while ethnic civil war caused significant loss of life in much of the former Yugoslavia and some of the non-Russian areas of the former Soviet Union. Multiculturalization in the states of North America and Western Europe, as well as cultural and sexual politics, brought increased demands for equality on the part of ethnic minorities and women for social justice and the benefits, including the social right of health care, accorded by the welfare state. Hispanics, for example, will become the largest ethnic minority in the United States early in the 21st century, yet have significantly less health insurance than any racial/ethnic group in American society (Angel and Ange1, 1996). Furthermore, changing patterns of social stratification and mobility have resulted in greater social, economic, and health adversity for the poor, accompanied by increases in the population of the underclass and the homeless (Ritchey, LaGory and Mullis, 1991; Wilkinson, 1996). To date, liberal societies have not fully delivered the progressive reforms inherent in the philosophy of the enlightenment. This means medical sociology needs to develop explanations for worsening health and inequities in health care, the need for culturally appropriate treatment for patients, and greater gender and racial diversity in the medical profession.
Consequently, both medical sociology and the wider society, as Bernice Pescosolido and Jennie Kronenfeld (1995) point out, now stands at a transition between social forms. Regardless of whether we call the current phase of modernity, late modern, high modern or postmodern, the fact remains that contemporary society is moving out of its postindustrial stage to the next era of social conditions (Bauman, 1992; Beck, 1992; Smart, 1993). Much of the sociological relevance of postmodernity lies in its destabilization of accepted meanings and efforts to adjust to changing social conditions. This is exactly the major challenge facing medical sociology at the millennium. According to Pescosolido and Kronenfeld (1995: 9): “The society that created the opportunity for the rise of a dominant profession of medicine, for a new discipline of sociology, and for a spinoff of the subfield medical sociology, is undergoing major change.” As the larger society adjusts to rapid social change, established concepts and solutions are no longer able to explain the new realities.
For example, common assumptions that the medical profession is all-powerful, the gap in health and life expectancy between social classes is closing in the welfare states of the West, and that health for most people is improving are not true. The medical profession is losing status and autonomy in the developed world (Hafferty and Light, 1995; Hafferty and McKinley, 1993), class differences in health persist world-wide (Wilkinson, 1996), and the health of low-income African-American males and middle-age male manual workers in most of the former Soviet bloc is declining instead of improving (Cockerham, 1997, 1998). Therefore, the principal challenge facing medical sociology in the 1990s and beyond is to accurately account for the health effects of postmodern social change. This requires intellectual flexibility and a willingness to extend the sociological imagination beyond its present borders. It will be necessary for medical sociologists to ask and answer important questions that inform the subdiscipline, its medical clients, policymakers, general sociology, and other interested parties.
A recent selective review of American medical sociology finds grounds for both pessimism and optimism about the future (Pescosolido and Kronenfeld, 1995). Pessimism stems from reduced funding opportunities for research from government agencies and private foundations, competition from other fields like medical psychology, medical economics, and health services research, and a sense of disconnection from the larger discipline. Yet there is also optimism as modern medicine increasingly recognizes the importance of social factors in disease and the current federal administration has taken medical sociology seriously by including its practitioners in efforts at health reform. It can also be argued that medical sociology still attracts significant funding, competition from other fields can be met by using distinctly sociological perspectives and interpretations in researching important—not trivial—questions, and there are signs of growing attachment to general sociology through the increased utilization of common concepts and theories.
The major areas of research in American medical sociology in the 1990s included the continuing construction of a large body of literature on stress-related topics (Thoits, 1995), AIDS (Rushing, 1995), aging and the health of the elderly (Haug, 1994; House et al., 1994), mental health (Cook and Wright, 1995; Turner and Marino, 1994), women’s health and gender issues (Auerbach and Figert, 1995; Lennon and Rosenfield, 1992; McKinley, 1996; Ross and Bird, 1994), health disadvantages of African-Americans (Braithwaite and Taylor, 1992; Ferraro and Farmer, 1996) and Hispanics (Angel and Angel, 1996), health services utilization (Pescosolido, 1992; Pescosolido and Kronenfeld, 1995), health occupations and professions (Hafferty and Light, 1995; Hafferty and McKinley, 1993), health organizations (Flood and Fennell, 1995), and health policy, health reform, and cost containment (Grey and Phillips, 1995; Mechanic, 1993; Starr, 1994). In addition, the American Journal of Sociology had a special issue on medical sociology in 1992 and the first dictionary of medical sociology (Cockerham and Ritchey, 1997) appeared in 1997. The Journal of Health and Social Behavior continued to focus on stress-related health problems in the 1990s, with lesser concentrations on mental health, women’s health and gender differences, substance abuse, and AIDS. A special issue appeared in 1995 on the state of the discipline in several selected areas.
Many of the current studies reflect problems or developments associated with postmodern social change, such as stress; the rise in sexually-transmitted diseases; the increase in the proportion of the elderly; greater participation of women in the labor force; growing poverty among some minorities; more self-care and use of alternative medicine, along with class-based differences in physician utilization; greater equality in the doctor-patient relationship and lessened control by physicians over the medical marketplace; the emergence of corporate medicine, HMOs, and managed care strategies; the rising cost of health care; and the growing number of persons without health insurance.
These studies do not generally portray disagreements and dispute within the subdiscipline concerning the interpretation of particular social phenomenon; rather, they are typically efforts by medical sociologists to account for the effects of changing social conditions in a variety of areas. Critiques are generally directed toward the medical profession and the federal government for failures in providing universal care and ending inequities. In this sense, one could argue that there is a unity of effort within the field, although the potential for debate and disagreement remain strong—especially in regard to controversial topics like gender and racial discrimination, health policy, health reform, and sociological theory. Whereas one might argue that American medical sociology is meeting the challenge of postmodern social change, the situation is far from resolved. Too many social problems in health remain and there is considerable uncertainty about the parameters of the next phase of modernity. Consequently, some medical sociologists may feel the subdiscipline is in a state of “crisis” and that some of its concepts and frameworks for analysis are outdated; yet the ultimate cause of the discontent is primarily lodged in the transition taking place in the wider society.
Relatively new areas of research linked to social change are also emerging, such as health lifestyles and international comparative studies. Health lifestyles are defined as collective patterns of health-related behavior based on choices from options available to people according to their life chances (Cockerham and Ritchey, 1997; Cockerham, Rtten, and Abel, 1997). Health lifestyles may include forms of interaction with physicians for physical examinations and other types of preventive care, but the majority of activities take place outside of the health care delivery system. These activities typically consist of practices involving food consumption, exercise, coping with stress, smoking, alcohol and drug use, risk of accidents, and physical appearance. In the social conditions of high or postmodernity, health lifestyles play the decisive role in determining an individual’s health status and life expectancy—especially in relation to chronic ailments like heart disease and cancer. Research attempting to define the theoretical parameters of health lifestyles (Cockerham, Abel and Lschen, 1993; Cockerham, Rtten and Abel, 1997), assess gender differences (Ross and Bird, 1994), and specify the powerful role of education in lifestyle selection (Ross and Wu, 1995) represent the leading studies to date.
While international or transnational comparisons of health and health care delivery systems are not new, the 1990s and the globalization tendencies existing in the world today brought new emphasis and interest to such studies in the United States. New books on comparative health problems and systems of health delivery were published (Gallagher and Subedi, 1995; Lassey, Lassey and Jinks, 1997; Subedi and Gallagher, 1996), along with papers investigating the poor health conditions in Russia and Eastern Europe (Cockerham, 1997; Field, 1995) and gender and health differences in Asia (Fuller et al., 1993). Research on health lifestyles and international comparisons are likely to attract greater attention from scholars in the 21st century. As people live longer, their lifestyles increasingly become the cause of or the solution to preventing the onset of many chronic diseases and controlling those diseases once they occur. And as the world becomes more global in its orientation and systems of trade, politics, and technology, as well as shared health problems, converge—work in international medical sociology is going to undoubtedly expand. The next new area of investigation, which is actually the return of an old problem, is infectious disease as old and new viruses—many with social connections—appear again to make people sick and kill them without respect to national boundaries.
Stronger links to general sociology are also developing, as seen in the increasing use of common research methods, concepts, and theories in medical sociology. The field of specialization, like the general discipline, does not have one dominant theoretical orientation. Functionalist theory in American medical sociology has been generally abandoned, while symbolic interaction remains important in qualitative studies but new developments in the theory itself have not been forthcoming. Conflict theory could be considered the leading paradigm, especially in studies of health reform, policy, organization, professions, and political interest groups, but the collapse of communism seriously impaired the potential of Marxist explanations and conflict theory is not effective in explaining health situations that are unrelated to conflict. Among the classical theorists, Max Weber remains important, particularly in relation to his ideas about lifestyles, authority, bureaucracy, and formal rationality. Among contemporary theorists, the work of French scholars like Michel Foucault and Pierre Bourdieu are influential. But, to date, as noted, there is no single or optimal theoretical approach in medical sociology.
Turning to Canada, medical sociology has become increasingly stronger. Canadians have their own medical sociology textbooks (Bolaria and Dickinson, 1994; Clarke, 1996) and medical sociologists contributed to important work on stress and the social gradient in life expectancy theory (Evans, Barer and Marmor, 1994). A journal, Health and Canadian Society, was begun in 1993. There is also an English-French division in Canadian medical sociology as there is in the larger society. French-Canadian medical sociologists tend to focus on Quebec, as seen in Carole Damiani’s (1995) book on dual medicine (alternative and professional), and are influenced by French sociology. Their English-speaking counterparts seem to ignore work in the French language and are influenced by American and British medical sociology.
In Britain, the 1990s were witness to continued research on class differences in health (Arber, 1997; Macintyre, 1997), with Richard Wilkinson’s book, Unhealthy Societies: The Afflictions of Inequality (1996), ranking as an important contribution. Mildred Blaxter (1990) conducted a major survey of health lifestyles, while Sarah Nettleton (1995) and Ellen Annandale (1998) produced new textbooks. Additionally, Paul Atkinson (1995) wrote a leading book on medical talk and Michael Bury (1997b) examined the impact of social change on health and illness. As for theory, British medical sociologists are an eclectic group. A major feature of their subdiscipline is qualitative research so symbolic interaction, particularly Goffman, is important, but conflict theory and poststructuralism, especially the work of Foucault, dominates much of their work as well.
As for journals, outgoing Social Science and Medicine editor Peter McEwan (1997: vii) observed that the main pattern of change over 30 years of his editorship was “explosion of the AIDS problem, greater willingness to accept the validity of qualitative articles, and a stronger urge to implement change with less concern over theoretical grounding.” In the 1990s, the sociological pages of Social Science and Medicine were largely filled by research on AIDS, women’s health, health care utilization, and health in developing countries. There were also special issues on health inequities in Europe (1990) and modern societies (1997). The Sociology of Health and Illness focuses primarily on qualitative studies on health occupations and professions, discourse in medical settings, chronic illness, and the experience of illness, as well as theoretical papers. A new journal, Health, was started in 1997. Moreover, the themes for the annual meeting of the British Sociological Association in 1990 were on health and society and in 1998 on the sociology of the body. British medical sociology remains robust.
In Germany, however, the situation is not so positive. Where cutbacks in funding have hit physicians harder than medical sociologists in Britain, the opposite has occurred in Germany where budget reductions have hit medical sociologists, not physicians. The journals Medizinische Soziologie and Mensch Medizin Gesellschaft ceased publication, and chairs in medical sociology at Mnster and Marburg were filled by physicians instead of sociologists. Siegrist published the most recent edition (5th) of his textbook in 1995, but no major German studies in medical sociology have appeared in the 1990s, with the exception of Gerhardt’s (1991) book on the relationship of health and society and Siegrist’s (1996) study of heart disease among blue-collar workers. Especially welcome would be studies on health topics related to German reunification, but few sociological publications exist in this area with work by Gnther Lschen and his colleagues (1997a, 1997b) a notable exception. Lschen also was senior author of an international study entitled Health Systems in the European Union (Lschen et al., 1995). Outside of Germany, developments in medical sociology on the European continent are promising as the field of specialization emerges in the formerly socialist states and high levels of activity continue in Scandinavia, especially Finland. Finnish work includes studies of gender and the health professions (Riska and Wegar, 1993) and health inequities (Lahelma and Valkonen, 1990).
Elsewhere, in Japan, books by Margaret Powell and Masahira Anesaki (1990) on Japanese health care and Tsunetsugu Munakata (1994) on AIDS rank as important works. Beginning in 1990, an Annual Review of Japanese Health and Medical Sociology has been published by the Japanese Society of Health and Medical Sociology with studies dealing largely with nursing, self-care, the elderly, and family support. Medical sociologists have also become especially active in Australia, with the publication of the second edition of Turner’s Medical Power and Social Knowledge (1995) and The Body and Society(1996), books by Devorah Lupton on health imperatives (1995) and medicine as culture (1994), and a reader on the sociology of health and illness (Lupton and Najman, 1995). In South Africa, a major work, entitled Health Care in South Africa (Rensburg, Fourie and Pretorius, 1992), provides an important sociological analysis of the evolution of health care from an apartheid to integrated system. In India, medical sociology continues to develop as seen in recent work on gender and health (Marthur and Sharma, 1995). Also, in 1997, the fourth Latin American Congress on the Social Sciences and Medicine was held in Mexico, which serves as evidence of the growth of the field of specialization in that region. There are now two journals publishing medical sociology in Latin America, Sald y Sociedad and Cincias Sociaise e Sade. Much of the current research in the region is concerned with social politics and health (Nunes, 1998). Overall, medical sociology has evolved into a global subdiscipline; however, the field is only some fifty years old and the full globalization of the subdiscipline—taking it well beyond its American origins—awaits in the 21st century.
Conclusion
This paper presented a global overview of the state of medical sociology at the millennium. While it is has not been possible to account for all developments in the field worldwide, the most important trends have hopefully been identified. This review forecasts the following: (1) greater convergence with general sociology; (2) overcoming competition from other fields by reliance on the sociological imagination and sociological perspectives, theories and methods—factors that make sociology unique; (3) increasing emphasis on solving practical problems in order to meet the requirements of funding agencies; (4) greater efforts to link theory to the analysis of practical or applied problems; (5) the emergence of more studies that ask “big” questions that are important to policymakers and the general public, than work on “small” and relatively insignificant questions that do little but address minor concerns; and, finally, (6) the expansion of the subdiscipline from beyond not only its American origins, but also its European roots—resulting in greater contributions from Asia, Latin America, and Africa. The capability to accomplish all of the above, however, rests on the ability of medical sociology to accurately anticipate, explain, and predict the health-related effects of postmodern social change.
Today, it can be said that medical sociology produces literature intended to inform medicine and be useful in medical practice and policy decisions, but research in the field is increasingly grounded in sociological perspectives. Consequently, medical sociology no longer functions as a field whose ties to the mother discipline are tenuous. Furthermore, medical sociology has not evolved as an enterprise subject to medical control, but now works most often with medicine as more of a partner and, if needed, an objective critic. It should not be presumed, however, that medical sociology evolved in conflict with medicine. Quite the contrary, medical sociology owes more to medicine than sociology for its origin and subsequent support. Even though there are those in medicine who denigrate the social sciences, medicine and other health-related fields, not sociology, provided the early recognition, funds, and jobs for medical sociologists that were not forthcoming elsewhere. Substantial support from medicine continues today.
While it might be argued that medical sociology has achieved more equal status with medicine as medicine’s professional power has waned, the relationship is spurious. Medicine’s deprofessionalization had nothing to do with medical sociology and everything to do with changes in the wider society and the medical marketplace. Medical sociology, in turn, simply matured with an important body of literature promoting its upward mobility among the professions. If medical sociology continues on its present course, it is likely to become one of sociology’s core specialties as health and the pursuit of health increasingly become a major factor in the conduct of everyday social life.