Overview

Of all the sub-categories of sociology that you will encounter, the most significant is that of health and illness. Across the world, and within the antipodes, the sociology of health is one of the largest researched areas in the discipline and contributes theories, ideas, and empirical studies that flow into public discussion. The area has its own journal in Australia, entitled the Health Sociology Review, which has been publishing articles on health since 1991 (under a different name from 1991-2000). Sociologists from Aotearoa New Zealand and Australia working in this space cover a range of topics from the impact of income and wealth on health (Kendall et., 2019),  the inequalities between ethnic groups in disease and morbidity (Gurney et al., 2020), to the gender/sex-based differences that exist in health outcomes (Schofield, 2002). However, the sociology of health has a long history of theory and research that stems from the classical era through to the modern and late/postmodern theorists of today (Collyer, 2015). While like most categories in sociology, there are several diverse ways of thinking about these matters, one unifying principle can be applied to all – that is the argument that sociological conditions and issues contribute importantly to the health of individuals in society. In what follows we will explore some of these theories and ideas, along with examining case studies and empirical content from Australia and Aotearoa New Zealand. Of course, like all of our chapters, there is a limited amount of space to cover all of what is a massive sub-discipline. Here, we have curated content that allows for a good overview of the field and provides some food for thought regarding health in our contemporary age.

The Biomedical Model and Social Determinants of Health

Before we can begin that journey, however, it is prudent for us to spend some time considering what is the dominant model of health in our contemporary times. If you recall in the chapter on culture, Max Weber’s rationalisation thesis assists us in understanding a significant change in how we understand our bodies. While in the past we might have attributed a large portion of our health and well-being to the Gods or other magical properties, modernisation and the rise of science stripped away the irrational, and created knowledge based on the scientific method. Rationalisation, and disenchantment, created the conditions for the rise of biomedical knowledge and the institutions that housed it. Put simply, this biomedical model contrasts sharply with traditional or premodern ways of seeing the world. Modern medicine and science, importantly, focused on explaining health through the scientific method, putting aside the mythical, religious or superstitious knowledge of the past.

Secondly, the biomedical model initially treated the body and mind as separate entities and positioned the body as a mechanism (much like an engine in a car), made up of different parts and treated through knowledge separately. Hence today, we have specialists that focus on very specific areas of our bodies from our internal organs through to our hair! Lastly, the biomedical model examines only the biological reasons for ill-health or lack of well-being, exploring different medical reasons for illness, while falling short of a broader sociological analysis as to why people are falling ill. As a result of this, the biomedical industry is now one of the largest in our society. Significant specialisations and organisations have arisen within medicine, that have significant power and status in our contemporary world. Importantly, this has also created a significant commercial enterprise, the pharmaceutical industry, which alongside medicine, has a major influence on our lifestyles. Economically, medicine (and the allied health disciplines around it) account for 10.5% of Australia’s and 10.03% of Aotearoa New Zealand’s gross domestic product (GDP) (explore the World Bank’s current data on this). Additionally, it is estimated that Australians collectively spent approximately $241.3 billion on health goods and services in 2022, which accounts for $9,365 per person (Mendez et al., 2022).

It is however widely recognised that the factors that make us healthy (or not healthy) are not simply biological or biomedical. For instance, data from across the globe concludes that there exists a social gradient of health for instance in relation to socioeconomic status (see later) – that being the poorer you are, the more likely you will have poorer health outcomes. The World Health Organisation (WHO) has long argued that we need to factor in the social determinants of health when considering how to deal with healthcare (Marmot et al., 2012). These non-medical factors can include (but not limited to) the following;

• Income and welfare systems – this is especially true when analysing the poorest countries of the world against the wealthier ones. For instance, the COVID-19 virus was found to be twice as deadly in countries with relatively low incomes.
• Education – this appears across various health and welfare challenges in the developed and undeveloped world. For instance, Raghupathi and Raghupathi (2020) were able to find in a review of health outcomes for OECD countries that those who achieved a higher standard of education, were more likely to have better health outcomes and mortality rates.
• Unemployment and job insecurity – employment means income (obviously!) and depending on the country of analysis, it can also mean poverty. Some countries have safety nets (what we call the welfare system) that do not allow people to drop too far below the poverty line. However, even in Sweden which has a relatively strong welfare system, Janlert, Winefield and Hammarstrom (2015) found that long-term unemployment had a detrimental impact on health.
• Housing and environment  – it is clear as well that housing has an impact on our health outcomes. Numerous studies in Australia for instance have shown that homelessness in all forms has a major detrimental impact on health and well-being (Clifford et al., 2019; Davies and Wood, 2018; Seastres et al., 2020). However, it is clear also that environmental conditions play a role. For instance, in a review from Coates et al., (2022) on Australia’s mortality rates, it was found that 354 people have passed away from heat waves from 2001 to 2018.
• Social inclusion/exclusion and support – another important issue is social capital – or the amount of support that one has in their community or family. Social capital has a major role in various health outcomes. For instance, Aminzadeh et al., (2013) found in Aotearoa New Zealand that young people who belonged to communities/neighbourhoods with higher levels of social capital also reported higher levels of well-being. This finding, along with others, suggests that neighbourhoods themselves have a role to play in our health status.

A number of other areas also contribute to the social determinants of health and well-being including family environment, health structures of the nation-state, food security, conflict, environmental catastrophes (including human-made ones such as for instance the Bhopal disaster – see below), and early childhood education/experiences. Although the conditions we experience are often biomedical and require intervention by doctors and others, the social determinants of the health model expose what are the sociological conditions that need to be dealt with to improve society’s health outcomes. The subdiscipline area within health called social epidemiology studies these issues, especially in relation to disease and the spread of viruses and so on. They also contribute to the study of the social determinants of health, demonstrating disparities in health outcomes amongst different populations of a nation-state or the world broadly.

Critiques of the Medicalisation of Everyday Life

Of course, sociologists have also critiqued the biomedical model for various reasons, not just because it ignores the social conditions that create ill health. Several sociologists working in the field heavily criticise the medical industry, especially for the direct and indirect power that it holds over society. This includes, as we will see later, the ownership of knowledge on what is ‘normal’, unpacked by French philosopher Michel Foucault. One of the most influential analyses of the industry and the dominance of the biomedical model emerged in the 1970s from Austrian theorist Ivan Illich (1926-2002) in his work called Limits to Medicine: Medical Nemesis (1976/1995). Illich’s critique of the medical model, and industry, stems from what he observed as the dominance of the medical profession and intervention in everyday life. His work focuses on what he called the ‘medicalisation‘ process – which effectively means the persistent and widespread uptake of medicine into individual lives. For Illich (1976/1995), problems that were once the domain of society, are increasingly subjected to medical knowledge and subsequent intervention. This meant the rise of specialist medical professionals across various areas such as childbirth, addiction, obesity and even hair loss! Illich (1976/1995) contested that these areas, once dealt with by ourselves or dismissed as part of nature (such as hair loss), are now medical problems, solved predominantly by medicine or other interventions.

Illich used the term iatrogenesis, as a concept to describe the situation. In short, iatrogenesis refers to the social and medical problems or what we might term ‘side effects’, due largely to the rise of medical intervention in our lives. There are three levels of iatrogenesis for Illich (1976/1995);

1. Clinical – Clinical iatrogenesis refers to the development of side effects in the quest to find the cures to everyday ills – such as pain medication (see our Learn More section below).
2. Social – Social iatrogenesis refers to the decline of knowledge and action on behalf of society in dealing with everyday ills. As such, society has become more reliant on the health and medical industries to deal with health and well-being, rather than becoming more adept at understanding and addressing problems as a community/society.
3. Structure – Structure iatrogenesis refers to the over-medicalisation of everyday life. Social and individual lifestyles are increasingly falling under the purview of the medical industry, and most importantly the pharmaceutical industry. For instance, we have turned ageing into a medical problem, to be dealt with scientifically, despite it being a natural process of life.

Moynihan et al., (2002, p. 888) summarise the problems of medicalisation in the following quote:

Inappropriate medicalisation carries the dangers of the unnecessary labelling, poor treatment decisions, iatrogenic illness, and economic waste, as well as the opportunity costs that result when resources are diverted away from treating or preventing more serious disease. At a deeper level it may help to feed unhealthy obsessions with health, obscure or mystify sociological or political explanations for health problems, and focus undue attention on pharmacological, individualised, or privatised solutions.

We might want to ask, have we become ‘unhealthy’ in our obsession with health? Deborah Lupton (2018) for instance in her book aptly titled Fat demonstrates how we have not just through the medical industry, but also via government, culture and media, become obsessed with ‘fat’ bodies. As a result, we have turned more to the medical industry to help us deal with obesity, by seeking drugs, diet fads, and other medical interventions, to deal with any potential fatness. While there is no question that obesity is an issue for Australia and Aotearoa New Zealand, someone like Illich might argue that turning to medicine to deal with it, only serves to potentially create more unintended consequences, and also further make society reliant on the medical industry.

Watch the interview with Deborah Lupton on ‘Fat’ below [5:25]:

It is important to clarify that all medicalisation cannot be treated with the suspicious nature that Illich’s (1976) thesis suggests. Prolific medicalisation theorist Peter Conrad (2007) for instance suggests that some medicalisation does produce a significant benefit for society. For instance, the creation of expertise coupled with the intervention of the medical industry has lowered rates of mortality and undoubtedly allowed us in places like Australia and Aotearoa New Zealand to live longer lives. Furthermore, Conrad (2007) suggests that there is also evidence of demedicalisation ongoing across the industry. Issues such as female hysteria, masturbation and homosexuality, once considered medical problems or deviant activities, have over time been removed, or challenged openly (such as female hysteria) for its validity. Conrad (2007) also argues that medicalisation can bring to light the suffering that some people experience, that has not been recognised or has been ignored in the past. An example here might be post-traumatic stress disorder (PTSD) which in the past society knew little about, but in recent times has become a major talking point, especially for ex-service personnel. Nevertheless, Conrad (2007) and others like him, are still critical of the over-medicalisation of everyday life inclusive of issues ranging from sleep to ADHD, sexual function and even death.

Watch the short animation below which demonstrates what Illich and others describe as the ‘medicalisation’ of everyday life [1:33].

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The medicalisation of pain is one area where Ivan Illich’s (1976/1995) thesis might apply well. Recently, the maker and distributor of the opioid pain reliever Oxycontin, Purdue Pharma, settled out of court for approximately $6 billion after it was found that the corporation was aware of the powerful addictive properties of the drug. Oxycontin and associated opioid medication helped create an epidemic of drug abuse in the United States, resulting, it is suggested, in the deaths of 630,000 Americans from 1999 to 2016 (Bernard et al., 2018). Pryma (2022) however, contends that the pain management crisis was not simply the result of big pharma. Rather, a network of specialist experts in pain management contributed through their collective selection of opioids as the most efficient way to deal with pain. Unfortunately, pain relief in this case resulted in large side-effects, that created a health crisis of its own. For someone like Illich, this is the problem of medicalisation of everyday life. Instead of society/individuals learning how to live and deal with problems, such as pain, we approach specialists or others, who medically treat the issue, but in turn, create significant social ills in the process. This is not to suggest that medical intervention in pain (or other areas) is not important. Rather, from Illich’s standpoint, it can create some serious ill effects on society, as we can see with Oxycontin.

Interestingly, in Australia, a recent decision about the use/misuse of painkillers illustrates Illich’s concern further. The Therapeutic Goods Administration in 2023 made the ruling that from 2025 onwards there would be restrictions on paracetamol (Panadol) purchasing. The arguments for this are found in this short video here. Several other decisions have been made by this same organisation to limit the side effects of misuse of over-the-counter pain medication, including a decision to limit codeine (such as Nurofen Plus or Panadeine) to prescription-only medication which according to one study has halved codeine-related poisoning.

This is perhaps an example of demedicalisation – where side-effects have been noted and attempts to remove them from social life, enacted.

What other areas of social life do you see as increasingly ‘medicalised’? Have you seen any instances where medicalisation has been reversed and decisions made to reduce side effects on the public?

Along with Illich, thinkers like Michel Foucault (1963/2002) have critiqued the medical industry for the power that it yields in determining normal versus abnormal. In a number of his works, Foucault (2002) attempted to trace the origins of what he called the ‘medical gaze’. For Foucault (1963/2002), the medical gaze is the ability of a doctor (or other specialist) to examine symptoms, narratives and other information through the lens of the biomedical model, eliminating information that is not relevant. The medical professional thus has power through ‘knowledge’, to define according to their expertise, what is illness or not. Subsequently, Foucault (1963/2002) argued that the doctor has a power over others, defined through their knowledge of biomedical science, thus the common adage knowledge is power, applies. For Foucault (1963/2002), this idea is not simply restricted to the hospital setting either. Expertise in a range of areas across modern life were rising during modernity in healthcare, education, policy, economics, law, etc, that means individuals in society were increasingly reliant on those with ‘power’ over them.

Foucault’s (Foucault et al., 2013) most significant criticism was levied at the ‘psy’ sciences in particular where he argued that psychiatrists had the capacity, through their knowledge base, to define, classify and then regulate people as mentally insane or not. The ‘gaze’ of the psychiatrist, backed by the ever-growing industry of knowledge on psychological normality/abnormality, meant that psychiatrists yielded enormous power. His main argument however is that throughout history, society has responded always to those considered ‘mad’. This usually resulted in the removal of those people labelled as such from society. For instance, mental illness in the middle ages was conceived of as punishment from God, and individuals were locked away, or worse still executed (Rössler, 2016). During the Enlightenment, however, this ‘irrational’ way of defining and dealing with the ‘mad’ was removed. Foucault (Foucault et al., 2013) however argued that this process was simply turned over to psychiatrists who continued the trend of removing people from society. For instance, the asylum for him was where those in power could remove problematic individuals from society, and be placed in cells separated from others to undergo treatment by trained psychiatrists. Patients were subordinated to medical surveillance and at times some unpleasant forms of medical treatment. For Foucault (Foucault et al, 2013) the power to define what is normal or abnormal was extremely important to understand, especially when we review the history of cases such as homosexuality or female hysteria. In both of these examples, psychiatry and associated medical knowledge constructed these as mental illness, and subsequently, for many years they were treated as such, despite what we know now (Drescher, 2015; Tasca, Rapetti, Carta & Fadda, 2012).

Erving Goffman (1961) also critiqued the mental asylum using a symbolic interactionist approach. Goffman took time to examine in particular how the patient in the asylum interacted not just with the doctors within, but with other staff, their environments and patients. The asylum for Goffman (1961) resembled what he would later describe as a ‘total institution’, in that it not only housed these people but also strictly controlled their everyday lives within it. You could say that other versions of total institutions like this are prisons, totalitarian states, and closed communities or religions (such as cults). The asylum for him though, attacked the core identity of the inmate by stripping away all notions of their original identity and imposing new identities upon them. This included removing clothing, names and other personal effects, along with putting them in cells, enforcing strict timetables, and other rules onto the everyday. For Goffman (1961), this also included rewards for good behaviour and punishment of the bad (such as solitary confinement). In short, the asylum destroyed the individual’s identity entirely and created an environment of total control over the person. However, Goffman (1961) also showed that individuals would adapt to their conditions within, taking on new roles, such as the cooperative or intransient patient. Thus while they were inside this total institution, there was still room for agency in adaptation and adoption of new identities.

Feminist researchers and theorists have also critiqued the role of the medical industry in controlling women’s bodies and minds. Ehrenreich and English (2010) for instance argued that women themselves are some of the major victims in medicalisation. In particular, in their book Witches, Midwives and Nurses: A History of Women Healers, they sketch out women’s history as objects in both theology and medicine. Initially, women were subjected to the patriarchal domination of the church, which governed their conditions, proclaiming madness and even in some cases, declaring women of difference as ‘witches’ (for instance review the Salem Witch Trials here). However, through the process of secularisation and rationalisation (see Weber), the power of religion faded, supplanted by medical science. However, women did not lose their place as the ‘object’ of analysis or moral judgement. Instead, through science, the female body and mind was subjected to male-dominated approaches to health care and science. This resulted in two outcomes. Firstly, areas of social life that were once traditionally the domain of the female health care provider, such as childbirth, became the domain of male-orientated scientific study, and intervention, displacing women. Secondly, female minds were the subject of significant scientific study, emphasising the abnormal, and producing new techniques to deal with these ‘constructed’ issues. Women were measured against what was deemed as ‘healthy’ in the male mind and subsequently positioned some women into the ‘unhealthy’ category due to their perceived irrationality and mental health issues. Women, through sciences (mostly medical and psychological), were thus afforded a lower status (sex-based class) in society and therefore laws including the right to vote, work and conduct other important business, were denied to them on the basis of this ‘scientific’ foundation.

Other feminists argue that even today, women’s minds and bodies are the subject of over-medicalisation. Riessman (1983) for instance argued that the medicalisation of birth control provided women with the sense that they were sexually free, but also turned them into objects for medical intervention. For her, this made women passive to their own bodies. Specifically, women’s reproductive systems were now in the hands of the medical industry, creating an improper power balance between what is a male-dominated industry and women. Furthermore, Riessman (1983) also showed how women were far more likely to be willing to submit to the medical industry than men. Women are more likely than men to visit medical professionals, more likely to go for periodic check-ups on their bodies, and furthermore, more willing to submit to psychological treatment (see also Bondi & Burman, 2001). Over the years, therefore, women’s bodies and minds have been the subject of a range of interventions, more so than men’s.

Doctor and Patient Roles – Parson’s Sick Role

American sociologist Talcott Parsons (1902-1979) developed a strong approach to sociology where he wanted to create a theory to explain societal behaviour fully. Parsons also developed a branch of sociology entitled ‘structural functionalism‘ which brought together thinkers like Weber and Durkheim to construct an overarching idea of how society would best run. In particular, and of importance to Parsons, was the idea of roles and that in a capitalist, liberal democracy, everyone acquired them, even children. These roles, along with the obligations and functions of them, allowed society to run smoothly while dealing with potential abnormalities along the way. Of those roles, medical personnel including doctors, nurses, allied health professionals and others, had important positions in society for Parsons (1951/2013) as they administered medical care in the most impartial manner possible keeping society fit and ‘functioning’. Parsons (1951/2013) in particular argued that the medical industry had to operate under the banner of universalism – that being, everyone has the right to medical care, and should be treated equally regardless of their personal circumstances.

For society to operate, Parsons (1951/2013) argued that there needed to be not just an obligation and responsibility placed on the medical professionals, but also on those who were sick themselves. This is where he introduced something termed the ‘sick role‘ This entailed a set of responsibilities and expectations that the sick person, as well as society, would adopt in relation to illness. The sick person’s roles and obligations for him were three-fold;

1. The person should desire to not be ill in the first instance, however, should also not be held responsible for their condition after falling sick. For instance, if someone catches influenza and is unable to work, society should not hold that person responsible and they ought to be exempt from their other everyday roles such as work.
2. The person should recognise that being ill is not desirable, and as such have an obligation to ensure that they are doing all they can to get better.
3. The person should adhere to advice and recommendations from health professionals to deal with their illness so that they can get better as soon as possible.

It is clear that Parsons (1951/2013) placed a lot of importance on the relationship and interaction between doctor and patient here. The interactions between them are grounded in a universal approach to helping others (in the case of the doctor) and a desire to get better as soon as possible to resume normal life (in the case of the patient). However, sociologists and others have critiqued this approach for various reasons. Some of these criticisms can be listed below;

1. There are others who are also involved in the ‘sick role’ that are not considered by Parsons (1951/2013). For instance, parents in relation to their children play a vital role in the decision to take their kids to seek health advice. Other people, such as your family or friends, may also play a role in telling you to seek medical attention.
2. Parsons (1951/2013) placed a lot of emphasis here on ‘getting better’, but of course, many people will never get better and as such, should they consistently play the sick role? For instance, long-term illnesses or chronic conditions will require consistent attention throughout their lives. Parsons’ (1951/2013) sick role does not account adequately for them.
3. Relatedly, Parsons (1951/2013) does not account for the role of societal stigma in relation to illness that others such as Goffman (1959/2009) might have. This includes stigmatisation of conditions such as mental illness throughout history, and diseases such as those sexually transmitted. As a consequence, Parsons (1951/2013) ignores the power of interaction between society and individuals, and the deviantisation of people with certain illnesses.
4. In certain times and conditions, doctors and nurses have to engage in triage decisions as to who is privileged for medical care, and who needs to be placed to the side. This was very evident during the early months of COVID-19 where in countries such as Italy, medical personnel had to make difficult choices as to who could be admitted to hospital due to the lack of resources. As Orfali (2020) shows, in Italy there were strict guidelines on age in relation to hospital admission, where the elderly were not prioritised for urgent care. In other countries such as France, priorities were given explicitly to healthcare providers first, ensuring that they looked after staff to keep hospitals running (Orfali, 2020). Parsons (1951/2013) does not account for the contexts in his universalist approach.
5. Finally, Parsons (1951/2013) places too much emphasis on the passivity of the patient as someone who simply adopts the advice of the medical care, and places enormous trust in the provider. As we will see below, others such as Giddens (1991) demonstrate that in today’s modern society, expertise is not simply left unchallenged like this.

Despite these failings of Parsons (1951/2013), the sick role exposed a number of important issues for sociologists to unpack. This included the structure of society, and how illness interrupts the everyday roles that we adopt within them. Furthermore, the sick role highlights the importance of the relationship between the medical industry and society generally, highlighting to us how reliant we have become on the medical model for our ongoing health and well-being. We have left behind traditional models of medical care now for the biomedical model, which as we saw above can be critiqued for its power over society. Nevertheless, Parson’s (1951/2013) approach to medicine is problematic for various reasons, the most important being the relationship between medical personnel and individuals today.

Challenging Expertise – Giddens’ Reflexivity

As modernity has progressed, so too have the number of occupations, specialists, professions and expertise, in every area of our social and individual lives. Health in particular is replete with professions that specialise in all sorts of medical issues. For British sociologist Anthony Giddens (1991), our modern life has become complicated by this explosion of experts. We are bombarded with information constantly, especially via the internet. However, what is clear, as you might be aware of yourself, is that these experts or specialists do not always agree with one another, and at times publicly criticise the knowledge, techniques or actions of others. This puts those in society in a difficult position where we, perhaps unlike the case in premodern or early modern societies, have to make a choice of who to trust and who to follow.

To understand this further we need to take a step back and follow what Giddens (1991) contests is the change from modernity into what he calls ‘reflexive modernity’. In short, Giddens (1991, p. 38) theorises that life has become a constant process of examining and reforming “social practices”, “in the light of incoming information about those very practices.” This is in large part due to the dramatic changes we have experienced in the latter half of the 20th Century including but not limited to significant changes in technology, the speed through which we receive information, the opening up of knowledge via the internet and the vast increased movement of people across the globe. Consider the changes for instance that have happened as a result of the uptake of Web 2.0 technology. While three decades ago we relied solely on television and the newspapers for our news, we now are fed information live and up-to-date 24/7 via social media and other applications. For Giddens (1991), this influx of information uproots traditional practices and creates new pathways for us to live our lives (see chapter on culture and identity).

While our great-grandparents perhaps had little choice in their identity formation and their knowledge consumption, today we have limitless information at our fingertips which inevitably for Giddens (1991) causes us to have an expansion of choice of how we live our lives. The process through which we consume, consider, rationalise and eventually choose a different path is described by Giddens as ‘reflexivity‘. To simplify the idea, the argument is that we no longer simply take as a given information that comes to us. Rather, we balance that information against others, including our own knowledge, and then consider it carefully before making a decision. Consider for instance what led to your decision in career. While in premodern and even early modern times, you were likely to either (a) follow your parent’s occupation, or (b) choose from a limited set of choices due to class or status, today you have an abundance of choice, and as such a significant amount of work needs to be conducted in analysing all information, acquiring even support from experts in the field.

Put this idea of reflexivity to work in health, and you can see what Giddens (1991) might say about the choices we have in front of us in health and well-being. Giddens (1991) in particular argues that expert systems, such as those found in biomedical healthcare, are complicated systems of knowledge and statuses that organise our individual healthcare today. However, these systems are being challenged consistently by other expertise/knowledge from both within and from the outside. Expert systems lay claim to truths, but these are consistently contested amongst each other as to what that ‘truth’ is. Therefore, on one hand, consumers of healthcare have choices now as to which specialists within the biomedical healthcare model they follow. For instance, consider the division between chiropractic science and physiotherapy. Both are advertised as sciences following the scientific method, but equally, both have disagreements about what therapies are best for spinal problems. As Giddens (1991) would argue, they both lay claim to the truth, but oppose one another. On the other hand, however, there has been a dramatic rise of alternative approaches to healthcare that lay outside the biomedical industry. Complementary and alternative medicines (CAMs) and practices for instance have led to a diverse range of new expertise and specialists who argue complement or provide proper alternatives to biomedical science. In Australia,  the popularity of complementary medicines is reflected in the estimated $5.6 billion dollars that Australians spend each year collectively on various items and services. From Giddens’ (1991) perspective, this reflects the growing reflexivity that we have adopted in our own health care.

The major problem for Giddens (1991) is that expert systems such as medical science have fallen victim to a lack of trust. In the past, for him, we were more likely to accept the authoritative model of health care, one where the doctor knows best, and we follow advice stringently. However, with the expansion and availability of knowledge, coupled with the breakdown of traditional social norms, we have become far less trusting of our experts. For Giddens (1991) and others such as Ulrich Beck (1992), a large portion of this distrust comes from the unintended consequences, or side-effects, that expertise has created in our lives. We as individuals are always seeking to negotiate who to believe and place our trust in when it comes to health care and well-being. Giddens (1991) therefore argued that trust is something that institutions and individuals seek to develop more than simply proving the science today. He contends that at a personal level, institutions work hard through persuasive ‘facework’ (a term he borrows from Goffman, 1963/2002) to instil a sense of authority, expertise and trust into potential consumers. We could see this ‘facework’ potentially in the way that health care is marketed to us. Consider an advertisement for a new drug, or specialist in health care. What sorts of ‘facework’ do you see invested in these? How does the medical industry attempt to instil trust into us?

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During the recent COVID-19 pandemic, the trust of expert systems and the government was put to the test. In both Australia and Aotearoa New Zealand,

rallies to protest against compulsory vaccination measures, lockdowns of the public, and other measures put in place to limit the spread of the virus, demonstrated the deep distrust that some of the public have towards government and public health care specialists. However, Goldfinch, Taplin and Gauld (2021) discovered in their survey research with 500 people in each country that public trust in both government and public health had reached a new high following the pandemic. In particular, trust had dramatically increased in government in both countries with approximately 80% of people in their sample agreeing that government was trustworthy. Furthermore, they also found that trust and confidence in public health care had risen significantly, with over 85% agreeing that specialists were working for the best interests of their countries. Yet despite this study, a recent poll conducted by the Australian National University discovered that only 63% of Australians had confidence in and trusted the hospital and health care systems, and 56% had confidence in state/territory governments! What do you think? Are we becoming more distrustful of our healthcare systems? If so, why do you think that might be the case? What institutions do you think we have the most trust in?

Class and Health Care

Unlike Illich and Foucault, Marxists tend to view the health-care system not simply as a powerful institution that infiltrates social lives, Rather Marxists contest the structured inequalities that exist, creating ill-health in the first place. Marx and Engels themselves wrote extensively about ill health and the structured inequality of capitalism (for more on their critique of capitalism see chapter on class and status). In particular, Engels (Engels & Kiernan, 1845/1987) in his treatise on The Condition of the Working Class in England went to some extent to describe the conditions of housing for the proletarian. He argued that the poor state and design of homes, along with the planning of neighbourhoods for the working class, created breeding grounds for disease. The root cause of ill health is therefore not the lack of medical care, per se, but rather the organisation, governance and structure of a capitalist society. Unlike contemporaries of their day, Marx and Engels contested the idea that ill health was individualistic or even biologically grounded in a form of social Darwinism. Rather, the poor health outcomes of the most vulnerable and poor in society, were the direct result of the ill effects of capitalism, that saw the proletariat become the property of the bourgeoisie. Engels (Engels & Kiernan, 1845/1987) in particular argued that the poor health outcomes of the working class were the responsibility of the middle-class bourgeoise and the government which he saw as only protecting the rights of those who were owners of property.

Over time, Marxist or critical theoretical critiques of health care followed suit with several arguing (especially in the 1980s) that individualistic efforts to explain poor health, only serve to obscure or gloss over the structural nature of poverty and the ill-health that follows (for instance see Navarro, 1980). However, other scholars have examined the transition from public health to privatised medicine where institutions, organisations and even hospitals have turned into profit-making enterprises. This is especially clear in the United States which has a significantly different model of health care than Australia or Aotearoa New Zealand. Nevertheless, healthcare systems such as Australia’s have been criticised for the transition to different modes of public policy regarding health. Fran Collyer and her colleagues (2015) for instance criticise the transition from a fully funded public healthcare model, to one that has started to privilege corporate healthcare, and private insurance in particular. This is most evident in hospital care and surgery where they argue that,

the increasing government support of the private healthcare sector also removes resources from the public system. In a small market such as Australia, where almost all surgeons operate in both the public and private sectors, increases in the level of private sector work (particularly where it is for private patients and elective surgery) diminishes the profession’s capacity to attend to those in the public sector […] and it is the public sector which cares for a much larger proportion of patients with relatively low socioeconomic status and more complex medical needs. (Collyer et al., 2015, p.281)

As a consequence of this movement towards private health care, the public system is overwhelmed and the ability for an uninsured person to obtain surgery for problems deemed not urgent is difficult. Consequently, wait times grow, resulting in an incentivisation towards private health care and insurance – something that the Australian government continues to provide a financial rebate to individuals who purchase private health insurance.

Marxists and those like them, emphasise therefore two major themes. Firstly, the nature of capitalism means that structurally, those who in the poorer classes tend to have poorer health outcomes. This bears out still to this day in Australia for instance. The Australian Institute of Health and Welfare (AIHW) captures this data in their annual health reports showing that socioeconomic factors have a direct correlation with health outcomes today. It is important to note that socioeconomic groups, as defined in the report, are not simply a measure of class. Rather, they are statistical measures developed by the Australian Bureau of Statistics (ABS) that groups the population into five – based on income, education, unemployment and occupation. The groupings are reflective of the disadvantage (based on those variables) of areas, not simply class groupings. Thus, it compares the most disadvantaged areas with the least disadvantaged areas.

What the AIHW reports show is that socioeconomic disadvantage repeatedly demonstrates a disparity in health outcomes on a range of measures across the 5 socioeconomic groups. This includes mortality rates where those in the lower socioeconomic groups were more likely to die from avoidable deaths than those in the higher groups. Comparing the lowest group to the highest, the AIHW found that the lowest were,

• 2.6 times more likely to die from chronic obstructive pulmonary disease than those in the highest socioeconomic category
• 2 times more likely to die from lung cancer than those in the highest socioeconomic category
• 1.6 times more likely to die from coronary heart disease than those in the highest socioeconomic category
• 1.3 times more likely to die from cerebrovascular disease than those in the highest socioeconomic category (AIHW, 2022, p. 3).

However, the socioeconomic group disparity goes beyond disease and death into other measures of health. This includes, for instance, smoking, where the lowest group is far more likely to smoke daily (3.6 times more) than the highest group. Furthermore, on issues like obesity, it tracks again that socioeconomic status matters with the prevalence of obesity declining from the lowest to the highest groups. This inequality even continued with COVID-19, with the pandemic disproportionately affecting the lowest socioeconomic group. As the AIHW (2022, p. 3) reports, “Of the 2,639 COVID-19 deaths that occurred by 30 April 2022, there were more than 3 times as many among people living in the lowest socioeconomic areas compared with people living in the highest socioeconomic areas”.

The second issue for Marxists, and those like them, as indicated earlier is access to good health care systems, education and social/cultural capital. In 1988, Australian sociologist Raewyn Connell argued for a “just health program” that would allow humans across all classes the chance to access good healthcare and called for the government to create pathways for equality of outcomes. In particular, she argued that the inequalities of health could not simply be overcome through the privatisation of health systems. Rather, health knowledge, skills and resources needed to be made available to all, along with access to quality health care including preventative care through education programs and so on.

One empirical example of this is private health insurance. Having access, as noted earlier, to quality private health insurance is a significant health benefit to those in countries like Australia. As Collyer and her colleagues showed in their 2015 study, the division between private and public health systems is connected to the availability of doctors and other medical personnel, along with expenditure by the government on health care costs. In Australia, private health insurance is linked to different socioeconomic and other measures. In a study conducted by the ABS, it was found that in 2014/15 those with private health insurance were more likely to come from employed, couple households with a qualification beyond high school (such as diploma or bachelor’s degree). Conversely, those without private health were likely to be migrants from Oceania, North Africa or the Middle East, and those from the lowest levels of socioeconomic disadvantage. Most people in follow-up questions simply argued that it was far too expensive to afford private health, and felt it an unnecessary burden on their budgets.

Marxist approaches to health, like this and that of Engels, allow us to look beyond the individual and into the core roots of social inequality. While we may have disagreements about the critique that Marx and Engels have on capitalism, we cannot deny the statistical reality that connects poverty to ill health. The question is how we overcome these things.

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One area of disparity in the classes in regard to health is that of dentistry. In a study conducted by Mejia et al. (2018) across Australia, Canada, New Zealand and the United

States, the problems of income were evident in relation to good oral health. The study (2018, p.8) in particular found that, “in terms of dental disease, this (income) reflects the ability to access oral health care, favouring populations with high income”. In addition to this, the researchers found that those with lower incomes self-reported through surveys a “lower self-rating” in terms of their oral health (Meija et al., 2018, p.8). Socially advantaged groups, according to the authors, were far more likely to consider their oral hygiene better off compared to those in lower advantaged groups. Interestingly, Aotearoa New Zealand held the widest inequality in the self-reported data on tooth decay across a variety of variables including education and income. The reasons for this are varied, but the authors surmise this might be due to the lack of public dental care available in New Zealand for adults, compared to the other three nations.

Several questions can be raised from this study regarding oral health. These include questions as to whether oral health care ought to be fully covered across the public health care systems. Is oral health care something that the nation-state should be ensuring for its population? Furthermore, what other areas of health care might display health inequalities like this? Should the state provide fully funded public health care for those issues as well?

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