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Chapter 1-4

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Health Studies
HLST 1010
Dennis Raphael

Chapter 1 Epidemiological Approaches to Population Health  Epidemiology- study of health and its determinants in specified populations with the often unstated goal of improving health o Epidemiologists conduct studies and report results  John Snow- association between deaths in various districts and the sources of drinking water o If we wish to produce health, we can do so without understanding all the links between causes and outcomes of disease  The logic of doing what is best for our component parts- our cells- and generalizing this prescription to the community of cells that comprise a human being may not be the best health advice for us  Japanese smoke most but lead the world in good health  Compared to other factors that affect a population, the effect of smoking may be secondary  Epidemiologists study the incidence and prevalence of diseases such as heart disease, lung cancer, and Alzheimer’s and attempt to identify the precipitating factors that lead to these afflictions  In discussion of disease we have to go to the source of the problem  Disease-focused approach- knowing whether or not someone has the disease, and then obtain a variety of supplemental information to determine what is going on  Development of powerful computers allows analysis of complicated studies of individual diseases  You have to control for socioeconomic status in a study, or you won’t find an effect  Defining a disease can also be political (ex. Homosexuality is considered a disease in some places and not in other places)  WHO definition of health- state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity  Self-assessed health (SAH)- asking people how healthy they consider themselves  For a population, consider life expectancy or infant mortality rate (IMR)  If a country’s IMR is increasing, it signifies political instability  Tiny differences in life expectancies can translate to huge disparities in deaths  There has been a profound deterioration of health in health in the US compared to other countries  US life expectancy is 4.5 years less than Japan  Epidemiologists can also collect other data such as measures of health care, air pollution, smoking rates, economic growth, dietary habits, education, etc., to see if there is some association between those data and our measure of health  Richard Wilkinson- the gap between the rich and poor in a country appears to be correlated with the population’s health  For a finding to be causative, there must be a dose-response relationship (more of one should produce more of the other) o There has to be some pathologic mechanism through which the effect could occur  The gap between the rich and poor in society represents how much the society cares for and shares with its members  Debate as to whether materialist or the psychosocial issues of relative poverty or deprivation predominate  Universal access to health care is not very important for producing health in a society  Biological plausibility for the pathological mechanisms relating to inequality is present  Whereas health care definitely helps some, it harms others, and for populations, whenever it has been studied, there appears to be little or no net benefit  Most commonly used measure of inequality is that of income differences  The relationship between income distribution and health among Canadian provinces is less pronounced than the situation among the US  The geographical level at which income distribution is measured affects the health outcome  In Nepal, the highest infant mortality rate is found in districts with the most egalitarian structure, where everyone is uniformly poor and starving  What produces health in a population? o Provisions of basic needs (food, water, shelter, security) o Provision of caring and sharing, especially in early life (distribution of wealth, resources, income, political power, status of women) o Access to basic health care services o Cultural elements of reciprocity, social harmony, and vigilant sharing o Focus on early life  Early life o By age two or three, research shows that as much as half of our health as adults is already programmed o Cohort study- following a group of people from before they were born until they die  Challenges: the need to follow people for longer than the lifespan of the investigator and huge costs o David Barker- significant stress during pregnancy can be linked to worse health later in a child’s life o Denmark- the only more egalitarian and rich country that has health outcomes comparable to the US, that people die younger  Women’s mortality increased as a result of unemployment  Women also started smoking due to this high stress  The impact of the family situation on the children born to these women was part of the lack of health improvement during that period  Biology of inequality o Early environment matters tremendously in producing the health of offspring o Stress during pregnancy affects the health of children and adults o Those lower in socioeconomic position in society have worse health outcomes that are independent of the effects of personal behaviours o Cortisol and adrenaline may be maladaptive and have lasting repercussions on the ability to mount a swift survival response when it is needed o Those with lower SES are affected more by chronic stress (obesity, adult-onset diabetes, and cardiovascular disease) o Early life circumstances and both biological programming and embedding are heritable o Epigenetic mechanism- heritable changes that are not due to alterations in the DNA, can transmit biology intergenerationally without being genetic o Psychosocial and other mechanisms that result from living in unequal societies have profound biological effects on our health  Methods used in epidemiology o Observational ecological studies o Cohort studies o Cross-sectional study o Multi-level modelling  Agriculture o Domestication of plants and animals resulted in declined human health o With the development of agriculture, a food surplus could be produced, allowing for inequality o Living in close proximity to domestic animals resulted in many infectious organisms changing hosts to produce human disease  Japan at the end of WWII o Japan became the healthiest country in the world in part because of economic policies resulting from the US occupation of the country at the end of WWII o Demilitarization- forbidden to have an army, resolve disputes peacefully o Democratization o Decentralization- concentration of wealth and power that existed in pre-war Japan was broken up  As the gap between the rich and poor grew, health in Russia declined  Canada is considerably healthier than the US, but it is less wealthy and spends less on medical care  Canada remained one of the world’s healthiest nations until this century when eroding government policies began to favour the rich  Health care and the public’s health o Medical care is always one of the leading causes of death  Shared political power, less income inequality, strong environmental regulations, and a better quality of environment are associated with better health outcomes Chapter 2 Sociological Perspectives on Health and Health Care  Sociology- study of human society (social structures and institutions, social relations and experiences) and the interaction of these elements  Sociology IN medicine- applying sociological theory or concepts toward a better understanding of health-related problems or creation of more informed public health policy  Sociology OF medicine- better understanding of society or sociological concepts through the lens of health problems, medical settings, or the organization of health care  Structural functionalism o Focuses on interrelationships between individuals and groups within society and the way in which it is structured to function in order to maintain the society as a whole o A.R. Radcliffe-Brown- the elements of society have indispensable functions for one another such that the continued existence of the one element is dependent on that of the others and on society as a whole o Parsons- illness as a state of disturbance in the normal functioning of the total human individual, including both the state of the organism as a biological system and of his personal and social adjustments o The role of a sick person in society is biologically and socially defined as deviant o The sick role  Exemption from normal social role responsibilities  Exemption from responsibility for his/her illness  Person has the obligation to want to get well and return to a normal social role  Obligation to seek technically competent help and comply with treatment regimens o Provider’s role is to legitimate the condition, treat the condition, and make the person well again o In order to do so, physicians are granted privileged and penetrating access to patients’ bodies and their private lives o Criticism- masks the variability in the temporary or legitimate nature of different illnesses, and the diversity in the actual behaviour of sick individuals and of their providers o Szasz and Hollender- elaborated different doctor-patient models arising from different types of illnesses  Patient passivity and physician assertiveness as the most common reaction to acute illness  Physician guidance and patient co-operation where a less acute illness was involved  Physicians providing advice on a treatment plan that patients had most of the responsibility to implement, most relevant for chronic illnesses and certain forms of disability  Symbolic interactionism o Focus is not on social institutions but on interacting individuals and the meanings they create o Key principles  Humans act towards things on the basis of meanings that things have for them  These meanings arise out of social interaction  Social action results from a fitting together of individual lines of action o Focus on less objective, macro-structural aspects of social systems than they do on the subjective aspects of social life and people as pragmatic actors o Goffman- three main forms of stigma:  Abominations of the body in the form of physical deformities  Blemishes of character in the form of socially deviant behaviour  Groups with minority status in society o Labeling theory (Goffman)- the impact of labeling a person as ill or deviant means that others will respond to him/her in accordance with that label, which is very difficult to shed o Illness career (Hughes)- illness experience in terms of the work that needed to be accomplished both with respect to one’s illness and everyday life o Medical students come to take on a cloak of competence as a form of impression management to convince others and themselves that they are sufficiently competent and confident to face the immense responsibilities of their privileged role  Social constructionism o Berger and Luckmann- everyday knowledge is creatively produced by individuals and is oriented toward particular practical problems o Facts are created by way of social interactions and people’s interpretations of these interactions o All medical facts are argued to be socially created products o Medical knowledge is depicted as mediating social relations such that disease categories reinforce existing social structures (medicine as an institution of social control) o Medicalization- process where a cluster of symptoms/life events/deviant behaviour comes to be medically defined as a disease o Conrad and Schneider- three levels by which medicalization occurs:  Conceptual level- medical vocabulary used to define a problem  Institutional level- medical personnel supervise treatment organizations or otherwise act as gatekeepers to state benefits  Interactional level- physicians treat patients’ difficulties as medical problems o Medicalization of deviance  Behaviour first defined as deviant  Prospecting- discovery of a medical conception of the disease/deviant behaviour first announced in a medical journal  Claims-making- promote the new medical designation  Legitimacy- appeal to the state for recognition of the medical designation  Institutionalization- official medical and/or legal classification system and in the establishment of treatment organizations  Materialism (conflict theory) o Society is based not on consensus but conflict o Karl Marx- society is structured into two key social strata: those who own the means of production (capitalist class) and those who do not (proletariat) o Social production of disease hypothesis (Vicente Navarro)- capitalist mode of production actually produces disease o Morbidity and mortality are higher among individuals doing routine types of work requiring low levels of skills than among individuals working in jobs that demand a large number of skills and which allow for some type of control over one’s own work o The driving down of wages and general economic inequality have also been known to influence health o Explanation of social class differences in health status  Measurement artifact- relationship between social class and health are inherent in the measures, this problem may result in an understating of class differences in health rather than an overstatement  Social selection- health affects social mobility and therefore social class, so that those less healthy are less likely to achieve higher levels of social class  Cultural/behavioural- gradients in health status are the result of social class differences in behaviours  Materialist- class differences in health are the result of social structural differences between the classes and the competitive character of capitalism o The power of the medical profession is derivative of the dialectical relationship between capital and medicine specifically in terms of the congruence between the ideology of Western biomedicine and the logic of capitalism  Feminism o Concerned with gender inequalities arising from the system of patriarchy o Society is inherently gendered such that men and women have fundamentally different experiences and access to power, and that these differences are not natural but socially constructed o Criticize the key theoretical perspectives outlined above for failing to adequately represent or otherwise take into consideration women’s perspectives o Institutional ethnography (Dorothy Smith)- a way to examine the link between the lived experience and the relations of ruling not afforded in theoretical perspectives previously discussed o Example: we treat childbirth not as a natural event of great significance, but as an illness o Medicalization of menopause- invention of estrogen-replacement therapy o Four themes in medical definitions of menopause  Women’s potential and function are biologically destined  Women’s worth is determined by fecundity (fertility) and attractiveness  Rejection of the feminine role will bring physical and emotional havoc  Aging women are useless and repulsive o One of the most notable features of the health care division of labour is its segregation by gender- both within and among professions- assigning a secondary status to women o Caring dilemma (Susan Reverby)- imposition upon nurses of a duty to care in a society that devalues the care that they provide both socially and financially  Caring is considered to be a natural extension of women’s roles as wives and mothers and not an esoteric skill worthy of professional status o Limitations- neglects the particular concerns of working-class women and women of colour  Anti-racism o Particular structural determinants of racism within society o The term “racialized” is used to signal that race is a historically and socially constructed category of differentiation and not in any way a natural one o Racializing groups often results in unequal treatment  Post-colonialism o Broader global and historical relations between societies that have been colonized and the colonizer o Sizable majority of colonized societies are also societies of peoples disproportionately of colour o Example- First Nations people in Canada and the decimation of their traditional health practices and systems of care following European contact o Causes of death and illness for First Nations people reflect those associated with poverty and inadequate standards of living, but systemic and structured racism is the ultimate cause of these social and economic circumstances o Establishment of health care systems modelled after the colonizing countries o High-income countries benefit from hiring immigrant professional labour both economically and politically  Postmodernism o Argue for the importance of subjectivism and microsociological analysis and consistent with symbolic interactionism and social constructionism, stress cultural relativism and a plurality of viewpoints o Foucault- medicine shifted its view of the body from patients’ descriptions of their maladies toward direct clinical observations and physical examinations or what he referred to as the “clinical gaze” o This gave the physicians considerable power to define health and illness and, by extension, measures of moral regulation and social control o Turner- an adequate medical sociology would require a sociology of the body, since it is only by developing a notion of social embodiment that we can begin adequately to criticise the conventional divisions between mind and body, individual and society  Medical sociology is strongest when it is cognizant of the importance of all levels of analysis Chapter 3 Health and Health Care: A Political Economy Perspective  Focuses on the links between health and the economic, political, and social life of people in different groups, classes, regions, or societies  US, one of the richest nations in the world, has the poorest health records of any of the developed nations  Materialist approach- views ideas and institutions as emerging from how a society organizes production, and uses such concepts as mode of production and class  Neo-liberalism- free enterprise policies produce economic growth, which in turn is the basis for all human well-being o Contrary- evidence indicates that high GNP is not necessarily highly related to well-being o States that we are our own products, what we are is the result of what we have done without constraints o Reality is that those with more money and power are at more of an advantage than those without  Idealism- gives primacy to the roles of ideas in history  Materialism- basic explanatory primacy to the way people live than to the ideas they produce o World shapes ideas more than ideas shape the world 
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