1. MEDICAL CARE: PHYSICAL AND MENTAL ILLNESS Chapter 10

2. The Problem in Sociological Perspective Health care outranks taxes, terrorism, and crime as problems the government needs to address. Consider that in 1960 Americans spent 28 billion dollars on healthcare. Today we spend 2624 billion (and that number continues to grow). Something has to be done to contain costs, but what that should be is the source of much debate.

3. The Problem in Sociological Perspective Industrialization and lifestyle  Let’s first put our medical system in context. We live in a post-industrial economy driven by technology.  Today, many people work sedentary jobs as opposed to engaging in a day of activity on the farm (this was the reality for most people just a century ago). Many people in industrial societies eat a diet rich in fats, sugars and meat. Many foods that people enjoy are processed and unhealthy. People also experience a considerable amount of stress.  The types of illness that people develop today are very different from those of the past. Today heart disease is the # 1 killer, and heart attacks, strokes diabetes, and other chronic diseases are common. In the past people were more likely to die from infectious disease.

4. Iatrogenisis  Iatrogenesis refers to illness caused by medical care staff.  We’ve all heard stories about the man who had the wrong arm or leg amputated, doctors performing surgery on the wrong patient, removing a healthy organ in lieu of the diseased one…..and the list goes on. Every year there are approximately 4,000 wrong-patient or wrong-surgeries in the U.S.  If the number of Americans killed by medical errors became an official classification of death, it would rank as number 6 in the top 10 leading causes of death!

5. What is health anyway?  In some ways what we define as healthy and normal is a social construction. Some think healthy is not being sick, and being able to function on a day to day basis. However the World Health Organization defines health as “a state of complete physical, mental, and social well being.” How many of us fit that definition?

6. The Problem in Sociological Perspective Changing ideas about health and illness The way pregnancy is handled by physicians today highlights the social nature of health and illness (see slide 9) Environment and disease on a global level Medical researchers are investigating how environment affects human disease and how human activities are reshaping the environment Asthma and diesel emissions Malaria, plastic bags and deforestation Lyme disease and climate change Lead and behavioral problems in kids (ADHD) Bisphenol-A (BPA- found in plastic) and cardiovascular disease, diabetes and behavior problems in children

7. The Social Organization of Medicine as a Social Problem An explosion in medical costs  Medical costs continue to soar Reasons for the explosion in costs  Increase in the standard of living, people live longer  Development of expensive technology  Seek out health care after illness arises, rather than investing time and energy in preventive care  Accepted view that medical care is a commodity that should be sold for profit

9. Medicine For Profit Medicine for profit: cesarean delivery  Some physicians are driven by profit Why have cesarean births increased?  Profit  Convenient for doctors  Technology About 1/3 of all children born in the US today are cesarean deliveries compared to only 5% in 1970. Most cesarean deliveries today are medically unnecessary.  A Feminist Controversy  Some argue that cesarean delivery takes power over childbirth away from women and places it in the hands of doctors  Other argue that cesarean delivery can empower women because they have more choice (sometimes)

10. To understand just how much medial costs have soared take a look at this birth certificate from 1962- you can see that to have a baby at that time cost $113! Today an uncomplicated vaginal birth in a hospital costs between $3000 -$7000 and an uncomplicated cesarean will cost approximately $12,000. Note how much a complicated pregnancy/delivery costs in this week’s film Sick Around America.

12. Medicine for Profit Medicine for profit: a two-tier system of medical care  Medicine for profit is also known as a fee-for-service system.  Two-tier system of medical care: one for those who can afford insurance, and another for those who cannot. You can imagine who gets better care.

13. Types of Insurance available in the U.S. 1. Private Insurance Plans  very expensive if you have a low deductible, but often allow full freedom to choose any doctor you wish.  to make these more affordable they are often offered with high deductibles (for example, every year, you pay the first $5000, $7500, or $10,000 before the insurance kicks in). This means that if you are healthy you may never actually use your insurance (it’s also an incentive NOT to go to the doctor unless it’s an emergency)  Private insurers in most states have the right to deny you benefits, so if you have a “preexisting condition” such as diabetes, you will likely be refused coverage (unless you get this insurance through your job). This is one problem that Obama’s health care reform addresses.

14. Types of Insurance Available in the U.S. 2. HMO’s (health maintenance organizations) are private insurers who provide medical care to subscribers for a fixed fee. This makes them less expensive. They tend to focus on disease prevention. HMO’s limit patient choices and in some cases have the right to refuse care altogether. 3. Government Insurance Plans  There are two different government insurance plans:  Medicare, which is part of the social security system. You qualify for this at age 65  Medicaid which helps poor people with special needs (i.e. the blind, disabled, pregnant). In 2005 13% of the population was enrolled in Medicaid.  In all about 27% of the population receives limited medical benefits from the government. Those who rely totally on government programs may find that their coverage falls short of their needs. 1 in 6 Americans (50 million people) has no heath coverage at all.

15. Cross-cultural comparisons of medical systems: how does the U.S. compare? Here are some interesting facts.  In China the government administers health care to everyone. They also have what are known as “barefoot doctors” who travel to remote villages to provide care.  Sweden’s economy is mostly market-based, but they have taken the socialist approach when it comes to health care, meaning they believe health care is a basic right for all citizens. People pay high taxes to fund this system, and physicians are government employees who are paid a salary rather than collecting fees from patients. The level of health in Sweden is high, surpassed only by Japan.

16. Cross-cultural comparisons of medical systems: how does the U.S. compare?  England also has a system of socialized health care in addition to privatized care. Government taxes pay for medical care for all citizens, and physicians divide their time between the national health care system and private practice.  Canada has an excellent health care system. However, physicians can work in private practice if they choose. Critics note that in Canada they use less high-tech medicine and the system can be slow to respond to people’s needs. Sometimes people have to wait months for major surgery. In short Canada does not match the US in providing the most technologically advanced procedures, but it outperforms the US in providing basic care to most of it’s citizens.  Check out this site: http://www.pbs.org/newshour/rundown/2012/10/health-costs- how-the-us-compares-with-other-countries.html for more information on how the U.S compares to other health care systems in the world (we spend the most, per person, by far- but we are not the healthiest!)http://www.pbs.org/newshour/rundown/2012/10/health-costs- how-the-us-compares-with-other-countries.html

17. Physical Illness as a Social Problem Life expectancy and infant mortality  Researchers analyze life expectancy when determining how healthy or ill a society is as a whole.  Infant Mortality Rate (IMR) Number of babies who die before 1 year of age, per 1,000 live births This is the most accurate measure of a group’s health conditions  Countries with less poverty have better health  the U.S. infant mortality rate has dropped significantly over the past century. However, 29,000 infants still die before age 1 in the U.S. Poverty is the biggest reason for this. The figure on the next slide illustrates the “geography” of infant mortality.

18.  On this map we see that those states with the highest poverty rates also have the highest infant mortality rates. People living in poverty experience more stress, they likely don’t eat as well, and they are less likely to receive prenatal care.

19. These statistics are remarkable considering we are a society with supposedly one of the best health care systems in the world.

20. The Importance of Prevention Lifestyle refers to dietary choices, frequency of exercise, stress levels, and whether you smoke or take drugs Two-thirds of Americans are overweight or obese. Obesity is linked to a number of chronic diseases and in many ways is a social class issue.  Poverty and lifestyle often go together, as the poor don’t have the means to buy expensive higher quality food, they experience more stress, are more likely to smoke, and are less likely to have insurance.

21. The importance of prevention Instead of focusing on lifestyle choices the emphasis in our healthcare system is on what is known as heroic medicine. Our medical system, in the pursuit of profit, creates a need for specialists. This emphasis on specialists has led to a shortage of primary care doctors who treat routine problems (these doctors usually earn less). This is problematic, since preventing illness is less costly then treating more serious conditions.

22. Mental Illness as a Social Problem Measuring mental illness  Experts argue that the rates of mental illness have increased because people are experiencing more stress while their social support systems are weaker  Attempts to measure rates of mental illness today are inaccurate  Data are inadequate because experts rarely agree on definitions and classifications of mental illness

23. Mental Illness as a Social Problem The social nature of mental illness  How we define mental illness is a matter of dispute  For example, psychologists say that to be classified as a mental illness a person’s thoughts/behaviors: go against social norms cause significant discomfort are maladaptive pose a danger  However, thoughts and behaviors are often a matter of interpretation, and even though there are specific guidelines, psychiatrists and psychologists may interpret symptoms differently (as may the patient!)

24. Mental Illness: Symbolic Interactionism Determining the meaning of symptoms and behavior  People from different backgrounds interpret symptoms differently For example, some people go the doctor when they get the flu, others wait it out, or try alternative therapies. Some people wait until an absolute emergency to see a doctor. Often this will depend on your social class (and whether or not you have health insurance) One can also think about how our culture encourages us to interpret symptoms, and the desired way to treat ailments (remember our discussion of ADHD?). For example, many go to the doctor seeking a prescription to treat an illness, rather than seeking to understand the reason behind the illness. Making lifestyle changes is often more difficult (and less profitable) than taking a pill.

25. Mental Illness: Symbolic Interactionism The significance of definitions  Different groups compete to get their view of health accepted and these definitions are socially created. For example, alcoholism is now considered a disease.  What about ADHD? As you know this has turned into national epidemic- but according to who?  One’s libido? All you need is a drug to fix that problem!  The LABELS that we put on feelings/behaviors matter because they influence our perceptions of what may otherwise be considered very NORMAL human experiences.

26. Social Inequalities in Mental Illness Social class and mental illness  Sociologists found that people’s emotional well-being declines with decreases in social class.  The poor are more likely to be depressed, anxious, nervous, and phobic There are four explanations for the greater emotional problems of the poor

27. Four explanations for the greater emotional problems of the poor:  The Drift Hypothesis  people with emotional difficulties tend to be less successful in life, so if they were once part of the middle-upper class they are more likely to “drift” to the lower classes  The Genetic Hypothesis  there is a genetic predisposition for developing mental illness. We know this is true in some cases, such as with schizophrenia. According to the genetic hypothesis, even if these genes were evenly distributed throughout the population, they would eventually “drift” towards the lower classes because of a lack of success.  The Socialization Hypothesis  children who are reared by disturbed parents are more likely to be disturbed- they will learn pathological ways of coping with life. This makes them less equipped to deal with the challenges of schooling and a career, therefore they will be more likely to live in poverty.  The Environmental Hypothesis- this is the explanation that sociologists prefer.  The feelings associated with mental illness are a result of the social environment. Living in poverty produces feelings of depression and anxiety. Being well off produces feelings of happiness. Consider life when you are financially secure- you have job stability, good benefits, a nice house, money for vacations and you can afford to send you kids to college AND if you are feeling down it is easy to seek treatment because you have the means. the health insurance) to do so.  Now consider if you are poor- you are constantly worried about job stability, or finding a higher paying job. You may live in an area where crime is widespread. You are likely to be without health insurance or a retirement plan. Subsequently you may become anxious and depressed and turn to alcohol or drugs as a way to cope.

29. Mental Health Services  The delivery of mental health services  Individual psychotherapy  Short-term directive therapy  Group therapy  Drug therapy  Consequences of ability to pay  Type of therapy does not depend on person’s problems, but on person’s ability to pay  The poor rarely receive individual psychotherapy (talk therapy) or short-term directive therapy. These forms of treatment are aimed at getting to the source of a problem and working through it.  Group therapy (such as a support group) is much less expensive, but often people are too mentally ill for this type of treatment, or are reluctant to share their problems publically. Instead many of the poor receive drug therapy. This type of treatment does not address the cause of a problem and instead often makes people lethargic and easier to handle. Of course, some people with mental illness receive no treatment at all. For example 25%-40% of all homeless people are mentally ill.

30. Social Policy: Proposed Solutions  HMO’s – Health Maintenance Organizations HMO care means that businesses pay a monthly fee for each worker (for example $450). The way it works is that if the employees health care costs more than this prepaid amount the, HMO loses money. If the employee’s health care costs less the HMO makes money. Since the focus is often on preventative care, costs will be presumably lower.  Being Paid to Stay Healthy Some business offer a worker rebate for staying healthy. For example, employees agree to a high deductible (i.e. $2000) and those who spend less than the deductible get the difference  Physician Extenders- physician assistants and nurse practitioners Many illnesses do not require the expertise of a doctor and can be treated by people who work under the supervision of a doctor. This type of care costs less.

31. Social Policy: Proposed Solutions  Training more Physicians Medical schools today graduate only as many physicians as they did 25 years ago. The problem is that there are 65 million more people today then there were 25 years ago. The result is that doctors have less time to spend with patients. Also, many physicians are going into specialty care. One proposed solution is to have the government finance new medical schools that are tuition free. In exchange for this, graduates could agree to spend a year in an area that is experiencing a doctor shortage (these are often in poor areas).  Preventative Medicine 1. Primary prevention includes improved nutrition, vaccinations, exercise, and not smoking. These are lifestyle changes. 2. Secondary prevention refers to detecting problems before going to a doctor- such as with a self-examination for breast cancer. 3. Tertiary prevention refers to managing disease. Using drugs to manage depression or insulin to manage diabetes are examples of tertiary prevention.

32. The Future of the Problem “Obamacare” seeks to address some of the problems with healthcare, but much more needs to be done. Here’s what we can expect for the future We can expect that there will be more technology, despite the high costs. The Internet will play a more prominent role. People are doing a lot more research over the internet concerning the illnesses they have. This can be positive because they may be better informed, but they also may be receiving false or misleading information. Ethical dilemmas- See Genetic Profiling: The Potential and the Dilemma on page 337

33. The Future of the Problem  In 1975 Rick Carlson made a series of predictions that have turned out to be accurate. He claimed that in the future we will be living in a more complex and stressful society (true), that we would have a large aging population with incurable degenerative diseases (true) and that there would be more illnesses resulting from lifestyle and environmental deterioration (true).  He claimed that we need a system that encourages people to demand better heath and not more medicine. This means that we must make health education a priority. He claimed we need to create a cultural environment that promotes health. This would include teaching nutrition and physical education in schools, creating relaxing work environments, designing more bike paths and walking trails in our communities, and building more parks. He believed there was, and is, much potential in our society to make this a reality. What do you think?