社会医学基本理论双语.pptx

Chapter 3:Principal Theories of Social MedicineHuazhong University of Science and TechnologyTongji Medical CollegeFaculty of Social MedicineContentsprefaceDefiningHealthandMedicineSociologicalPerspectivesonHealthandMedicineSocialCapitalandHealthPart 1 PrefaceSection 1.1 A Story of Social MedicineSeventeen-year-oldJimDavis(apseudonym)wascheckedintothe rehab centertwodaysagebythisparents.Today,heiscurledintoa fetal positiononthebedinhisroom,hisbodyconvulsing.Periodically,hegetsupscreamingandtearsthesheetsoffhisbedorthrowsachairagainstthewall.Jimisgoing through withdrawal,butfromwhat?Isheaddictedtoheroin,perhaps,orcocaine,alcohol,orevennicotine?No,JimspsychologistexplainsthatJimisan Internet addict.Ahighschoolseniorand,untilrecently,honorsstudent,Jimspendsmorethansixhoursadayon-line.Hequitlong-distance runningandwithdrewfromotherextracurricular activitiestohavemoretimefortheInternet.Thenhebeganskipping classesandcallinginsicktohispart-time employer.Hisparentsinsistedthathecutdownhistimeon-line,butJimcouldntseemtodoit.WhentheyremovedJimscomputerfromhisroom,heatfirstbecomedepressed,butthenhewentintoarage,threateningtokillhimselfifhisparentsdidnotreturnhiscomputer.Thisswhenthedecidedtoseekprofessionalhelp,whicheventuallyledtoJimsadmissiontoarehabilitation centerthatusuallytreatsdrugandalcoholabusers.CliniciansreportthattheyareseeinganincreasingnumberofpeoplewithInternet addiction,acompulsivedisordersimilartouncontrollablegambling,binge eating,anddrug and alcohol abuse.Butsociologistsseethesereportasthelatestexampleofmedicalization,the process of defining a behavior or condition as an illness in need of medical treatment.Sociologistsbelievethatillness is not simply a biological or physiological condition.Rather,illness is socially constructed.Whatgetsdefinedasillnesshasasmuchtodowithasocietyscultureaswithobjectivesymptoms.Section 1.2 Relations of Concept and TheoryThestructureofatheory:concept,variable,proposition,hypothesis.ConceptAbstractofphenomenaRelationsofconceptandtheory:concept is a section of theory;a theory is made up of a group of logic-related concepts.VariableConceptwithmulti-dimension.PropositionAstatementaboutthecharacteristicofaconceptortherelationsofagroupofconcepts.Categoriesofproposition:axiom,law,hypothesis.HypothesisA tentative statement about the relationship ofrelated-variable.Part 2 Defining Health and MedicineSection 2.1 What is health?Somepeopledefinehealthassimplytheabsenceofillness,butthisvaguedefinitionraisesmorequestionsthanthisanswers.Forexample,whenshouldweconsiderapersonisillwhenthatpersonisunabletoperformnormalsocialroles?Ontheonehand,anindividualsassessmentcanbeproblematicbecauseresearchshowsthatwhilemostpeopleconsidertheirverygoodorexcellent,onlyasmallpercentageiscompletelyfreeofphysicalailmentsatanygiventime(U.S.Departmentofhealthandhumanservices,1996).Ontheotherhand,ifwedefinehealthsolelyintermsoftheabsenceofdisabilityorincapacitation,weoverlookthethousandsofpeoplewhoareillbutwhocontinuetocarryouttheirdailyactivitiesforavarietyofreasons,suchaseconomicnecessary.Astheseexamplesillustrate,health is multidimensional.Inadditiontoaphysiologicaldimension,healthalsohaspsychologicalandsocialdimensions.Consequently,wehaveadoptedtheWorldHealthOrganizationsdefinitionofhealthasa state of physical,mental,and social well-being.Thisdefinitionmakesthepointthatwecannotconsiderapersonhealthyifsheorheisemotionallydistressedorlivinginahazardousenvironment,evenifthepersonisfreeofphysicalillness.Section 2.2 Health and SocietyStandardsofhealthvarycross-culturally.StandardsofhealthvaryovertimeStandardsofhealthreflectthedominantvaluesandnormsofasocietyHealthisaffectedbyasocietyslevelofeconomicdevelopment.Standards of health vary cross-culturallyWhatisconsideredhealthyorwholesomeinonesocietymayberegardedasunhealthyorharmfulinanother.Forinstance,physicalconditionsthatwouldbediagnosedasseriousskindiseasesbyU.S.physiciansarenotconsideredevensymptomsofillnessbytheKubaofSumatra.Definitionsofhealthandillnessmayalsobemanipulatedforpoliticalreasons.Forexample,inJapan,wherethenationalgovernmentownsthecountryslargestcigarettesmanufacturingcompany,anymedicalreportsthatwarnofthehealthhazardsofsmokingmustalsoincludeclaimsaboutcigarettesbenefits,suchashowsmokingcigarettescontributestocreativity.Standards of health vary over timeLittlemorethanacenturyago,physiciansbelievedthathysteriawascausedbytheuterusbreakingfreeandmovingthroughthebody.Thus,bydefinition,allhystericswerewomen,andthe“cure”wasremovaloftheuterus(hysterectomy).Hysteria,whichistodaycalledhistrionic personality,isstillamedicallyrecognizeddisorder,butitisnotthoughttohaveaphysicalcause,norisitonlydiagnosedinwomen;25to50percentofindividualswithhistrionicpersonalityaremen.Standards of health reflect the dominant values and norms of a societyConsiderthatintheUnitedStates,whereindividualismishighlyprized,somepeopledevelopaphobiaofbeing embarrassed,whereasinJapan,wheregroup welfareisvaluedovertheindividual,somepeopledevelopafearthattheymightembarrass others.Healthstandardsmayalsobeusedtoenforcenorms.InmanyWestAfricancountries,forexample,youngwomenareexpectedtobevirginswhentheymarry.Toguaranteemarriageability,parentsusuallyhavetheirdaughters“circumcised”(theirexternalgenitalsareremovedandthevaginaissewnclosedexceptforasmallopeningtoallowthepassageofmenstrualblood),eventhoughtheprocedureoftenresultsincomplications,includingshock,hemorrhage,and tetanus.Inthiscountries,thecircumcisionservesasameansofsocialcontroltoensureyoungwomensconformitytotheirsocietyssexuality norms.Health is affected by a societys level of economic development.Economicallyundevelopedsocietieshavehighratesofillnessandhealth,especiallyfrompreventable infectious diseases.Asasocietydevelops,deathfrominfectious diseasesdeclinesdramatically,sothatindustrialized societiesenjoythehigheststandardsofhealth.Thisdoesnotmeanthatindustrializedsocietiesareillness-free,however.Infectious diseasesmaybeundercontrol,butindustrializationgeneratesotherhealthproblems.Onlyinindustrializedsocieties,forexample,doworkerscontractlife-threatening illnessesbecauseofoccupational exposuretocotton fibers,coal dust,asbestos,mercury,andnumerouschemicals.Section 2.3 What is medicine?Medicineisthe social institution established to identify and treat illness and promote health.Goals of medicine:prevention of disease,relief of suffering,care of the illandavoidance of premature death.Section 2.4 Medicine and SocietyJustashealthreflectsthecultureandstructureofasociety,sodoesmedicine.Weusuallythinkofmedicineafterthefactthatisoncewehavegottensick,werelyonmedicinetomakeusbetter.Thiskindofmedicine,curative medicine,focuses on treating people who are already ill.Incontrast,preventivemedicineseekstoestablish conditions that keep illness from occurring.IntheUnitedStates,preventive medicinehasbeengettingmoreattentioninrecentyears.Weareallfamilywiththecurrentcampaignstoquitsmokingand“eat heart healthy”.Butforthemostpart,medicineinUnitedStateshastraditionallyemphasizedcure than prevention,anemphasisthatfollowslogicallyfromoursocietysvaluesofindividualismandfreeenterprise.Theindividualissupposedtodeterminehisorherownhealthneeds,findasourceofhealthcare,andpayforthatcareprivately.Part 3 Sociological Perspectives on Health and MedicineTheStructuralFunctionalistPerspectiveEvaluatingtheStructuralFunctionalistPerspectiveTheSymbolicInteractionistPerspectiveEvaluatingtheSymbolicInteractionistPerspectiveSection 3.1 The structural functionalist perspectiveThestructural functionalist perspectiveonhealthandmedicinewasformulatedlargelybyTalcottParsons(1951).AccordingtoParsons,ahealthypopulationisessentialtosociety.Healthpeoplecanperformthesocial rolesnecessarytokeepsociety functioningoptimally.Illness,then,isdysfunctionalbecauseitpreventspeoplefromperformingtheirsocialroles,atleasttemporarily.Thus,thesocialinstitutionofmedicineplaysa vital roleintheoverallfunctioningofmedicinebymakingmembershealthy.Ofcourse,everyonegetssicksometimesandwhentheydo,Parsonsargued,theyfollowa socially prescribed role.Physiciansalsohavespecificrole expectations.Section 3.1.1 The Sick RoleParsonsidentifiedfourcharacteristicsofthesick role,thebehaviorsdefinedbyasocietyasappropriateforpeoplewhoaresick.First,sick people are excused from their usual responsibilities,such as attending class or working.However,whilesayingyouresickmightinitiallyevokesympathy,youwontbeexcusedfromyourobligationsforlongunlessyourillnessisverifiedbyarecognizedexpert,suchastheschoolhealthserviceoryourphysician.Second,sick individuals are considered“worthy”of others sympathy only if they did nothing to precipitate their illness.Consider,forexample,therecentlawsuitsbroughtagainstthetobacco industrybysmokerswithseriousillnesses.Jurieshavebeenreluctanttoawarddamagesbecausetheplaintiffsknewsmokingwasharmfultotheirhealth,butkeptdoingitanyway.Third,the sick person must display a sincere desire to be well.Someonewhoclaimstobeilltoavoidwork,getoutofasociologyexam,orbepamperedbyothersisnotconsideredlegitimatelysickbysociety.Finally,the sick person must do everything possible to get well.Ifthesickpersonmakesnoattempttogetmedicalhelporignores“doctors orders,”heorsherelinquisheslegitimateclaimtothesickrole.Thehelp-seeking elementofthesick rolereadsustoconsiderthe role of help provider,thephysician.Section 3.1.2 The Physicians RoleAccordingtoParsons,the physicians rolehastwocomponents.Oneistoevaluate peoples claimsofillness,assessingwhethertheyarereallysickand,ifso,determining the cause of their ailment.Thesecondcomponentofthephysicianssroleistocure the sicksotheycancarryouttheirnormalsocialroles.Section 3.1.3 The relationship between the physicians role and the sick rolethephysiciansroleandthesickroleareinterdependent.First,patientsmustsupplytheirmedicalhistoryandsymptomsinorder forthephysiciantofulfillthefirstcomponentofhisorherrole.Then,tofulfillthesecondcomponents,thephysiciandepends onthepatienttofollowinstructions.Despitethisinterdependence,thespecializedknowledgeofthephysicianmakesthephysician-patient relationship unequal.Thelevelofinequalityvariescross-culturally,butthephysicianalwayshastheuppershandintherelationship.Parsonsdidnotviewpatient-physicianinequalitynegatively,though.Thephysiciansimplyknowswhatisnecessaryforapersontogetbetter,sothepatientshoulddefertohimorher.Section 3.2 Evaluating the Structural Functionalist PerspectiveParsonssanalysisofthe sick roleshowshowsocial normsimpingeonbothhealthandillness.Parsonsalsocorrectlydepictsthe physicianasthegatekeepertothesick role.Butparsonssideashavealsobeencriticized.Some,forexample,saythatParsonssconceptofthesick roleimpliesthatapersonasonlytemporarilyillandcanberestoredtonormalfunctioning relativelyquickly.Thisistrueifthepersonissufferingfromanacute illness,which,thoughoftenserious,iscurable.Butchronic illnessprolongedillnessthatmaybecontrolled,butnotcuredispermanentlyincapacitatingandpreventsapersonfromeverresumingnormalsocial roles.Parsonsisalsocriticizedforputtingtoomuchemphasisonindividual responsibilitywhiledownplayingthesocial structural factorsthatcanaffecthealth.Forinstance,Parsonssclaimthatpeoplewhocontributetotheirownafflictionhavenolegitimateclaimto the sick roleoverlooksthefactthatsocial structural factorsalsoshapepeoplesbehavioralchoices.Advertising,forexample,promotesagreatdealofunhealthybehavior,includingsmokingandalcoholconsumptionFinally,Parsonshasbeencriticizedforignoringthenegativeconsequencesofsocial inequalityforhealthandmedicine.Sickpeoplemaywishtogetwell,forexample,buttheiraccesstomedicalcaremaybelimitedbytheirfinancial status.Section 3.3 The symbolic interactionist perspectiveSymbolicinteractionistsareprimarilyconcernedwiththemeaningspeoplegivetotheirsocial interactions,sotheyfocus on how health and medicinearesociallyconstructed.Quiteapartfromobjectivesymptoms,healthandillnessaresociallydefinedbythemembersofasociety.InLithuania,forexample,thereareaboutasmanyrear-end car collisionsasinNorwayandtheUnitedStates,butLithuanianeverreportthelingering neck pain,calledwhiplash,commonlyreportedbyNorwegianandAmericanaccidentvictims.Lithuaniansdonthavestrongerneckmusclesandtheircarsarentsafer,sowhydonttheygetwhiplash?Researchersbelievetheanswerliesinhowthesituationsaresociallydefined.InLithuania,peoplearenotaccustomedtosuingoneanotherforanyreason,letaloneaccidentliability.Lithuaniansdonothavepersonal injury insurance;iftheyareinjuredinanaccident,thegovernmentspublic health insuranceprogrampaysthemedicalbills.Whenarear-endcollisionoccurs,theydefineitasamajorinconvenience,not becausetheywillmissworkbecauseofneckpain,but becauseitissodifficulttogetsparecarpatsinLithuania.Incontrast,inNorway,whichhasthehighestnumberofwhiplashcasesintheworld,thereismuchtobegainedfromdefiningarear-end collisionasaninjury-producingeventbecauseinsurance companiesgenerouslycompensateindividualsforchronic disabilitycausedasinjurysuitsarecommonplace,rear-endcollisionsaredefinedasinjurieshealontheirownwithinafewdaysorweeksandrequirelittleornotreatment.ThisisnottosaythataccidentvictimsinLithuanianeverexperienceneckpain,orthatpeopleonNorwayandtheUnitedStatesonlypretendtobeinpain.Rather,accordingtosymbolic interactionists,thesocial expectationsthatindividualsattachtoaneventshapehowtheyexperienceitandthemeaningstheygivetotheexperience.Symbolic interactionists are also interested in how medical treatment is social constructed.Thinkaboutyourmostrecentvisittoaphysicians office.Afterbeingseatedinthewaiting area,youwereprobablyescortedtoanexamining roombyanurse,whotooksomebasicmedicalinformation(yourweight,temperature,andbloodpressure).Oncethenursefinished,youarelefttowaitforthedoctor.Thedoctorwasntdifficulttorecognizesincesheorhehadseveralpropsthatdesignatedthestatusdoctor.Forexample,thedoctorprobablyworea white lab coatwithastethoscopeprotrudingfromthepocket.Thetwoofyoumayhaveinitiallyexchangedsmalltalk,buttheconversationwaslikelylimited toyouansweringthedoctorsquestions.Althoughthedoctormayhaveaddressedyoubyyourfirstname,youinvariablyusedthetitle“doctor”whenaddressingherorhim.Thedoctoralsoprobablyusedaspecialized vocabulary,referringtoyoursore throatas“pharyngitis”oryourswollen pinky fingerasyour“fifth digit”Each elementoftheinteraction,includingthepropsandthelanguage,contributetothesocial constructionofthestatusesphysicianandpatientandthephysician-patient relationship.Therelationshipitselfisclearlyhierarchal,withthedoctorassumingtheroleofauthority.Section 3.4 Evaluating the Symbolic Interactionist PerspectiveThesymbolicinteractionistperspectiveisvaluableforemphasizingthesocial natureofhealthandmedicine,whichwetypicallythinkofonlyinbiologicalterms.Infact,thedefinitionspeopleattachtoparticularbehaviorsorconditionslabelingthemhealthyorunhealthy,wellorsickoftenderiveasmuchfromnonmedical factorsasfrommedical onesNevertheless,thesymbolicinteractionistperspectivehasbeencriticizedfordownplayingtheobjective realityofhealthandillness.Afterall,peopledogetsickandsufferdebilitatingphysicalillness,regardlessofwhethertheyareprofessionallydiagnosedorsociallylabeledsick.Illnesscanalsoexitindependentofs