Health and Medicine

In This Chapter

409 Cultural Definitions of Health and Illness 412 Health Care in the United States 418 Sociology and Issues of Public Health in the United States 423 Developing a Sociology of HIV/AIDS 425 Global Issues in Health and Medicine 426 Why Should Sociologists Study Health?

What do you Think?

Should universities and colleges regulate and punish the use of “study drugs”?1. Do you think that use of the Internet, like the use of drugs or tobacco or alcohol, can become an addiction? If so, how should society respond?

Why are the poor more likely than their middle-class counterparts to be obese? What sociological factors might researchers look at to understand this correlation?

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The Rise Of “Study Drug” Use Among U.S. Students

In the fall of 2011, Duke University in North Carolina added a new bullet point to its list of behaviors that constitute academic dishonesty: “the unauthorized use of prescription medication to enhance academic performance.” This policy, which so far has not been adopted at most other universities, represents Duke’s attempt to address student use and abuse of so-called study drugs, prescription medications intended to alleviate conditions such as attention-deficit/hyperactivity disorder (ADHD). Sales of prescription stimulants such as Ritalin and Adderall have surged in recent years: From 2006 to 2010, they increased from $4 billion to more than $7 billion. According to the Higher Education Research Institute, about 5% of incoming freshmen in 2011 had diagnosed ADHD (Johnson, 2011). But the proportion of students using the drugs prescribed to treat ADHD is larger. By one estimate, as many as a quarter of students on some college campuses have used the drugs in the past year (Trudeau, 2009). According to a recent study, 62% of college students will be offered such stimulants by their fourth year (Wild, 2013).

Interestingly, a report on the problem argues that those using “study drugs” are more likely to perform below average academically and exhibit poor study habits. At the same time, the use of such substances—sometimes called “Ivy League crack”—is found among students at all levels of achievement. Students take the drugs to enhance their concentration and increase the time they can spend on tasks, though such use also carries the risk of irregular heartbeat, panic attacks, addiction, and even death (Johnson, 2011). With more students using them, concerns about the drugs’ legality and safety have been accompanied, as at Duke, by questions about how institutions of higher education should respond.

Duke administrators believe that use of the drugs by students to whom they have not been prescribed constitutes cheating, a position supported by the university’s newspaper. A recent study suggests that many college students do not agree. In a survey of 1,200 male college freshmen, more respondents labeled the use of performance-enhancing drugs for sports (such as anabolic steroids) as “unethical” than condemned the use of stimulants for the purpose of improving grades (George Washington University, 2012).

Why would the use of drugs to enhance performance be judged more harshly in one context than in another? In an interview, Tonya Dodge, one of the authors of the study, suggested that “in sports there can be only one winner so misuse of a substance is less acceptable for achieving success than in academics. In academics, one’s success does not necessarily come at the expense of someone else, but in sports it does.”

Do you agree with Duke University that the use of “study drugs” is a form of academic dishonesty? Or do you believe, as

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many students in the study suggested, that it is okay because one student’s improvements do not come at the expense of his or her peers? Should the drugs be more fully regulated because of their medical dangers—or because they constitute cheating? Or should their use be permitted for those willing to take the health risks? What kinds of policies, if any, should your university or college enact in response to this phenomenon?

At one time, sociology and medicine went their separate ways. In the past half century, however, this situation has changed significantly (Cockerham & Glasser, 2000; Weitz, 2012). Today it is widely accepted that sociology can contribute to our understanding of mental and physical health and illness, social group disparities in health, and public health issues such as smoking and obesity—and the growing use and abuse of “study drugs” by young people.

In this chapter, we look at health and medicine from a sociological perspective. We focus on the important role that social forces play in health and health care in the United States, and we address issues at the crossroads of medicine, health, public policy, and sociology. We begin by distinguishing health from medicine. We then turn to an examination of the ways in which ideas about health and illness are socially constructed in culture. We look at health and safety, as well as the relationship between class status and health care and outcomes in the United States, delving into the important issue of health care access and reform in the United States. Further, we highlight sociological issues related to public health, including tobacco use, obesity, and teen pregnancy. We offer ideas about the development of a sociology of HIV/AIDS, a problem that continues to threaten lives, livelihoods, and entire communities and countries. We finish with a consideration of global issues of health and their sociological roots.

Research has shown that people in every age group benefit physically and mentally from regular exercise. In this photo, an 84-year- old South African woman exercises outside her Soweto home. City authorities in Soweto have invested in parks and outdoor gyms to encourage residents to be active.

Culture and Health Care

Health: The extent to which a person experiences a state of mental, physical, and social well-being.

Medicine: An institutionalized system for the scientific diagnosis, treatment, and prevention of illness.

Preventive medicine: Medicine that emphasizes a healthy lifestyle that will prevent poor health before it occurs.

Cultural Definitions of Health and Illness

Although health and medicine are closely related, sociologists find it useful to distinguish between them. Health is the extent to which a person experiences a state of mental, physical, and social well-being. It encompasses not merely the absence of illness but a positive sense of soundness as well. This definition, put forth by the World Health Organization (WHO, 2005), draws attention to the interplay of psychological, physiological, and sociological factors in a person’s sense

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of well-being. It makes clear that excellent health cannot be achieved in purely physical terms. Health cannot be realized if the body is disease-free but the mind is troubled or the social environment is harmful.

Medicine is an institutionalized system for the scientific diagnosis, treatment, and prevention of illness. It focuses on identifying and treating physiological and psychological conditions that prevent a person from achieving a state of normal health. In this effort medicine typically applies scientific knowledge derived from physical sciences such as chemistry, biology, and physics, as well as psychology. In the United States, we usually view medicine in terms of the failure of health: When people become ill, they seek medical advice to address the problem. Yet, as the above definition suggests, medicine and health can go hand in hand. The field of preventive medicine—medicine emphasizing a healthy lifestyle that will prevent poor health before it occurs—is of key interest to health professionals, patients, and policy makers.

The Sick Role

Cultural definitions of sickness and health and their causes vary widely (Sagan, 1987). There are sick roles in every society. Sick roles are rooted in cultural definitions of the appropriate behavior of and response to people labeled as sick and are thus sociologically determined (Cockerham & Glasser, 2000; Parsons, 1951, 1975). The sick role of being mentally ill, for instance, varies enormously across time and space (Foucault, 1988). In some societies, mentally ill people have been seen as having unique spiritual qualities, while in others they have been labeled as victims of demonic possession. In modern societies, mental illness is characterized sometimes as a disease with physiological antecedents and at other times as a sign of character weakness.

One of the pioneers in the sociology of medicine, Talcott Parsons (1975), observed that, in the United States, the role of “sick person” includes the right to be excused from social responsibilities and other “normal” social roles. Parsons, whose theories reflect a functionalist perspective on social life, suggested that illness is both biologically and socially defined, because a “normal” state of functioning includes both physiological equilibrium and the ability to enact expected social roles and behaviors.

Even if illness results from a lifestyle that puts a person at risk, society does not usually hold him or her accountable. On the other hand, the sick person has a societal obligation to try to get well and to seek competent medical help in order to do so. Failure to seek help can lead others to refuse to confer on the suffering individual the “benefits” of the sick role.

The notion that a sick person is enacting a social role may remind us of Erving Goffman’s (1959) ideas about humans as actors on a social stage. Goffman suggested that life is like a dramatic play, with front and back stages, scripts for certain settings, costumes, and props. In order to define situations in ways that are favorable to ourselves, he argued, we all play roles on the “front stage” that conform to what is expected and that will show us in the best light.

Imagine a doctor’s office as a stage: The doctor arrives wearing a “costume” (often a white lab coat and stethoscope). The patient also wears a “costume” (a cloth or paper gown rather than street clothing). The doctor is expected to greet the patient, ask questions about the illness, examine the patient, and offer advice. The patient is expected to assume a more passive role, submitting to an examination, accepting the diagnosis, and taking advice rather than dispensing it. Now imagine a scenario in which the doctor arrives dressed in evening attire, and the patient gives the doctor medical counsel or refuses to lie on the examining table, choosing instead to sit in the rotating “doctor’s chair.” The result would be failed expectations about the encounter, as well as an unsuccessful social and medical interaction. As Parsons pointed out, the sick person has an expected “role,” but so too do doctors, nurses, and others who are part of the “sick play.”

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Sociologist Talcott Parsons introduced the concept of the “sick role,” which offers sociologists the opportunity to think about the condition of being ill as not only a physical condition, but also a social status with particular characteristics and expectations.

The Social Construction of Illness

Parsons’s model underscores the fact that the sick role is culturally determined. Illnesses that are culturally defined as legitimate, such as cancer and heart disease, entitle those diagnosed with them to adopt the role of sick person. The afflicted are forgiven for missing time at work, spending days in bed, and asking others for consideration and assistance. A seriously ill person who persists in leading a “normal” life is given credit for an extraordinary exertion of effort.

Changes in U.S. society’s response to alcoholism highlight the importance of cultural definitions of illness. In the middle of the 20th century, people addicted to alcohol were widely seen as weak and of questionable character. In 1956, however, the American Medical Association (2013) declared alcoholism an illness. With the broad acceptance of this medical model of alcoholism, alcoholics often expect and receive sympathy from family members for their illness, employers may offer programs to help them fight the disease, and the government funds research in an effort to combat the problem.

While there also exists a disease model of drug addiction (Le Moal & Koob, 2007), someone addicted to illegal drugs is more likely than an alcoholic to be denied the sick role. Cocaine, heroin, and methamphetamine addicts, for example, face the possibility of being sent to prison if they are found in possession of the drugs, and they may or may not be referred for treatment of their addiction. In at least 19 U.S. states, women who use illicit drugs during pregnancy are subject to civil or even criminal charges. In 2014, Tennessee passed a law that permits prosecutors to charge a woman with criminal assault if she uses narcotics while she is pregnant. The first new mother was arrested and charged under this law in April 2014 (McDonough, 2014). While there are clear reasons to be concerned about the welfare of infants born to addicted mothers, it is less clear that there are greater benefits to criminally charging new mothers and separating them from their children than to supporting their recovery in treatment programs.

Sociology and the Sick Role Concept

College Student Drug Use

Some drug addiction is widely understood as “illness” while some is labeled as “deviance,” transforming the status of the individual who carries the label (Goffman, 1963b). What explains the difference? Do you think these differing definitions are justified?

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Inequality Matters

Feminist Standpoint Theory and the Construction of “Female” Ills

Joan Jacobs Brumberg writes in The Body Project: An Intimate History of American Girls (1997):

According to Victorian medicine, the ovaries—not the brain—were the most important organ in a woman’s body.

The most persuasive spokesperson for this point of view was Dr. Edward Clarke, a highly regarded professor at Harvard Medical School, whose popular book Sex in Education; Or, A Fair Chance for the Girls (1873) was a powerful statement of the ideology of “ovarian determinism.” In a series of case studies drawn from his clinical practice, Clarke described adolescent women whose menstrual cycles, reproductive capacity, and general health were all ruined, in his opinion, by inattention to their special monthly demands. . . . Clarke argued against higher education because he believed women’s bodies were more complicated than men’s; this difference meant that young girls needed time and ease to develop, free from the drain of intellectual activity. (pp. 7–8)

Medical facts and information are powerful and, because they are cloaked in the credibility of hard science, come to be seen in society as neutral, universal, and true. Feminist standpoint theorists such as Dorothy Smith (1987, 2005) suggest, however, that because “facts,” including medical knowledge, have, until quite recently, been produced almost exclusively by men, they reflect a “male standpoint” on the world. Standpoint theorists argue that women’s standpoints may well be different from men’s, and that “facts” produced from just one standpoint cannot be seen as neutral or universal.

A key part of standpoint theory is the analysis of the power that lies in the production of knowledge, and it asks, “Who has the power to produce ‘facts’”?

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In the 19th century, female hysteria was a commonly diagnosed “ailment” among women. Today is it not recognized as a medical category at all. In the 19th century, women’s ills were almost exclusively labeled by male physicians. Can you see a connection between these facts?

Think It Through

▶ Does the creation of the medical “knowledge” described above about female education and ovulation suggest that men’s and women’s research and conclusions may be conditioned by the researchers’ positions in society? How likely is it that a female physician or researcher would have come to the scientific conclusion that education interferes with women’s menses or reproductive capacity?

Sick roles: Social roles rooted in cultural definitions of the appropriate behavior of and response to people labeled as sick.

Health Care in the United States

Health care can be defined as all those activities intended to sustain, promote, and enhance health. An adequate health care system includes more than the provision of medical services for those who need them—it also encompasses policies that minimize violence and the chance of accidents, whether on the highways, at work, or at home; policies that promote a clean, nontoxic environment; ecological protection; and the availability of clean water, fresh air, and sanitary living conditions.

SOURCE: Alpers, P., & Wilson, M. (2012). Guns in the United States: Facts, Figures and Firearm Law. Sydney School of Public Health, The University of Sydney.

Health and Public Safety Issues

By the standards noted above, few societies come close to providing excellent health care for their citizens. Some, however, do much better than others. The record of the United States in this regard is mixed.

On one hand, the U.S. government spends vast sums of money in its efforts to construct safe highways, provide clean drinking water, and eliminate or reduce air and ground pollution. Laws are in place to regulate working conditions with the aim of promoting healthy and safe workplace environments: The federal Occupational Safety and Health Administration is responsible for enforcing stringent regulations intended to guard the lives and health of U.S. workers. Local health inspectors visit the premises of restaurants and grocery stores to check that food is handled in a sanitary manner, and agricultural inspectors check the quality of U.S. and imported food products. States require drivers to use seat belts, motorcyclists to wear helmets, and children to be strapped into car seats, all of which have been shown to reduce injuries and fatalities in road accidents. While these efforts do not guarantee the safety of life, work, food, or transport, they contribute to public safety in important ways.

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On the other hand, compared to most other modern countries, the United States is more violent, a factor that compromises safety, in particular for some high-risk groups. Gun violence and firearm accidents leading to death are serious problems in the United States (Table 16.1). Children ages 5 to 14 are killed by guns in the United States at a rate 11 times higher than the rates of 22 comparable large, high-income countries. A recent analysis of WHO statistics on gun deaths found that fully 80% of the gun deaths in 23 industrialized countries happened in the United States (Richardson & Hemenway, 2011). Homicide is a leading cause of death among young African American males, and the majority of this violence is perpetrated using guns (Kaiser Family Foundation, 2006; Violence Policy Center, 2010). Studies have also noted that rates of homicide victimization are higher in U.S. states with high rates of gun ownership, as are rates of gun suicides (Miller, Azrael, & Hemenway, 2007).

Domestic violence puts thousands of women at risk: At least 85% of victims of domestic violence are women, and an average of three women are murdered by a husband or boyfriend every day in the United States. In 2010, 38% of all female murder victims in the United States were killed by a husband or boyfriend (National Center for Victims of Crime, 2012). The abuse may start young: In one study, one in three adolescent females reported being physically and/or sexually abused by a dating partner (Davis, 2008). Additionally, 9% of high school students report purposeful physical abuse by a partner within the past 12 months (National Center for Injury Prevention and Control, 2014). This occurs in spite of the fact that there are myriad laws against abuse, mechanisms for securing restraining orders against would-be attackers, and shelters for battered women. Efforts to protect victims and potential victims of domestic violence may fall short because batterers are often given a pass by those hesitant to interfere and because victims lack resources to leave their abusers or fear reprisals.

Different social groups experience different degrees of violence and safety. Black Americans are far more likely than Whites to be victims of homicide, and women are more likely than men to be killed by intimate partners. Why are some groups in society more vulnerable to violence? Is there a link between physical safety and the power a group has (or does not have) in society? What do you think?

Technology & Society

Addiction and the Internet

A recent advertisement for a leading telecommunications company opens with an earnest spokesman meandering through a family’s home

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and declaring, “Today we live online.” He adds that in a just a few years, the number of gadgets in our homes will double. Around him, four family members are engaged in their own individual electronic worlds, each interacting with someone or something other than those in his or her immediate environment. The scenario is presented as pleasant, progressive, and unproblematic. Might something be missing from this picture?

Scientific studies point to a growing epidemic of technological dependency, even addiction. A recent Newsweek article on the issue notes, “In less than the span of a single childhood, Americans have merged with their machines, staring at a screen for at least eight hours a day, more time than we spend on any other activity including sleeping” (Dokoupil, 2012a). Some Internet users neglect sleep, family, and health in favor of the virtual world: In one extreme case, a South Korean couple allowed their infant daughter to starve while they were nurturing an online “baby” for hours at a time (BBC, 2010). At least 10 cases have been documented of Internet surfers getting fatal blood clots from prolonged sitting at the computer. While most cases are not so acute in their consequences, the American Psychiatric Association considered including “Internet addiction disorder” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the foundation of modern mental health practice, as a diagnosis “for further study” (Dokoupil, 2012a). However, when DSM-5 was published in 2013, the disorder was not included.

How many hours each day do members of your family spend on line? What about your friends and you? What are the costs and benefits of our increasing dependence on electronic gadgets and social media?

Richard Lewisohn / Contributor/Getty Images

The Creation of “Madness”

Internet Addiction

A recent publication by psychiatric researchers in Asia, which has very high rates of heavy Internet use, particularly by gamers, points out, “A functional magnetic resonance imaging (MRI) study found that a cue-induced online gaming urge among individuals with Internet gaming abuse activated brain areas similar to those involved in craving in people with drug addiction” (Yen, Yen, & Ko, 2010). Observers suggest that while questions remain about whether brain changes lead to addictive behavior or heavy Internet use fosters brain changes, it is becoming increasingly clear that technology is linked in some way to problems that include addictive behavior, declining attention spans, increasing impulsiveness, anxiety, and depression.

Think It Through

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▶ Is “living online” stigmatized in our society, or is it celebrated? If Internet or other technology use is addictive and vast swaths of people, particularly the young, are becoming addicted, how should society respond?

Health care: All those activities intended to sustain, promote, and enhance health.

Social Inequalities in Health and Medicine

By nearly every measure, health follows the social class curve: Poor people are more likely than their better-off counterparts to suffer chronic illnesses and die earlier. Among children, poverty affects health, food security, housing stability, and maltreatment, with the former two factors playing a significant role in the likelihood of developing chronic illnesses and other negative outcomes such as malnutrition, stunted growth, and suppressed immunity (Henry, 2010). Recessions and economic slumps also hurt families, straining their ability to afford quality food and health care.

Lower-income people are more likely to live in areas that have high levels of air pollution, which raises their risks of asthma, heart disease, and cancer (Calderón-Garcidueñas & Torres-Jardón, 2012). Many have a greater probability of exposure to violence and the mental and physical health problems that entails. Their work is also more likely to involve physical and health risks than is the work of middle- and upper-class people (Commission to Build a Healthier America, 2009). Figure 16.1 highlights class differences in self-perceptions of health and well-being.

The poor often have less healthy diets than do their higher-income counterparts: Inexpensive foods may be highly processed, fatty, and high in sugar. Fresh fruits and vegetables and lean meats may be out of financial reach for those who struggle to make ends meet, and time pressures can limit a workingman’s or -woman’s opportunities to shop for and prepare healthy foods. Children in poor communities may also lack access to safe places for active outdoor play and exercise. Another factor that affects the health of the poorer classes is the fact that they are less likely to perceive the symptoms of illness as requiring attention from a physician (Keeley, Wright, & Condit, 2009).

Figure 16.1 Self-Reported Health Status by Income, 2011

SOURCE: Centers for Disease Control and Prevention. (2012). Table XIII. Crude percent distributions of health status among persons aged 18 years and over, by selected characteristics: United States, 2010. Summary health statistics for U.S. Adults: National Health Interview Survey, 2010.

Figure 16.2 Life Expectancy in the United States, 2011

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SOURCE: Hoyert, D. L., & Xu, J. (2012). Deaths: Preliminary data for 2011. National Vital Statistics Reports, 61(6). Washington, DC: Centers for Disease Control and Prevention.

Because race and class closely intersect in the United States, racial minorities, on average, suffer from poorer health than Whites, which is reflected in the discrepancies in life expectancy between the two groups (see Figure 16.2 above). In 2010, the overall life expectancy at birth in the United States was 78.7 years. White women’s life expectancy was higher at 81.3, while Black women’s was lower at 78.2. White men had a life expectancy of 76.6 years, but their Black counterparts had a life expectancy of just 72.1 years (Centers for Disease Control and Prevention [CDC], 2011a). The differences are linked to, among other factors, higher rates of death among Blacks due to heart disease, cancer, diabetes, and homicide. Inequalities, however, start even before birth, since poor mothers are less likely to have access to prenatal care. A report prepared for the Annie E. Casey Foundation suggests that “at any age, and at any income, education or socioeconomic level, an African American mother is more than twice as likely to lose her infant as a white woman” (Shore & Shore, 2009, p. 6). These findings are supported by 2008 data (Table 16.2) showing a mortality rate of 5.52 per 1,000 for White babies and a far higher rate of 12.67 deaths per 1,000 live births for babies of Black mothers (Hoyert & Xu, 2012).

Race, Pollution, and Health

Income Inequality and Health

The medical establishment in the United States has also used poor minorities to advance the frontiers of science. In the infamous Tuskegee study, which ran from the 1930s to the 1970s, Black males who had contracted syphilis were intentionally left untreated so researchers could study the progress of the disease (Brandt, 1983; Washington, 2007). During the Cold War, U.S. government agencies funded and conducted hundreds of research tests on unwitting citizens to assess the effects of radiation and other by-products of war (Budiansky, Goode, & Gest, 1994). These tests were usually conducted on the poor and disproportionately on minorities (Washington, 2007). This chapter’s Global Issues essay further explores the issue of medical testing on human beings and the questions that inevitably arise about who benefits from such activities and who loses.

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SOURCE: Centers for Disease Control and Prevention. (2012). Infant Mortality Statistics from the 2008 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports, 60(5).

Global Issues

Rich Countries and Poor Patients

Who benefits from disease and poverty in developing countries? Your initial response is likely to be a decisive “nobody!” But considered from a conflict-oriented perspective, the question may elicit a different response. As noted in this chapter, U.S. medical science “benefited” from the diseased bodies of Black men in the Tuskegee study, as well as from the subjects’ relative powerlessness and lack of knowledge about what was happening to them in the study (Washington, 2007).

Recall that sociologist Herbert Gans (1972) asserted that the nonpoor benefit from having a class of poor people (see Chapter 7). He was not arguing in favor of poverty—he meant that because poverty is positively functional for the nonpoor, its elimination could be costly for more economically well-off and powerful groups. Gans’s work offers us a way of understanding why poverty exists and persists, even in a wealthy country like the United States.

We can construct a similar conflict-oriented argument around global poverty and disease. Who benefits from global inequality and poverty—for instance, from the poor health that often accompanies economic marginality?

In terms of health and medicine, the existence of poor, undereducated populations in developing states benefits the West by offering pharmaceutical companies “guinea pigs” on whom to test new medicines where fewer restrictions on testing with human subjects are in force. Examples were cited by a Washington Post investigation in 2000: “An unapproved antibiotic was tested by a major pharmaceutical

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company on sick children during a meningitis epidemic in Nigeria. The country’s lax regulatory oversight, the sense among some doctors that they could not object to experiment conditions for political or economic reasons, the dearth of alternative health care options, combined with the desire of the company to rapidly prepare for market a potential ‘blockbuster’ drug underpinned a situation in which disease victims were treated as test subjects rather than patients” (quoted in Eglitis, 2010, p. 203).

A 2012 report on India noted that in one hospital that serves India’s lowest societal caste, the Dalits, pharmaceutical trials conducted by British and German companies had resulted in injuries and deaths. Some of the hospital patients or their families were illiterate and signed consent forms they could not understand. Others claimed they were never asked for consent. “Over the past seven years, some 73 clinical trials on 3,300 patients—1,833 of whom were children—have taken place at Indore’s Maharaja Yeshwantrao Hospital. Dozens of patients have died during the trials, however no compensation has been paid to the families left behind” (Lloyd-Roberts, 2012). The poor patients in the trials were, according to the report, hesitant to question what was happening to them. Many felt grateful that they were getting access to drugs they would not be able to afford themselves. Few understood that some of those drugs were untested. According to the report, in the 7 years leading up to 2012, almost 2,000 drug trials had taken place across the country.

Controls on drug testing in many countries of the developing world are less stringent than in countries such as the United States and Canada. Clinical drug trials run in countries such as Nigeria (shown here) have led to criticism of pharmaceutical company practices.

The Washington Post / Contributor/Getty Images

Think It Through

▶ Who benefits from global poverty—and who loses? Is it possible for Western companies to conduct drug safety trials in poor developing countries in a way that benefits the companies, the patient participants, and Western consumers?

Access to Health Care

One important reason the poor—as well as some families in the working and middle classes—in the United States are less likely to experience good health is that a notable proportion are unable to access regular care for prevention and treatment of disease. In the fall of 2010, 3 years after the start of the Great Recession and shortly before the Patient Protection and Affordable Care Act (which we discuss below) was signed into law, the U.S. Census Bureau reported that more than 16% of people in the United States were without health insurance, the highest figure in 23 years (Kaiser Family Foundation, 2010a). Key sources of this decline were the economic crisis and the associated rise in unemployment; most U.S. adults get health insurance coverage from their employers. Workplace coverage is variable, however, and ranges from full

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benefits requiring little or no financial contribution from the employee to partial benefits paid for through shared employer and employee contributions. Cost-saving measures in U.S. workplaces in recent decades have shifted a greater share of the cost of these benefits from employers to employees.

As the economic picture has improved since 2010, many people have gone back to work, but millions of employees are still uninsured or underinsured. This problem has been worsened by a changing labor market and economic structure that favors part-time or contractual employment, with fewer benefits such as the employer-based health insurance coverage that has traditionally applied to full-time employees.

A substantial number of Americans have access to health care through government-funded programs such as Medicare, an elder insurance program that covers most of those ages 65 and over (about 41.5 million in 2012) and some younger residents with disabilities (about 9.4 million in 2012) (Centers for Medicare and Medicaid Services, 2012). Medicaid, a shared federal and state insurance program that provides coverage for many poor adults and children, reached an enrollment of 54.1 million in June 2012 (Kaiser Family Foundation, 2013b). Medicare was created in 1965 to serve as a federal health insurance program for people age 65 and older, regardless of income or medical history. It covers very diverse populations, since most people over the age of 65 and those with permanent disabilities are entitled to coverage (Kaiser Family Foundation, 2014). Medicaid, on the other hand, is the country’s major health insurance program designed to assist low-income people of all ages with their health care needs, but it is not available to everyone who needs long-term services; to be eligible for Medicaid, individuals must meet stringent financial qualifications (Kaiser Family Foundation, 2012a).

A contemporary issue related to Medicare is the fact that members of the post–World War II baby-boom generation (those born between about 1946 and 1964) are now entering the 65+-year-old cohort. As the “boomers” reach eligibility age, their massive numbers will have an effect on the nation’s need for health care dollars and resources. The U.S. Census Bureau reports that between 2000 and 2010, the 65+ age cohort grew at a faster rate than the total population; the total population of the United States increased by less than 10%, while the population of those 65 and older grew by more than 15% (Werner, 2011). The increase in eligible Medicare recipients, medical advancements that extend the lives of the elderly, and a relatively smaller tax base are the ingredients of a debate over care and government spending that will grow more acute in the years to come (Antos, 2011). The effect of the Obama administration’s health care legislation on Medicare is not yet fully clear.

At the opposite end of the age spectrum, the State Children’s Health Insurance Program (SCHIP) was created in the late 1990s in an aggressive effort to cover more uninsured children. Because individual states administer SCHIP in partnership with the federal government, state governments largely dictate its implementation, so the comprehensiveness of coverage and eligibility standards vary from state to state.

While the care that the poorest U.S. adults can access through Medicaid is limited, it is often the working poor and other low-income employees who are shut out of insurance coverage altogether. They are most likely to be working in economic sectors such as the service industry (fast-food restaurants, retail establishments, and the like) that provide few or no insurance benefits to employees, while earning too little to afford self-coverage but too much to qualify for government health coverage. The fact, as noted above, that low-income people are more likely to have health problems has also affected their ability to get insurance coverage in the past, because insurers were allowed to exclude those with “preexisting conditions” such as diabetes, high blood pressure, and other illnesses and disabilities.

Ebola and the Making of Pariahs

The Patient Protection and Affordable Care Act (known simply as the Affordable Care Act, or ACA), signed into law by President Barack Obama in 2010, endeavors to expand insurance coverage to most people in the United States at a time when the numbers of the uninsured had been rising. The goal of this health care overhaul is to bring more people into the insurance fold by making coverage more broadly accessible and affordable, in part by requiring that everyone buy insurance and that private insurance companies offer coverage under new terms that extend benefits to those who may have had difficulty purchasing insurance in the past, such as those with preexisting conditions. While the purchasing mandate (or “individual mandate”) went into effect in 2014, other parts of the ACA were already in place when the U.S.

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Supreme Court ruled on the constitutionality of the mandate in June 2012. Among these provisions were the requirement that insurance companies permit young people up to age 26 to remain on their parents’ health insurance policies if they do not have other coverage.

Since its passage, the ACA has been the source of heated political debate. President Obama and other supporters of the act argue that the new law is expanding insurance coverage to a broader swath of people, many of whom had been locked out of the insurance market due to preexisting conditions or unaffordability of individual insurance policies. They suggest that the law supports this expansion of coverage through the operation of new state-level insurance markets (or exchanges) that keep prices down by enabling purchasers to buy insurance as part of a group. Those with low incomes are eligible for federal subsidies to support their insurance purchases. Supporters also note that as the population of uninsured people declines, so will taxpayer-borne costs, including those incurred when the uninsured seek medical care at emergency rooms, which are obligated by law to treat everyone regardless of their ability to pay.

Figure 16.3 Per Capita Health Care Spending for Selected Developed Countries, 2010

SOURCE: Kaiser Family Foundation (2013) Health Expenditure Per Capita.

Opponents argue that the U.S. government is overstepping the limits of its powers in requiring that people purchase health insurance or pay a penalty tax for failing to do so. Many see the individual mandate as an infringement on their freedom to choose whether or not to purchase insurance. There have also been attempts to portray the ACA as a path to “socialized medicine,” though most people will still receive their insurance through private insurance companies rather than through the government.

Both supporters and opponents of the ACA have expressed concerns about the costs of the U.S. health care system. Indeed, the United States spends more per capita on health care than most economically developed states (Figure 16.3), though many of its health indicators compare poorly to those of its peers. Opponents of health care reform argue that the ACA will drive up costs by, for instance, requiring insurers to cover those who have costly health conditions. Supporters of the law point out that having a large pool of uninsured contributes to higher costs when they fail to get preventive care and must resort to far more costly emergency room care. The cost trajectory of health care is not yet clear. Certainly, an aging U.S. population will likely need more, not fewer, health care services in the future. The effect of the ACA on both U.S. health indicators and access to care will become clearer with the passage of time.

Can Technology Expand Health Care Access?

Would you like to have a “doctor on demand”? Some technological innovations are bringing health care into people’s

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homes, opening the door for greater access to medical care as well as a potential reduction in unneeded doctor’s office visits. As a recent Time magazine article on the technological expansion of access to medical care points out, such technology was “previously reserved mostly for luxe private practices or rural communities that lack access to health care” (Sifferlin, 2014). Today, it may be coming to an app near you.

New technological innovations like Doctor on Demand, Health Tap, and AskMD offer a range of services, from the opportunity to ask physicians medical questions by text and receive free responses to online appointments that require payment for consultations. Beneficiaries of these technologies include both patients, who have new avenues to reach medical professionals, and doctors, as online consultations can help them build their public profiles and earn some extra income.

Are there potential pitfalls to the use of these technologies as well? Are there potential losers? Those patients who have acute or urgent needs are still best served by personal visits to physicians. As well, those who do not own computers or smartphones or cannot pay the fees for online consultations may still be locked out of these opportunities. “Doctor on demand” technology may, however, offer a potential vehicle for bringing medical advice to both advantaged and underserved communities. Can you think of ways that technological innovations like these could be used to address medical needs across the income spectrum?

Sociology and Issues of Public Health in the United States

Public health is the science and practice of health protection and maintenance at a community level. Public health officials try to control hazards and habits that may harm the health and well-being of the population. They have long sought to educate the public about the hazards of tobacco use, for example, and to prevent young people from taking up smoking. More recently, they have warned that obesity is becoming an ever more serious problem for young and old alike. The issue of teen pregnancy has also garnered attention, though rates of pregnancy among teenagers have fluctuated.

Smoking

One of the largest and most profitable industries in the United States is the manufacture and sale of tobacco products, estimated to be a $47.1 billion industry. At the same time, tobacco is the number one cause of premature death in the United States, claiming more than 443,000 lives each year and surpassing the toll from alcohol, homicide, suicide, drugs, auto accidents, and AIDS combined (CDC, 2011c). Even nonsmokers are at risk. The CDC (2011c) estimates that secondhand smoke exposes 88 million nonsmokers to measurable levels of toxic chemicals associated with cigarette smoke. About 90% of men and 80% of women who die of lung cancer are smokers (U.S. Department of Health and Human Services, 2004). According to the CDC (2014b), smoking-related lung cancer deaths averaged 74,300 per year among men and 53,400 per year among women from 2005 to 2009. While the smoking rate in the United States fell between 2000 and 2005, it has since stalled at about 21%, a figure that translates to more than 45 million smokers (CDC, 2011c).

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Communications researcher Jean Kilbourne (1999) says female-targeted cigarette ads often contain subtexts about female thinness, using “thin,” “slim,” or “light” in the product name. Ads also imply that smoking can help women lose weight; in the past Lucky cigarettes urged, “Reach for a Lucky instead of a sweet.”

While statistics on morbidity, meaning the rate of illness, and mortality, the rate of death, highlight important medical aspects of cigarette smoking, we can also use sociological analysis to illuminate this public health issue. Why do so many people continue to smoke and so many young people take up smoking despite the evidence of its ill effects? Why do more men than women smoke? Why are young women the fastest-growing population of new smokers? (See Figure 16.4.) Why does the government not regulate the production and sale of such an addictive and dangerous product more stringently?

Sociology offers us some insight into these questions. Among other things, cigarette advertising both constructs and reinforces gender stereotypes (Kilbourne, 1999). Male smoking has been associated with independence, ruggedness, and machismo (think of the Marlboro Man, an iconic figure in U.S. advertising). On the other hand, female smoking has been associated with images that are elegant, chic, and playful or carefree. A symbolic interactionist might highlight the way in which a cigarette is more than just tobacco rolled in paper. To a young teen, it might be a symbol of maturity; to an older teen, it might represent being cool or rebellious. In what other ways do cigarettes function as symbols of self in our society?

Figure 16.4 Cigarette Smoking in the United States, 2012

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SOURCE: Centers for Disease Control and Prevention. (2012). Adult Cigarette Smoking in the United States: Current Estimate. Smoking & Tobacco Use.

Two Theoretical Perspectives On Public Health: The Case Of Cigarettes

The conflict perspective offers some insight into why cigarettes are not regulated more stringently despite their addictive properties: Who benefits from the existence of a large population of smokers? Who loses?

Smoking may give pleasure to smokers, but its benefits are largely outweighed by its consequences, which include poorer health and a thinner wallet. Smoking does, however, bring profit to the tobacco companies, which have tenaciously defended their product for decades. Tobacco companies are generous contributors to candidates for political office. They are advantaged by wealth and access to the halls of government, where their voices are heard. While the smoker gets a mixed bag of benefits (pleasure) and consequences (addiction, disease, financial cost) from smoking, cigarette companies clearly benefit from purchases of their goods and the recruitment of new smokers—men and boys, women and girls—to replace those who die or quit.

Is the easy availability of cigarettes also functional? A functionalist might suggest that, in fact, it is positively functional in its creation of jobs, which range from tobacco farming to marketing and lobbying for the tobacco cause, and in its contribution to rural economies that depend on income from farming tobacco. The highly coveted plant has been subject to human cultivation and use for hundreds of years. Consider its historical functions: Tobacco became a major influence in the development of the economy of early America. During the Revolutionary War, profits from the tobacco trade helped to the Revolution by serving as collateral for loans provided to Americans by France (Randall, 1999). In contemporary times, according to the Center for Responsive Politics (2013), the tobacco lobby employed about 133 lobbyists and spent more than $17 million on behalf of 25 clients in 2011 alone. The modern tobacco industry is a multimillion-dollar enterprise with a strong political influence despite increased awareness of the deleterious effects that tobacco products have on the human body.

Obesity in America

Viewing cigarette smoking through a theoretical lens lets us see it as more than just an individual choice or action. Rather, cigarettes and smoking are social symbols and phenomena with profound effects on public heath, as well as sources of profit for some and pain for others.

Public health: The science and practice of health protection and maintenance at a community level.

Morbidity: The rate of illness in a particular population.

Mortality: The rate of death in a particular population.

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Obesity

The CDC identifies obesity in the United States as a national health problem: It is a major cause of mortality, second only to smoking. According to the CDC (2012d) and the Kaiser Family Foundation (2011), more than 34% of adults in the United States between the ages of 20 and 74 are obese, and more than 63% are overweight (this statistic includes those who are classified as obese). The rates of being overweight/obese vary by gender and ethnicity, as we see in Figure 16.5.

The rate of obesity in American children has risen even faster and is twice what it was in the late 1970s. Children who are much bigger than their peers sometimes experience social ostracism. Further, they may suffer serious health effects. Very obese children have been observed to suffer health problems once believed to affect only older adults, including heart attacks and type 2 diabetes (CDC, 2012e). With the popularity of sedentary activities such as video games, participation in social media, and television viewing, society will likely see this problem increase.

Figure 16.5 Rates of Obesity and Overweight in the United States by Race and Ethnicity, 2012

SOURCE: The Kaiser Family Foundation. (2011). Overweight and Obesity Rates for Adults by Race/Ethnicity, 2011. Statehealthfacts.org

Among the factors to which the rise in size has been attributed is that families in the United States eat more meals outside the home than in the past, and many of these meals are consumed at fast-food establishments. As well, the portions diners are offered in restaurants are growing because many ingredients have become very inexpensive. In Fast Food Nation, Eric Schlosser (2001) notes that “commodity prices have fallen so low that the fast food industry has greatly increased its portion sizes, without reducing profits, in order to attract customers” (p. 243), a point supported by mathematician and physicist Carson C. Chow, who argues that the obesity epidemic in the United States is an outcome of the overproduction of food since the 1970s (cited in Dreifus, 2012). Federal subsidies for food production favor meat and dairy, which soak up almost three-quarters of these funds. Just over 10% support the production of sugar, oils, starches, and alcohol, and less than a third of 1% support the growing of vegetables and fruits. These data show that the U.S. Congress has opted to subsidize the production of foods that contribute to obesity rather than those, including fruits and vegetables, recommended in the government’s own nutrition guidelines (Rampell, 2010).

Physician and scientist Deborah A. Cohen (2014) argues in her book A Big Fat Crisis that “obesity is primarily the result of exposure to an obesogenic environment” (p. 191), and she points to three key components of that environment. First, she notes (consistent with Chow) that factors like agricultural advances have led to an abundance of cheap food. Second, she suggests that the availability of food, particularly junk food, has grown: More than 41% of retail stores, including hardware stores, furniture stores, and drugstores, offer food. Third, food advertising has vastly expanded. Cohen notes that grocery stores today earn more from companies paying for prime display locations than from consumers buying groceries.

Damage to health is not the only harmful effect of obesity. In 2010, a study found that, on average, the annual individual

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cost of being obese in the United States was $4,879 for women and $2,646 for men. Obese women were also more financially disadvantaged than were obese men and suffered 38% more job-related costs, such as absenteeism (Dor, Ferguson, Langwith, & Tan, 2010).

Clearly, obesity is a complex phenomenon driven by a variety of factors—biological, genetic, environmental, social, and economic. As you will see below, poverty is also an important factor in the prevalence of obesity. From a sociological perspective, we consider the connection between the personal trouble and the public issue of obesity and overweight. That is, if one individual or a handful in a community are obese, that may be a personal trouble, attributable to genetics, illness, eating habits, or any other set of factors. However, when more than one-third of the U.S. population is obese (Ogden, Carroll, Kit, & Flegal, 2012), including majorities in some communities, this is a public issue and one that, to paraphrase C. Wright Mills, we may not hope to explain by focusing just on individual cases. Rather, we need to seek out its sociological roots.

Teen Sex and Pregnancy

Consider how this issue might look through the conflict lens. Who benefits, and who loses? While “losers” in this instance are surely those whose health is compromised by excessive weight, there are also macro-level effects such as lost productivity when employees miss work due to obesity-linked illnesses such as diabetes. In fact, the CDC has estimated that the medical care costs associated with obesity in the United States total about $147 billion annually (Finkelstein, Trogdon, Cohen, & Dietz, 2009).

Who benefits? The food industry, particularly fast-food companies, arguably benefit when consumers prioritize quantity over quality. By offering bigger portions (which cost only a bit more to provide), restaurants draw bigger crowds and bigger profits The $60 billion weight-loss industry (Clark, 2011; Marketdata Enterprises, 2011) also benefits, since the rise in obesity exists in the presence of widespread societal obsession with thinness. Often, the same companies that market high-fat, unhealthy foods also peddle “lite” versions (Lemonnier, 2008).

Private Lives, Public Issues

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Poverty, Malnutrition, and Obesity

Obesity and being overweight are, in important ways, what many of us would see as “private troubles,” reflecting choices individuals make about nutrition, exercise, and health. Clearly, however, these public health problems affect millions in the United States. No less important to sociologists is the fact that the risk of falling into the categories of obese or overweight is not evenly distributed across social groups in this country.

Think for a moment about the problems of hunger and malnutrition. What kinds of images enter your mind? Are you picturing the heartrending scenes of starvation in the world’s least developed countries that are brought to us by the media? Yet hunger and malnutrition are also present in our own country, though their manifestation is often quite different. Poor access to nutritious food in the United States is more likely to be manifested in obesity than in emaciation. Consider, for example, that some of the country’s poorest states have the highest obesity rates. In Kentucky 30.4% of adults are obese; in Louisiana, 33.4%; and in Mississippi, 34.9% (CDC, 2012d).

Among the demographic groups most likely to be poor are also those most at risk of obesity; fully half of African American women are obese, as are 45% of Hispanic women (CDC, 2012d). Those without a high school education are more likely to be obese (32.9%) than those who complete high school (over 29%) or college (nearly 21%; Ogden, Lamb, Carroll, & Flegal, 2010). According to the Handbook on Obesity, “In heterogeneous and affluent societies like the United States, there is a strong inverse correlation of social class and obesity” (quoted in Critser, 2003, p. 117).

Can we use the sociological imagination to examine the relationship between poverty and obesity? What sociological factors are pertinent for understanding this phenomenon? Though individual factors such as bone structure, genes, appetite, and personal choices have an important influence, obesity is also a product of social environment and socioeconomic conditions. Those who are poor are more likely to consume less nutritious food for a host of reasons. Nutritionally poor food is generally less expensive than high-quality goods, and large grocery stores with wide selections and competitive pricing are disproportionately located in suburbs, while convenience stores plying overpriced, processed foods serve inner-city communities (Critser, 2003), though some cities, including Washington, D.C., have increased the incentives they offer for big grocery stores to locate in poor neighborhoods.

Obesity is not exclusively about overconsumption of food. Factors including the higher cost of healthy meals and the lack of access to recreational spaces also play a key role in understanding why many Americans, particularly the poor, struggle with obesity.

The poor are also more likely than those in other socioeconomic groups to have limited access to recreational facilities such as safe playgrounds and sports fields that offer opportunities for exercise. Facing budgetary pressures, some schools in poor neighborhoods have cut important physical education programs. Good nutrition, healthy lifestyles, and healthy weight are privileges of class in ways we may not have imagined.

Think It Through

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▶ What kinds of social programs or policies might a sociologist design to address the prevalence of overweight and obesity in poor communities?

Teen Pregnancy

About 750,000 teenage girls become pregnant in the United States each year, and an estimated 444,690 give birth (Kost & Henshaw, 2012). Most of the young mothers (about 81%) are unmarried when they give birth (Henshaw, 2002; Turner, 2003). Figure 16.6 shows changes in the birthrate among teens across recent decades.

Figure 16.6 Birthrates for Teens of Different Races Ages 15–19 in the United States, 1993–2012

SOURCE: Data from Martin, J.A., Hamilton, B.E., Osterman, M.J.K., Curtin, S.C., & Mathews, T.J. (2013). “Births: Final Data for 2012.” National Vital Statistics Reports, Vol. 62, No.

Pregnancy and births among teenagers are public health issues because young women who conceive or give birth before their bodies are fully developed put themselves and their babies at risk. Compared to older mothers, teen mothers have worse health, more pregnancy complications, and more stillborn, low-weight, or medically fragile infants. But teen pregnancy and birth are of more than medical concern. They are also associated with another public health problem: poverty.

Giving birth early and outside marriage compounds the risk that young women and their children will become or remain poor; about 34% of all female-headed households in the United States live below the poverty line, compared with about 7% of married-couple families (DeNavas-Walt, Proctor, & Smith, 2012). Parenthood is a leading cause of dropping out of school among teenage women; teen mothers are at greater risk than their peers of not completing high school—only about 40% of women who become mothers before the age of 18 earn a high school diploma, and fewer than 2% earn a college degree by age 30 (National Campaign to Prevent Teen Pregnancy, 2010).

The relationship between teen pregnancy and birth and poverty is complicated. On one hand, as noted, early and unwed motherhood compounds the risk of poverty. On the other hand, poverty is itself a risk factor for teenage motherhood: An estimated 80% of teen mothers grew up in low-income households (Shore & Shore, 2009), and poor teens have a higher incidence of early sexual activity, pregnancy, and birth than their better-off peers (National Campaign to Prevent Teen Pregnancy, 2010).

In her book Dubious Conceptions: The Politics of Teenage Pregnancy (1996), sociologist Kristin Luker suggests that poverty is a cause as well as a consequence of teen pregnancy and birth. She argues that poor young women’s probability of early motherhood is powerfully affected by “disadvantage and discouragement” (p. 111). By disadvantage she means the social effects of poverty, which reduce opportunities for a solid education and the realization of professional aspirations. Consider, for instance, a high school senior from an affluent household: She may spend her 18th year contemplating whether to begin college immediately or take a year off for travel abroad. A young woman who hails from a poor household in rural Louisiana or the Bronx’s depressed Mott Haven neighborhood may have received an inferior

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education in her underfunded school, and, having little money, has no hope for college. Travel beyond her own state or even city is unthinkable. Local jobs in the service industry are an option, as is motherhood. Discouragement, according to Luker, is the effect of poverty that may prevent poor young women from exercising agency in confronting obstacles. In an impoverished situation, the opportunity costs of early motherhood—that is, the educational or other opportunities lost— may seem relatively low.

Notably, a study by Kathryn Edin and Maria Kefalas (2005) found that many poor young women embrace early motherhood as an honorable and even desirable choice. Some of the women the researchers interviewed also saw it as something that “saved” them from trouble with drugs or the law and “matured” them. Most of the women Edin and Kefalas interviewed expressed a desire to marry and embark on a career in the future. At the same time, discouraged by what they perceived as a limited pool of stable partners, whose marriageability was compromised by poor employment prospects and problems such as alcohol and drug use, the women did not put marriage ahead of motherhood, though many retained hopes for marriage at a point when they felt financially independent. In neighborhoods where early motherhood was the norm, many expressed a preference to have their children while young, a preference shared by the young men with whom they had relationships. While few of these young women’s pregnancies were planned, many couples took no steps to avoid pregnancy.

Early parenthood is a leading reason that teen women drop out of school. About a third cite this reason for leaving high school. Staying in school, however, is key to job prospects that enable families to stay out of poverty. What might schools do to encourage young mothers to graduate?

Tina Stallard / Contributor/Getty Images

Though rates of teen motherhood remain higher in the United States than in many other economically advanced countries, they have declined in some groups. Among other factors, the use of condoms has increased markedly (U.S. Department of Health and Human Services, 2013), perhaps due to a desire to protect against both pregnancy and sexually transmitted infections. There have also been small drops in the numbers of teenagers approving of and engaging in premarital sexual activity, and the rate of births among teenage women has dropped compared to the rate in earlier decades (Ventura & Hamilton, 2011).

Teen pregnancies and births are social facts, or phenomena that, as Émile Durkheim put it, we can explain only by using other social facts. That is, to understand sociologically both the rise and the fall of the rates of teen pregnancies and births, we must recognize that these are not just “personal troubles” or individual issues, but that they are fundamentally tied to other economic, social, and cultural issues in society.

Developing A Sociology of HIV/AIDS

The case of acquired immunodeficiency syndrome (AIDS) and the virus that causes it, human immunodeficiency virus (HIV), is another example of the importance of understanding the social construction of illness. Perceptions of HIV/AIDS and those who contract HIV have varied across time, depending on who the most visible victims have been. As well, the infection—which is a global pandemic—demands a sociological approach because it is closely intertwined with a host of

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sociological issues, including gender inequality, poverty, violence and conflict, and the pursuit of both medical breakthroughs and profits in a globalizing world.

It is estimated that more than 1 million persons in the United States have HIV/AIDS. Of these, about 236,000, or 1 in 5 (about 20%), have not been diagnosed and likely do not know they are infected (CDC, 2011b).

Gender and HIV/AIDS

We can better understand the spread of sexually transmitted diseases, including HIV/AIDS, if we examine how these diseases are related to gender and inequality. Globally, the number of women with HIV/AIDS has risen: Fully half of new infections are now diagnosed among women. In some regions, women’s infection rates outpace men’s: In sub-Saharan Africa, of the 22.5 million people living with AIDS, 60% are women (UNAIDS, 2010b).

Norms and traditions in many regions reinforce women’s lower status in society. In some traditional communities in Africa, for example, it is socially acceptable—or even desirable—for men to have multiple sexual partners both before and after marriage. In this case, marriage itself becomes a risk factor for women. Many women also still lack accurate knowledge regarding sexually transmitted diseases, a problem made more acute by widespread female illiteracy in poor regions. Women who are uninfected may not know how to protect themselves, and women who are infected may not know how to protect their partners.

Figure 16.7 Estimated New HIV Infections in the United States by Subpopulation, 2010

NOTE: MSM stands for “Men who have sex with men.” IDU stands for “Injecting drug use.”

SOURCE: The Kaiser Family Foundation. (2009). Estimated Numbers of Persons Living with an AIDS Diagnoses, All Ages, by Race/Ethnicity, 2009. Statehealthfacts.org

Figure 16.8 HIV/AIDS Prevalence by Race and Ethnicity in the United States, 2009

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SOURCE: Centers for Disease Control and Prevention.

Gender stereotypes and vulnerability to HIV/AIDS are also pertinent. In a New York Times Magazine article examining the phenomenon of Black men who present themselves to the outside world as heterosexual but engage in homosexual activity “on the down low,” Benoit Denizet-Lewis (2003) writes about a culture of Black masculinity in which Black male bisexuality and homosexuality are little discussed and little accepted. Hence, Black males who want to have sexual relationships with males are often compelled to put on a facade for their families and society. In the words of one man on the down low, “If you’re white, you can come out as an openly gay skier or actor or whatever. It might hurt you some, but it’s not like if you’re black and gay, because it’s like you’ve let down the whole black community, black women, black history, black pride” (quoted in Denizet-Lewis, 2003). An important consequence is that some men who are having sex with other men are also having sex with women—wives and girlfriends. Notably, CDC (2010a) data show that Blacks made up about half of those found to have HIV in 2008, but only about three in five had ever been tested for HIV. This suggests that many men who are HIV-positive are likely unaware of their status, which puts them, as well as their partners, whether male or female, at risk.

Figure 16.9 HIV/AIDS Prevalence Worldwide, 2010

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SOURCE: Data from UNAIDS. (2010). HIV Prevalence Map. United Nations Programme on HIV/AIDS Global Report 2010.

Poverty and HIV/AIDS

Across the globe, there is a powerful relationship between the risk of HIV/AIDS and poverty. China, for instance, has experienced a rise in new cases in the past decade. A serious epidemic was detected in central China’s Henan Province, where tens of thousands of rural villagers have been infected in the past decade through selling their blood for money under unsafe and unsterile conditions. In China as a whole, it is estimated that at the end of 2005 there were 55,000 commercial blood and plasma donors infected with HIV (“AIDS in China,” 2007). In developing countries, economic insecurity and the lack of gainful employment sometimes drive workers (particularly men) to seek work far from home. For example, migrant workers from surrounding countries toil in the mines of South Africa. Away from their families and communities, some of these men seek out the services of prostitutes, who may be infected (UNAIDS, 2010b).

The sex workers themselves are often victims of dire and desperate economic circumstances. Women in the sex trade, some of whom have been trafficked and enslaved, are highly vulnerable to HIV/AIDS. They have little protection from robbery or rape and limited power to negotiate safe sex with paying customers, though some countries, such as Thailand, have sought to empower sex workers to demand condom use (UNAIDS, UNFPA, & UNIFEM, 2004).

Poor states, as well as poor individuals, are vulnerable to the ravages of disease. Consider the cases of many southern African states: HIV prevalence among adults ages 15–49 is about 25% in Botswana, 23% in Lesotho, and 13% in Zimbabwe (Lesotho, 2012; Republic of Botswana, 2012; Zimbabwe, 2012). The high rates of infection and death among young and middle-aged adults also mean that countries are left with diminished workforces. Without productive citizens, the state of a country’s economy declines, further reducing the resources that might be put into HIV/AIDS prevention or treatment. Even those who are training the next generation of workers have been hard-hit by the disease: In Zambia, the number of teachers dying of AIDS outpaces the number graduating as teachers (Oyoo, 2003). While HIV/AIDS is far from limited to poor victims or poor countries, poverty clearly increases the risk of disease at both the individual and the national level.

Violence and HIV/AIDS

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Women’s risk of contracting HIV/AIDS is increased by situations of domestic violence. Data gathered by the United Nations suggest that up to half the women in the world may experience violence from a domestic partner at some point; this includes forced sex, which is not likely to take place with a condom (UNAIDS et al., 2004).

The rape of men by other males, not uncommon in prison settings, can also be implicated in the spread of the infection. In many countries, the incidence of HIV/AIDS in prisons is significantly higher than the incidence of the disease in the noninstitutionalized population. Part of this phenomenon is linked to the sharing of needles among drug-injecting prisoners or to consensual male sexual activity, but part is also linked to the underreported sexual violence behind bars.

Much progress has been made in developing medicine that helps keep HIV/AIDS under control and maintains one’s quality of life, and even better advancements have been made in prevention, awareness, and education on how to avoid contracting HIV. Nevertheless, it continues to be a global epidemic that claims millions of lives. In this photo, a woman infected with HIV who has been ostracized from her village sits outside her small hut.

HIV/AIDS in Poor Countries

Healthcare for Sexworkers

HIV/AIDS is a medical issue. It is also a sociological issue. Vulnerability to infection is compounded by factors such as gender stereotypes and poverty. At a time when hope of new treatments and prevention strategies has materialized but the pandemic continues to ravage communities and countries, a sociological perspective can help us to identify the social roots of HIV/AIDS and to seek the most fruitful paths for combating its spread.

Global Issues in Health and Medicine

Ever since human beings first began to migrate from their African origins, taking their illnesses with them, the spread of disease has known no global boundaries. Plagues and epidemics have traveled from populations that have developed some degree of biological immunity to others that have not. During the 14th century, the bubonic plague, known as the Black Death, arrived in Europe by way of Asia and eliminated a third of the European population in only 20 years. The European conquerors of the Americas brought syphilis and other diseases with them that virtually eliminated the indigenous population in many areas (Thornton, 1987).

U.S. soldiers returning from Europe at the end of World War I carried previously unknown influenza strains that killed an estimated 20 million people worldwide. Today, tuberculosis, once all but eliminated from the industrialized nations, is making a comeback, with new treatment-resistant strains brought by immigrants from poor nations.

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In 2010, the United States publicly apologized to the nation of Guatemala when it was discovered that in the 1940s, U.S. government researchers deliberately infected hundreds of Guatemalan mental patients with gonorrhea and syphilis for observational purposes and encouraged them to transfer their infections to others (Bazell, 2010). Such unethical experiments endanger larger populations by introducing diseases that can erupt in outbreaks.

Global Disparities in Heart Health

Overall, however, the 20th century witnessed a striking global triumph over many diseases, as sanitation, clean water, sewage systems, knowledge about the importance of diet, and other public health and medical practices and treatments spread throughout the world. For example, in only a few years, the WHO’s plan for “Health for All by the Year 2000” succeeded in immunizing half the world’s children against measles, polio, and four other diseases (Steinbrook, 1988). Successes have continued into the 21st century. In 2004, the Bill and Melinda Gates Foundation, working with the Global Alliance for Vaccines and Immunization, was able to vaccinate an estimated 78% of children in the world against diphtheria, tetanus, and whooping cough (Bill and Melinda Gates Foundation, 2006). Today, the Bill and Melinda Gates Foundation (2013) reports that it is 99% of the way toward eradicating polio and that a new vaccine will save the lives of an additional 400,000 children per year on a global scale. Successes such as these have produced a sharp decline in death rates in most of the world’s countries (Andre et al., 2008).

The AIDS epidemic is the most recent example of the global spread of a fatal disease. What makes it unique is the rapidity with which it spread around the world, to industrialized and less developed nations alike. HIV/AIDS is also a global issue in terms of treatment and prevention. Globalization is both functional and dysfunctional for real and potential victims of the infection. On one hand, HIV/AIDS was global in its path of spread, and it appears likely that its defeat will also be global, as it was for other once-deadly and widespread diseases such as smallpox, polio, and malaria (Steinbrook, 1988). There is a concerted global effort to combat the disease. Doctors across the globe work together to share information and knowledge on HIV/AIDS and their efforts to stop it. International organizations including the United Nations are also instrumental in leading information and empowerment campaigns.

On the other hand, globalization has thrown obstacles in the path of those who seek to expand the reach of therapeutic drugs that lengthen health and life for those with the infection. The global market in HIV/AIDS treatment has been dominated by Western pharmaceutical companies, most of which have jealously guarded their patent rights on the drug therapies shown to be most effective for treatment. Their fierce desire to protect patents and profits has made it more difficult for drug makers in developing states to manufacture less expensive generic versions that could save more lives in poor countries.

Together with HIV/AIDS, one of the most threatening diseases in developing countries is malaria: According to some estimates, malaria is a threat to no less than half the global population. It kills more than 800,000 people every year. The most vulnerable populations are children and pregnant women in Africa, which has the most malaria deaths (CDC, 2012b).

The toll taken by malaria is felt at the individual, community, and national levels. For individual families, malaria is costly in terms of drugs, travel to clinics, lost time at work or school, and burial, among other expenses. For governments, malaria means the potential loss of tourism and productive members of society and the cost of public health interventions, including treatments and mosquito nets, which many individuals are unable to pay for themselves (CDC, 2012b). Malaria, together with HIV/AIDS and tuberculosis, has attracted a substantial proportion of available funding from international and national donors and governments seeking to improve the health of populations in the developing world.

Critics of international health spending priorities point to a growing threat in the developing world that has not received substantial funding or attention: chronic disease. Heart disease, stroke, and cancer have long been chronic maladies associated with the habits of the populations of developed countries, such as overeating, lack of exercise, and smoking. One scientist notes that while 80% of global deaths from chronic diseases take place in low- and middle-income countries, those illnesses receive the smallest fraction of donor assistance for health. Of the nearly $26 billion allocated for health in 2009, just 1% targeted chronic disease (Lomborg, 2012).

Chronic disease, however, is a growing threat in the developing world, driven by a dramatic rise in both obesity and

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smoking. According to the World Health Organization, global obesity rates doubled between 1980 and 2008. The WHO estimates that about half the adult populations of Brazil, Russia, and South Africa are overweight. In Africa, around 8% of adults are obese. While these figures are low compared to those in the United States, where two thirds of adults are estimated to be overweight and one third are obese, the numbers are rising. A variety of factors contribute to this phenomenon, including growing incomes in many parts of the developing world, which enable more consumption, economic changes that shift work from physical labor to indoor and sedentary labor, and the movement of fast-food restaurants into new regions where people can now afford to splurge on burgers and soda (Kenny, 2012).

While smoking has decreased in many developed countries in recent decades, it has grown dramatically in some parts of the developing world. Today, about 80% of smokers live in the developing world (Qian et al., 2010). By some estimates, China has 350 million smokers (which is more people than live in the United States), and about 60% of Chinese men smoke. Tobacco use has grown fourfold in China since the 1970s and has become a key component of the nation’s growing prosperity. Cigarettes, and particularly expensive brands of cigarettes, are given as gifts to friends and family; red cigarettes are special presents for weddings, bringing “double happiness.” China also has its own tobacco manufacturing industry, which is run by the government. This creates a conflict of interest, since the same entity that regulates tobacco and might be interested in promoting better public health is profiting from the large number of tobacco users (PBS, 2010). Since 2001, when China joined the World Trade Organization and its markets opened to new goods, Western cigarette makers have also been aggressively marketing their products there, targeting relatively untapped consumer categories such as women, who are otherwise less likely than men to smoke (Qian et al., 2010).

Growing income and improvements in the standards of living in developing countries represent important changes. For the most part, these changes are positive and include growing opportunities for education, health care, and access to technology, among others. At the same time, the chronic diseases long associated with the developed world threaten populations in new ways. Whether and how the international community, national governments, and local institutions react to these problems today will have an enormous impact on the health of populations in the decades to come.

Why Should Sociologists Study Health?

Even as our medical and technological knowledge grows, threats to the goal of a healthy society and world continue to expand. In a globalizing world, no one is isolated from diseases spawned in distant places; we are all part of the same community, linked by communications, travel, and commerce. Neither are we isolated from the far-reaching consequences of health dangers that threaten to destabilize regions far from our own. In a world where the very poor exist together with the very wealthy and billions are seeking to scramble up the ladder of prosperity, the acute illnesses of poverty can be found alongside the chronic maladies of affluence. Sociology offers us the tools to examine the sociological antecedents of a spectrum of public health problems.

By using a sociological perspective, we can recognize the ways that medical issues such as HIV/AIDS intersect with social phenomena such as gender inequality, gender stereotypes, violence, and poverty. We can examine the global obesity epidemic through new eyes when we see that individuals’ choices about food and fitness are made in social and economic environments that profoundly affect those choices. While medicine and technology clearly have an enormous amount to contribute to reducing the consequences of serious health issues, including HIV/AIDS, obesity, and tobacco-related illnesses, sociology too has a role to play in discovering the social roots of and imagining creative, constructive responses to health problems that threaten many lives and livelihoods.

The Most Dangerous Idea in Mental Health

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