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The sociology of health: An introduction
682
E~OOKREVIEWS
THE SOCIOLOGY OF HEALTH: AN INTRODUCTION Random House, New York, 1970. 134 pp. $2.50.
by
ROBERT
N. WILSON.
IN A small paperback book, Robert Wilson, a sociologist teaching in a school of public health, has attempted to portray the field of medical sociology as it appears to him. He states that his book is neither a comprehensive text, nor an exploration of any aspect in depth. Instead, he considers it to be a “preface” or “‘first statement”, in which he has attempted to communicate some of the salient issues in the field, and the themes which he sees as offering both intellectual excitement and humane involvement. Within the frame work of what he has set out to do he has succeeded admirably. Lucidly written, his boukreads like a series of essays and should capture the interest of a wide range of people interested in health affairs today, including the intelligent layman, the health practitioner. and the social scientist. Following the approach suggested by Robert Straus, Wilson divides his book into two major sections, the sociology of medicine and sociology in medicine. The sociology of medicine is called the view from the outside and is considered to be the detached analysis and observation of the social organization of the total health arena, (the community, the health facilities, the health professions, and patient-practitioner relations) motivated primarily by a sense of sociological problem. Sociology in medicine, on the other hand, is the view from the “inside”, and consists of the “more intimate, applied and conjoint research and teaching, motivated primarily by a sense of healtlz problem”. He includes in this section such topics as the distribution of illness, social factors in the production of illness, social patterns in the treatment of illness and the implications of social change for health in the future. Wilson believes that medical sociology was centered in the first category in its earlier stages, but today, sociologists interested in health and illness are more and more likely to be regular members of a health team taking on a wide variety of roles from researcher to active practitioner. Many sociologists question the value of this type of breakdown, considering sociological analysis to be sociological analysis whether or not it happens to be motivated by a desire to contribute to the solution of social problems. Actually, the breakdown i, probably irrelevant to the organization of the book because several chapters in the first section could have been prompted equally well by a sociologist’s sense of health problem. For example. the current problems of the delivery of health services require a keen look at such topcs as the distribution of lay versus professional decision-making powers in the community, the organizational dilemmas in our large, complex, bureaucratic. in-patient facilities. the consequences of the increasing diversification and professionalization of the health occupations, and alternative models of patient-practitioner relations: yet Wilson discusses all of these topics in the first section. One could also argue that because he approaches hi5 topics conceptually in the second section (the view from within), this portion could have beefi prompted equally well by a sense of sociological problem, such as the necessity to explain the links between location in society, life styles, and the distribution of illness or the use of health resources. The reason sociologists divide the health field in this way could be considered a sociological question in itself, and it may have more to do with the value positions they are willing to take or the professional groups they are willing to identify with. than with the logical divisions in their subject matter. Wilson sees the search for definitions of health and illness as a vital activity, which not only influences research, but the entire sweep of medical action. More than this, he believes
BOOK REVIEWS
683
It can produce a fuller conception of man, and deepen our realization of what it means to be a human being. He favors the idea of defining health as functional competence in enacting social roles. Each approach has its advantages and disadvantages, and it should be noted that this definition tends to cut off questions about variations in the relationship between states of health or illness (defined by other criteria) and competence in enacting social roles, a question one might be particularly interested in when a number of different population groups are under investigation. Wilson points to a number of issues and dilemmas facing the health professions and society at large. He views patient-practitioner relations within the framework of social roles, and predicts a number of important changes in these roles in the future. Noting that all of the health occupations tend to pattern themselves on the ideal image of the physician, he considers them to be engaging in an unrealistic struggle for parity, which primarily results in damaged pride, frustration, and impaired performance. Nevertheless, he also thinks there is a clear trend for the revision of the physician’s role from the dominant position it holds today, to a more “first among equals pattern”. He also describes the built-in dilemma of the professionalization of the health occupations, which, although it raises morale and contributes to the maintenance of standards, also promotes occupational loyalty at the expense of team collaboration, with consequent fragmentation and depersonalization of patient care. He thinks that the pressures of change will continue to force changes in the role of the established health professionals. They will gradually move from being frontline practitioners to being teachers, supervisors, and consultants . . . they will be charged with seeing that the work is done rather than doing it themselves. This means that unless their preparation, now primarily devoted to the development of clinical skills, is changed to include management and consultative skills, they will be inadequately prepared for the tasks before them. All of these things have been said before, but Wilson pulls them together in a particularly graceful way, as issues to think about, issues which are not insoluble, and issues which have only begun to be tackled. Turning to the distribution of illness in the general population, the author develops a number of interesting hypotheses concerning aspects of the social structure which promote varying states of health within different groups of people. At one point, for example, he engages in a provocative discussion of the etiology of the increased amount of illness found in the disadvantaged sector of the population. Using an open system, multi-causal model of health and illness, he suggests that in addition to the obvious defects of poor nutrition and housing, and inadequate medical care, this group suffers from a syndrome of “social psychological insufficiency”, made up of generalized feelings of inferiority and generalized incompetence. He speculates that lack of symbolic stimulation from the earliest days of their lives, coupled with lack of stimulation and reward in the community, interferes with the development of normal competence motivation. This in turn promotes a vicious cycle of incompetent performances, failure, punishment, and feelings of inadequacy which lead to further inadequate performance. Unhealthy living patterns are the result, followed by disease. He theorizes that a countersyndrome of “sufficiency” protects the health of those ranking high in the social structure. They are exposed to a reverse train of events, leading to competence, deep engagement with work, high rewards, and, as a consequence, they experience a zest for life which is health-promoting. A sense of the prevalence of vast societal change permeates this book. More remarkable perhaps, is the spirit of optimism which characterizes Wilson’s outlook. No matter how bleakly he describes organizational dilemmas in the current scene, he typically comments
BOOK REVIEWS
684
on some positive aspects immediately thereafter. Even as he notes that genuine primary prevention is seldom achieved, because it asks a kind of commitment to community management and deliberate change which is alien to American culture, he points to the progress made in secondary prevention, (early intervention in illness). Again, after describing what to many people seem, the almost insoluble problems of the bureaucratic, split-authority, hospital organization, he expresses confidence in a developing ferment of organizational change as the society “at last” focuses its genius for problem-solving on the problems of the delivery of health care . . . “problems which were once the frills of our national life.” Although Wilson’s book provides a stimulating and very readable introduction to the sociology of health, it also has some flaws for the serious student, in that occasionally the author refers to the work of others without providing footnotes as to where the work mentioned may be found. Indeed there are remarkably few fbotnotes throughout the book although there is an annotated bibliography at the end for suggested further reading. This was obviously a deliberate policy, but it does mean that it would be difficult to assess from reading this book just where the boundaries of our knowledge lie. As many sections of the book are speculative, they probably could be best viewed as offering some intriguing hypatheses. The links between the social structure and the production of illness-the specific societal mechanisms which either protect people from, or promote illness are controversial and require much more investigation. Perhaps this little book will inspire some to tackle them. RUTH GALE ELDER, Ph.D. Sociology
and Nursing,
Health Sciences
Building,
State University qf New York at Buflalo, Buffalo, New York.
SURVEY OF THE INCIDENCE OF SPEECH DEFECTS IN SOUTH-EAST QUEENSLAND by MARY A. MACFADYEN. Vol. 1, No. 2. University of Queensland Press, St. Lucia DEALING with speech problems falls into the no-man’s land between health and social welfare services. It is interesting to compare two epidemiological investigations completed recently on Australian school children by a member of each camp. MacFadyen from Queensland is a speech therapist; the other study was undertaken by Farrar,* a medical officer in the Tasmanian health department. Both investigators used similar survey methods although the Tasmanian study was more carefully designed; for instance, we are not told how the sample of Queensland schools was selected. Results were remarkably similar: 18 per cent of Queensland children fell into the “potential speech therapy” category by comparison to the 15 per cent considered to have defective speech in Tasmania. For each survey the general aim was to define needs in order to arrive at solutions on management. Here the paths diverged. MacFadyen was concerned solely with estimating the number of therapists needed for coping with speech-defective children in two educational grades (5-8 year olds). She came up with the astronomical figure of 287 speech therapists. Farrar was concerned more with finding a reliable way to screen young children in order to predict * FARRAR. J. E. (1970) Factors predictive of reading failure, Project report, Department Social Medicince, University of Sydney (to be published).
of Preventive
&
E~OOKREVIEWS
THE SOCIOLOGY OF HEALTH: AN INTRODUCTION Random House, New York, 1970. 134 pp. $2.50.
by
ROBERT
N. WILSON.
IN A small paperback book, Robert Wilson, a sociologist teaching in a school of public health, has attempted to portray the field of medical sociology as it appears to him. He states that his book is neither a comprehensive text, nor an exploration of any aspect in depth. Instead, he considers it to be a “preface” or “‘first statement”, in which he has attempted to communicate some of the salient issues in the field, and the themes which he sees as offering both intellectual excitement and humane involvement. Within the frame work of what he has set out to do he has succeeded admirably. Lucidly written, his boukreads like a series of essays and should capture the interest of a wide range of people interested in health affairs today, including the intelligent layman, the health practitioner. and the social scientist. Following the approach suggested by Robert Straus, Wilson divides his book into two major sections, the sociology of medicine and sociology in medicine. The sociology of medicine is called the view from the outside and is considered to be the detached analysis and observation of the social organization of the total health arena, (the community, the health facilities, the health professions, and patient-practitioner relations) motivated primarily by a sense of sociological problem. Sociology in medicine, on the other hand, is the view from the “inside”, and consists of the “more intimate, applied and conjoint research and teaching, motivated primarily by a sense of healtlz problem”. He includes in this section such topics as the distribution of illness, social factors in the production of illness, social patterns in the treatment of illness and the implications of social change for health in the future. Wilson believes that medical sociology was centered in the first category in its earlier stages, but today, sociologists interested in health and illness are more and more likely to be regular members of a health team taking on a wide variety of roles from researcher to active practitioner. Many sociologists question the value of this type of breakdown, considering sociological analysis to be sociological analysis whether or not it happens to be motivated by a desire to contribute to the solution of social problems. Actually, the breakdown i, probably irrelevant to the organization of the book because several chapters in the first section could have been prompted equally well by a sociologist’s sense of health problem. For example. the current problems of the delivery of health services require a keen look at such topcs as the distribution of lay versus professional decision-making powers in the community, the organizational dilemmas in our large, complex, bureaucratic. in-patient facilities. the consequences of the increasing diversification and professionalization of the health occupations, and alternative models of patient-practitioner relations: yet Wilson discusses all of these topics in the first section. One could also argue that because he approaches hi5 topics conceptually in the second section (the view from within), this portion could have beefi prompted equally well by a sense of sociological problem, such as the necessity to explain the links between location in society, life styles, and the distribution of illness or the use of health resources. The reason sociologists divide the health field in this way could be considered a sociological question in itself, and it may have more to do with the value positions they are willing to take or the professional groups they are willing to identify with. than with the logical divisions in their subject matter. Wilson sees the search for definitions of health and illness as a vital activity, which not only influences research, but the entire sweep of medical action. More than this, he believes
BOOK REVIEWS
683
It can produce a fuller conception of man, and deepen our realization of what it means to be a human being. He favors the idea of defining health as functional competence in enacting social roles. Each approach has its advantages and disadvantages, and it should be noted that this definition tends to cut off questions about variations in the relationship between states of health or illness (defined by other criteria) and competence in enacting social roles, a question one might be particularly interested in when a number of different population groups are under investigation. Wilson points to a number of issues and dilemmas facing the health professions and society at large. He views patient-practitioner relations within the framework of social roles, and predicts a number of important changes in these roles in the future. Noting that all of the health occupations tend to pattern themselves on the ideal image of the physician, he considers them to be engaging in an unrealistic struggle for parity, which primarily results in damaged pride, frustration, and impaired performance. Nevertheless, he also thinks there is a clear trend for the revision of the physician’s role from the dominant position it holds today, to a more “first among equals pattern”. He also describes the built-in dilemma of the professionalization of the health occupations, which, although it raises morale and contributes to the maintenance of standards, also promotes occupational loyalty at the expense of team collaboration, with consequent fragmentation and depersonalization of patient care. He thinks that the pressures of change will continue to force changes in the role of the established health professionals. They will gradually move from being frontline practitioners to being teachers, supervisors, and consultants . . . they will be charged with seeing that the work is done rather than doing it themselves. This means that unless their preparation, now primarily devoted to the development of clinical skills, is changed to include management and consultative skills, they will be inadequately prepared for the tasks before them. All of these things have been said before, but Wilson pulls them together in a particularly graceful way, as issues to think about, issues which are not insoluble, and issues which have only begun to be tackled. Turning to the distribution of illness in the general population, the author develops a number of interesting hypotheses concerning aspects of the social structure which promote varying states of health within different groups of people. At one point, for example, he engages in a provocative discussion of the etiology of the increased amount of illness found in the disadvantaged sector of the population. Using an open system, multi-causal model of health and illness, he suggests that in addition to the obvious defects of poor nutrition and housing, and inadequate medical care, this group suffers from a syndrome of “social psychological insufficiency”, made up of generalized feelings of inferiority and generalized incompetence. He speculates that lack of symbolic stimulation from the earliest days of their lives, coupled with lack of stimulation and reward in the community, interferes with the development of normal competence motivation. This in turn promotes a vicious cycle of incompetent performances, failure, punishment, and feelings of inadequacy which lead to further inadequate performance. Unhealthy living patterns are the result, followed by disease. He theorizes that a countersyndrome of “sufficiency” protects the health of those ranking high in the social structure. They are exposed to a reverse train of events, leading to competence, deep engagement with work, high rewards, and, as a consequence, they experience a zest for life which is health-promoting. A sense of the prevalence of vast societal change permeates this book. More remarkable perhaps, is the spirit of optimism which characterizes Wilson’s outlook. No matter how bleakly he describes organizational dilemmas in the current scene, he typically comments
BOOK REVIEWS
684
on some positive aspects immediately thereafter. Even as he notes that genuine primary prevention is seldom achieved, because it asks a kind of commitment to community management and deliberate change which is alien to American culture, he points to the progress made in secondary prevention, (early intervention in illness). Again, after describing what to many people seem, the almost insoluble problems of the bureaucratic, split-authority, hospital organization, he expresses confidence in a developing ferment of organizational change as the society “at last” focuses its genius for problem-solving on the problems of the delivery of health care . . . “problems which were once the frills of our national life.” Although Wilson’s book provides a stimulating and very readable introduction to the sociology of health, it also has some flaws for the serious student, in that occasionally the author refers to the work of others without providing footnotes as to where the work mentioned may be found. Indeed there are remarkably few fbotnotes throughout the book although there is an annotated bibliography at the end for suggested further reading. This was obviously a deliberate policy, but it does mean that it would be difficult to assess from reading this book just where the boundaries of our knowledge lie. As many sections of the book are speculative, they probably could be best viewed as offering some intriguing hypatheses. The links between the social structure and the production of illness-the specific societal mechanisms which either protect people from, or promote illness are controversial and require much more investigation. Perhaps this little book will inspire some to tackle them. RUTH GALE ELDER, Ph.D. Sociology
and Nursing,
Health Sciences
Building,
State University qf New York at Buflalo, Buffalo, New York.
SURVEY OF THE INCIDENCE OF SPEECH DEFECTS IN SOUTH-EAST QUEENSLAND by MARY A. MACFADYEN. Vol. 1, No. 2. University of Queensland Press, St. Lucia DEALING with speech problems falls into the no-man’s land between health and social welfare services. It is interesting to compare two epidemiological investigations completed recently on Australian school children by a member of each camp. MacFadyen from Queensland is a speech therapist; the other study was undertaken by Farrar,* a medical officer in the Tasmanian health department. Both investigators used similar survey methods although the Tasmanian study was more carefully designed; for instance, we are not told how the sample of Queensland schools was selected. Results were remarkably similar: 18 per cent of Queensland children fell into the “potential speech therapy” category by comparison to the 15 per cent considered to have defective speech in Tasmania. For each survey the general aim was to define needs in order to arrive at solutions on management. Here the paths diverged. MacFadyen was concerned solely with estimating the number of therapists needed for coping with speech-defective children in two educational grades (5-8 year olds). She came up with the astronomical figure of 287 speech therapists. Farrar was concerned more with finding a reliable way to screen young children in order to predict * FARRAR. J. E. (1970) Factors predictive of reading failure, Project report, Department Social Medicince, University of Sydney (to be published).
of Preventive
&