Health has always been a dominant concern of society, Virchow’s famous statement that medicine is nothing but politics on a grander scale has resonances not only for a sociological understanding of health but also for broader societal trends. In this regards sociological investigations into health have been one of the recurring themes of the discipline . Indeed in many instances sociologists have worked with health professionals in some of the landmark studies associated with health.
The modern western world is dominated by images of health, of healthy bodies and the oppositional fear of illness. Illness and threats of illness are perhaps the most problematic of modern conditions . Health stories dominate our media, for example one need only look at the recent experience with the SARS virus to see not only western concerns over health but how these concerns can migrate and affect the global environment. Even with the sophistication of modern medicine endemic diseases and epidemics threaten society or are perceived to threaten society. HIV, cancer and new resistant and deadly types of viruses are all threats to the social order and threats also to the individual’s sense of order . Even relatively isolated outbreaks such as cases of food poisoning receive large amounts of public attention and serve to highlight the degree of importance which is attributed to health by citizens.
Away from western concerns we can see that a vast gulf exists between
western and developing countries and their conceptions of and problems
with health. The rise of chronic illnesses in the west as the prime
incidence of illness contrasts starkly with the situation in much of
the world where the main threats are from diseases long eradicated in
the west. Indeed global patterns of inequality are not the only one
with western society replicating traditional patterns of inequality
related to income in health status .
Thus what is healthy and crucially how a healthy society is to be
measured and gauged varies tremendously and is related strongly to
where one is in the world. Indeed insomuch as sociology has had an
interest in health this is in turn a reflection of the interest which
society itself has in health . To western societies health is a
critical component of social policy, in many countries it attracts and
consumes the largest amounts of public expenditure and in individual’s
daily lives notions of health and illness dominate our conceptions of
ourselves
But what is it which we define as health and how do we define being
sick. These questions are in turn related to what are the strategies we
pursue in attaining our health related goals. The traditional medical
model for answering these questions and defining the concepts involved
is the bio-medical model and we can see the many sociological theories
that have developed as arising out of dissatisfaction at the way in
which the bio-medical model operates .
In this essay two of the most diametrically opposed models are
examined, namely the bio-medical model above and the social
constructivist model which has emerged since the late 1970s. These two
theories represent critically different ways of conceiving of and
thinking about health and illustrate also a much broader concern about
trends in society reflected in and represented by these concerns with
health and definitions of health.
Bio-medical Model
This is the model perhaps of most familiarity to people and it is also
the model which dominates not surprisingly the medical professions
themselves. It is we might say the scientific model of health . In its
simplest form we can say that at the root of this model is a
reductionist logic common to all of the scientific disciplines. In
other words this model proposes that the incidences of disease and
hence abnormal conditions of health are located within discrete disease
causing factors . It is the biomedical model which has dominated expert
thought on health since the Enlightenment and indeed even before this
as Greek medicine sought to explain disease and health through
reference to the various ‘humours’ which comprised bodily make-up. Its
influence can be felt not only within the medical professions but also
across a wider spectrum of society. It has coloured our perceptions of
health but even more importantly also our perceptions of illness as the
biomedical model is most concerned when aberrations to health occur
rather than with the ideal health state. Thus biomedical models are
about the incidence of disease rather than the absence of health. This
is a vital point for consideration as it reflects some of the dominant
practices in health care . As such the bio-medical model represents the
scientific neutrality perspective of medicine and the story it tells is
one of human progress towards the conquering of disease .
These twin precepts, namely reductionism and supposed neutrality and
progress have been criticised heavily from sociology . It is fair to
state however that despite the criticisms levelled at the bio-medical
model, some of which we examine subsequently in our discussion of an
oppositional framework to the above that many of the medical advances
with which we are familiar may possibly have arisen only out of the
application of such a model. Thus while criticisms about the
reductionism inherent in the position may be valid it must be allowed
that advances based on the bio-medical model have been in instances
effective in the diagnosis and treatment of illnesses.
However there are limitations even on a scientific ground. The
bio-medical model with its emphasis on prolonging life for as long as
possible is now in a paradoxical position due to the fact that by
prolonging life and increasing life expectancy more people now survive
for a longer period of time thus becoming more at risk from suffering
from chronic as opposed to acute illnesses for which techniques
developed as a result of the bio medical have had very little efficacy .
The bio-medical model has thus far proved to be at an impasse in
relation to chronic illnesses and due to the reason that chronic
illnesses are now the major form of illness within western societies it
is not surprising then to note a shift away from unqualified support of
the bio medical model and its practitioners among the general public
towards a support of alternative practices of medicine . Signs of this
shift can be seen in the increased support for both alternative
practices and also within governmental policy where we can see a
detectable shift in strategy away from the bio medical model reliance
on curative medicine towards a more public health orientated
preventative medicine .
But while the bio-medical model seems to be undergoing revisions its
most strident critic can it be argued originate from social
constructivist critiques of health, healthcare and medical knowledge
generally.
Social Constructivist
In contrast to the bio-medical model and indeed not only in contrast
but in criticism also of that model is the theoretical framework
offered by social constructivism. Drawing on primarily the work of the
French theorist Michel Foucault social constructivism offers a radical
conception of both the term health and the very processes of knowledge
through which information about health is generated.
What is the core component of the social constructivist viewpoint then?
In order to consider what social constructivism has to say about health
we must consider what the theory has to say about how knowledge is
constructed. Unlike the positivistic biomedical model which assumes
that there are priori conditions of both health and disease which are
to be uncovered through the application of rigorous scientific methods
of discovery social constructivists contend that it is the very
scientific methods themselves which generate the conditions to which
they ascribe states of both health and illness . Thus for social
constructivists rather than a curative holistic manner being at the
heart of modern medicine instead their lies a layer and totality of a
surveillance regime epitomized by the investigation and social control
ascribed to medical practitioners over those who are deemed ill or not
healthy .
This has radical implications for an understanding of health and it has
been the source of contested debates about the veracity of such claims.
The most successful applications of these theories have been in the
field of mental health reflecting Foucault’s own concerns but the
application of these theories to other aspects has gone hand in hand
with a developing and burgeoning sociology of the body. Building on
Foucault’s works the sociologist Bryan turner has suggested that the
problems of bodies for societies have been of how to regulate and
control these bodies within space and time so as to ensure the
effective ordering and management of society. In other words how the
Hobbesian problem of social order can be solved through bodily
regulation .
If we follow this line of thinking health then becomes less what we
think it is and more about what constructs are built up around health
through the operative processes of various discourses. In this respect
so social constructivist in opposition to positivistic disciplines
suggest that subject precedes object, or that through the categories
which are generated by discourses we then come to define these
categories and further integrate them into a disciplinary base
As such then in relation to health, what matters most is not whether we
are sick or not but whether we perceive ourselves to be sick, or
whether we are perceived to be sick by society and more critically the
experts who are custodians over the knowledge of who is sick or not.
Thus the reductionism of the bio-medical model is rejected as there are
neither simple single explanations for disease nor any simple
definitions of health but rather a complex negotiated set of
perceptions arising out of discourses.
Therefore these two models offer us diametrically opposed conceptions
of health. In relation to the bio-medical model for example we can see
the desire and motivation to prolong life through the use of any and
all means. From this we can begin to understand the current tensions
for example in relation to euthanasia where medical professions are for
the most part predominantly aligned with keeping patients alive, even
if it is against their express wishes.
Similar problematic aspects of the biomedical model can be detected
when we examine the emergent phenomena of the New Genetics which can be
seen in its most negative light as taking the reductionist element of
the biomedical model to even new extremes . Indeed the biomedical
model may be argued to be taking on even more ascriptions by utilizing
genetic knowledge to encompass a much wider spread of ‘disorders’ under
the remit of health. Hence we see the rise of media stories related to
the discovery of genes for criminality, alcoholism and other genes for
conditions which we may have previously perceived as being a function
of social problems rather than them being a medical one.
However the social constructivist position is not without its faults
either. While a measure of success can be determined through research
as to the history of insanity or in sexuality and what constitutes a
disorder in terms of a person’s healthy sexuality it is less clear how
social constructivism can deal with health issues which have a
verifiable physical manifestation . Thus while we can point out that a
discourse of knowledge, control and/or surveillance surrounds those who
unfortunately suffer from some disease, such as diabetes for example,
the incidence of disease also exists in a measurable way.
However we can continue the line of thinking advanced by social
constructivist theory to suggest that what is important is the way in
which this knowledge of those who suffer from diabetes informs the
process by which they are treated yet social constructivism must still
deal with the fact that the people involved and who are diagnosed with
diabetes do indeed suffer from a disease with fatal consequences if
left untreated.
Thus not all medical conditions are socially constructed in terms of
their effects but what is socially constructed is the ways in which we
perceive the person suffering from an illness and the strategies and
techniques which are developed with dealing with the person who suffers
from the illness. It is perhaps in this regard that the most valuable
insights of social constructivist viewpoints in relation to health may
be gleamed.
Therefore the emergence of major public health movements in the western
world must be considered as to whether they represent a layer of
surveillance and control or whether they are a response of governments
to changing healthcare needs . Whether or not a new paradigm for health
will emerge as a result of social constructivist critiques (as well as
other critiques of the bio-medical model) remains to be seen but social
constructivism in particular offers intriguing insights into how our
conceptions of health and illusive definitions of it are constructed.
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