Abstract This article examines current trends in theory in medical sociology and
nds that the use of theory is ourishing. The central thesis is that the eld has reached
a mature state and is in the early stage of a paradigm shift away from a past focus on
methodological individualism (in which the individual is the primary unit of analysis)
toward a growing utilization of theories with a structural orientation This outcome is
materially aided by research methods (for example, hierarchal linear modeling,
biomarkers) providing measures of structural effects on the health of the individual that
were often absent or underdeveloped in the past. Both quantitative and qualitative
methods can be utilized in such research and qualitative studies based on symbolic
interaction or social constructionism are not disqualied because of their methodologies
and focus. Structure needs to be accounted for in any social endeavor and contemporary
medical sociology appears to be doing precisely that as part of the next stage of its
evolution.
Social Theory & Health (2013) 11, 241255. doi:10.1057/sth.2013.12;
published online 26 June 2013
Keywords: medical sociology; contemporary sociological theory; Durkheim;
Marx; Weber; middle range theories
Cockerham
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living standards and achieve a positive level of health, they can continue
to increase their wealth but not be any healthier if class differences do not
diminish. The greater the social inequality between rich and poor, the larger the
health disparities, even if the population is healthy overall. This thesis was
initially greeted with enthusiasm (De Maio, 2010). However, other studies failed
to replicate the ndings and the hypothesis has been rejected by study after study
for over a decade (Beckeld, 2004; Eberstadt and Satel, 2004; Link et al, 2013).
Eberstadt and Satel (2004, p. 36) refer to the income inequality hypothesis as
a doctrine in search of data rather than a scientically proven hypothesis.
Thus, the broader spectrum of conict theory is in decline, but there is important
work in the related areas of Marxist theory and political economy that allow it
to currently avoid the fate of structural functionalism.
As for symbolic interaction, Ritzer and Yagatich (2012) nd it on life support
and headed toward zombication. When symbolic interaction appeared to
reach its limits, some in the eld transferred its approach to other areas, such as
the study of embodiment, the experience of illness, adjustments to aging and
using the concept of negotiated order to study organizations (Charmaz and
Belgrave, 2013). Some symbolic interactionists embraced post-modern theory,
but that perspective, despite its early promise to explain social change, was
unable to account for the structure of post-modern society after its transition
from modernity, never gained a foothold in medical sociology and can be
considered a zombie theory as well (Cockerham, 2007). Symbolic interaction
theory, on the other hand, continues, as it also underlies many qualitative
methods and grounded theory, while inuencing a major branch of social
constructionism. Social constructionism takes the view that scientic knowledge about health and illness is produced by subjective, historically-determined
human interests and is subject to change and reinterpretation (Olafsdottir, 2013).
The more that social constructionism is inuenced by symbolic interaction,
the more agency oriented it is; the closer it is to its other branch, that based on
Foucault, the lesser the role for agency.
Given the beleaguered status of its three traditional categories of theoretical
work, it might be presumed that theory development in sociology is in trouble.
This is not true. The problem is with the outdated categories, not a lack of vibrant
theories or theorizing. Rather, what we are seeing in the rst decade of the
twenty-rst century is growth and change. Most signicantly, as noted, there is
a return to theories that focus on social structures that is an essential component
of what sociology is actually about. This is consistent with Durkheims ([1895]
1950, pp. 127128) original view that: Society is not a mere sum of individuals;
rather the system formed by their association represents a specic reality that has
its own characteristics. This reality is distinct not only from individuals, but also
from other realities, such as the biological and psychological.
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Interestingly, the classic theorists from the beginning of the discipline whose
work is most relevant to modern notions of structure have had the greatest
survivability, namely Emile Durkheim, Karl Marx and Max Weber.
Durkheim
Sociologys story as an academic eld, as is well-known, largely originates with
Durkheim. His only work having a possible direct link to medical sociology is his
study of suicide. Durkheim ([1897] 1951) applied basic sociological principles
(for example, norms, values, social solidarity) to the problem of suicide (a highly
individual and private act) in Western Europe in the late nineteenth century by
identifying certain social conditions external to the individual that stimulated the
taking of ones life. His focus was not on physical, but moral health (Lukes,
1973). A principal nding was that individual peculiarities did not explain the
social features of suicide nor did the physical environment; rather, there were
decisive social forces at play (Fournier, 2013).
While sociology has moved a considerable distance since Durkheims pioneering efforts, we see his inuence today in medical sociology in the rapidly growing number of studies of social capital and health. Social capital is generally
described in the research literature as a characteristic of social structures consisting of a network of cooperative relationships between residents of particular
neighborhoods and communities. Networks providing social capital are characterized by interpersonal trust, norms of reciprocity and mutual aid, and a
supportive social atmosphere within which people look out for one another
and interact positively with a sense of belonging. People embedded in such
supportive networks have been consistently found to have better health and
longevity than those who lack this resource (Song, 2013). In locales where there
are serious social problems (for example, crime, stress, slums) and breakdowns
in social networks, social capital is reduced or absent with the residents having
poor health and shorter life spans (Scambler, 2012b).
Turner (2003) and others (De Maio, 2010; McDonnell et al, 2009) nd that the
various theories of social capital, such as those by Putnam, Lin and Bourdieu,
are contemporary applications of Durkheims ([1897] 1951) theory of suicide in
which individuals are protected by their close integration into society. Turner
(2003) observed that Durkheim never used the term social capital, but maintains
that his concepts of social solidarity and social facts are still valid in illustrating
how social capital is protective of the health of the individual. Theories of social
capital are of interest to medical sociologists because they can be a social
mechanism linking inequality to health or, conversely, enhancing the health of
people in neighborhoods and communities with high levels of it. The message
of social capital research, however, is not to claim individual-level characteristics are unimportant or are superseded by such capital, but that structural
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variables like communities can have a causal impact on health. This outcome is
also seen in the relatively new area of emerging research in medical sociology on
neighborhood disadvantage that investigates unhealthy urban living conditions. This research focuses on variables specic to neighborhoods, not individuals, such as the physical environment (for example, quality of housing, water,
air), availability of services (for example, banks, police, re, sanitation, health
care), and social and cultural factors (for example, social networks, single-parent
families) that impair health through psychological distress or exposure to
unhealthy living situations (Pearlin et al, 2005).
Marx
As for Marx, he appears to be having something of a comeback in the early
twenty-rst century. Literally written off as a dead dog in sociology a few years
ago (Callinicos, 2007) and critiqued by this author (Cockerham, 2013b) for the
failure of MarxistLeninist doctrine to produce healthy societies in Europes
former communist states, recent work in the political economy of health nevertheless shows a Marxist revival. An attribute of Marxist theory for modern
neostructural research is Marxs ([1852] 1954, p. 10) oft-cited statement that:
Men make their own history, but they do not make it as they please, they do not
make it under circumstances chosen by themselves, but under circumstances
directly found, given, and transmitted from the past. Therefore, although
individuals have choices, their choices are constrained by existing social structures, especially the economic systems in which they work.
The political economy critique in medical sociology centers on examining
the inequalities in the health-care marketplace when such care is treated as
a commodity in capitalist medical systems to be sold to those who have the
means to pay for it and beyond the reach or with lessened availability on the part
of those who cannot. In this scenario, health care is a privilege, not a right.
Socioeconomic disadvantage in society at large is thus converted into health
disparity as reduced opportunities for quality health care combine with the
greater likelihood of having an unhealthy lifestyle and increased exposure to
adverse living conditions, disease and injury. It is also relevant to note that
health-care delivery systems themselves do not evolve randomly. They are
deliberate creations that reect the social and political philosophies of the
populations that construct them. These philosophies underlie the policies made,
institutions formed and levels of funding provided for health care.
The recent resurgence in Marxist political economy appears linked to the
global economic crisis of 2008. A review of the causes of that crisis shows an
ideology of wealth appropriation and prot-maximizing strategies on the part
of individuals and major nancial corporations, along with a disregard for risks
that led to the global sub-prime mortgage debacle. Some nancial institutions
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failed, massive government loans were required for others and there was
a sharp rise in unemployment, loss of investments, a weakened economy, a few
criminal indictments and the dispossession of assets, particularly homes, from
vulnerable people. The effects of that crisis and other economic problems
are still lingering, particularly in the euro-zone. Even though safety nets are
provided by the state in capitalist economies in the form of welfare benets,
such benets can be reduced or curtailed in a major scal crisis thereby
accelerating the vulnerability of the disadvantaged (Scambler, 2012b). Thus,
we see another situation in which health can be harmed from structural
conditions over which individuals have no control.
Weber
Webers contributions to contemporary medical sociology generally fall into
three areas: (i) SES, (ii) lifestyles and (iii) rationality and bureaucracy. These
concepts underlie many studies in medical sociology today on social class and
health, health lifestyles and hospitals. The concept of SES, consisting of measures
of income, education and occupational prestige, comes from Weber and is the
standard measure of class position in American sociology. His notion of formal
rationality and bureaucracy remains central to studies of hospitals and other
health care organizations, even though there is variance from usual bureaucratic
procedures in clinical care. The most recent inuence of his work in the early
twenty-rst century is found in research on health lifestyles. Weber ([1922]
1978) associated lifestyles not with individuals but with status groups, thereby
showing they are principally a collective social phenomenon. Moreover, lifestyles are based on what people consume rather than what they produce.
Therefore, for Weber, the difference between social classes did not lie in their
relationship to the means of production as advocated by Marx, but in their
relationship to the means of consumption. It is obvious to say that the afuent
consume considerably more and higher-quality resources than the poor, including resources that promote health and ward off illness (Phelan et al, 2004).
Weber maintained that lifestyles consist of two components: life chances
and life choices. A persons life chances are the probabilities they have in life to
nd satisfaction and are largely determined by their SES and other factors that
shape the choices people make in their lives, including their lifestyle. There is
a dialectical relationship between life choices and life chances, with life choices
representing agency and life chances a proxy for structure. While choices about
lifestyles are voluntary, life chances which primarily represent class position
either empower or constrain choices as choices and chances interact to determine outcomes. This concept joins with Bourdieus notion of the habitus as the
centerpiece of Cockerhams (2005, 2013a, b) health lifestyle theory. Cockerham
denes health lifestyles as collective patterns of health-related behavior based
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Current Developments
While classical theories still inuence some of the current work in medical
sociology, few contemporary theoretical schools of thought are linked to named
theorists in what seems to be a characteristic of modern theorizing. Prominent
exceptions include Foucault and Bourdieu. Otherwise, the clear trend is toward
the utilization of theories of the middle range that are specic to both particular
substantive areas of study in medical sociology and to this period of theoretical
development and its corresponding methodological advances. These theories
include medicalization, fundamental cause, life course, as well as health lifestyle
theory noted above, and others. As will be seen, each of these theoretical perspectives tends to take a neostructural approach.
Foucault
Foucaults work has inuenced a number of studies in medical sociology and
related areas, such as the sociology of the body, emotions, social constructionism
and feminist theories critiquing male patriarchy. A major focus was on power
relations. He provided social histories of clinics, prisons and sexuality that
depicted the manner in which knowledge produced expertise. This knowledge
was used by professions and institutions, including medicine and psychiatry,
along with religion and the state, as a means of social control and regulation.
Knowledge and power were described as being so closely connected that an
extension of one meant a simultaneous expansion of the other. He used the term
knowledge/power to express this unity. When it came to medical practice,
Foucault (1973) found two distinct trends in the history of medicine: what he
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line of behavior as opposed to others that might be chosen. These perceptions are
developed, shaped and maintained in memory through socialization, experience
and the reality of the persons class circumstances. While the behavior selected
may be creative and even contrary to normative expectations, behavioral choices
are typically compatible with the dispositions and norms of a particular group,
class or the larger society; therefore, people tend to act in predictable and habitual
ways even though they have the capability to choose differently. Through selective
perception, the habitus adjusts aspirations and expectations to categories of the
probable that impose boundaries on the potential for action and its likely form.
Of all Bourdieus (1984) works, the one most relevant for medical sociologists
remains his book Distinction, in which he systematically accounts for the
patterns of cultural consumption and sees individual taste determined by
a class-based distance from necessity. He includes an analysis of food habits
and sports that describes how a class-oriented habitus shapes these particular
lifestyle practices. The merit of Bourdieus analysis for understanding the
relationship between class and health lifestyles lies in his depiction of the relative
durability of various forms of health-related behavior within particular social classes
and the relatively seamless fashion in which he links agency and structure
(Williams, 1995). The transcendence of the barriers between agency and structure
is what is likely to give Bourdieus work legs into the future. Although some might
view his work as overly deterministic, he nevertheless provides a framework for
medical sociologists to conceptualize health lifestyles and for sociologists generally
to address the agency-structure interface (Cockerham, 2005, 2013a, b).
Middle-Range Theories
Currently, there are several middle-range theories active in medical sociology.
Perhaps the most popular at this time are fundamental cause, medicalization and
life course. Fundamental cause theory is playing a leading role in the United
States in promoting a structural orientation toward health and mortality. This is
seen in Link and Phelans (1995, Phelan et al, 2004; Phelan and Link, 2013)
assertion that social conditions are fundamental causes of disease. In order for a
social variable to qualify as a fundamental cause, Link and Phelan (1995, p. 87)
hypothesize that it must (i) inuence multiple diseases, (ii) affect these diseases
through multiple pathways of risk, (iii) be reproduced over time and (iv) involve
access to resources that can be used to avoid risks or minimize the consequences
of disease if it occurs. They dene social conditions as factors that involve
a persons relationships with other people.
When fundamental cause theory is reduced to its most basic proposition, it is
the idea that resources consisting of money, knowledge, power, prestige and
social connections are vital to maintaining a health advantage (Phelan and Link,
2013). Conversely, an absence or shortage of these resources causes poor health
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outcomes and earlier deaths. People with resources have less risk of exposure
to preventable diseases in the rst place and are better able to achieve positive
outcomes when they occur by employing their resources. Persons with lower
income, education and social status lacking such resources not only have greater
exposure to risk and more likelihood of the risk being realized, but also a
diminished capacity for preventing negative consequences.
Medicalization theory, in turn, is largely based on the work of Conrad (2007,
2013) and its use has become widespread in North America and Europe.
Medicalization means to make medical, which in the case of medical sociology
refers to the process by which non-medical problems (deviant behavior, natural
life events, problems in living and health enhancements) become redened to
varying degrees as medical, with the medical profession taking jurisdiction over
their management. Conrad observes that the engines (the social forces) underlying medicalization have shifted from the medical profession to the pervasive inuence of biotechnology, the pharmaceutical industry, consumerism and
genetics, as well as physicians.
Life course theory is not associated with one particular theorist, but the body
of work advances the proposition that people go through a sequence of age-based
stages and social roles within particular social structures over the course of their
lives (Mortimer and Shanahan, 2003). In medical sociology, this perspective
suggests that socioeconomic disadvantages originating in childhood accumulate
over the life course to especially disadvantage health in old age. Not discussed
here because of space limitations, but nevertheless part of medical sociologys
arsenal of middle-range theories are those of intersectionality, cumulative inequality/
cumulative disadvantage, role strain, the stress process, labeling, trust, conservation of resources, social disorganization, critical realism, actor-network and a
host of others adding to the theoretical richness of the eld.
Conclusion
The use of theory is ourishing in medical sociology and this is particularly
apparent in theories bringing structure back into prominence in explaining the
social determinants of health and disease (Cockerham, 2013b). This development, as noted, is materially aided by research methods providing measures of
structural effects that were often absent or underdeveloped in the past. These
measures are both quantitative and qualitative; therefore, qualitative studies
based on symbolic interaction or social constructionism are not disqualied
because of their methodologies and focus. Structure needs to be accounted for in
any social endeavor and contemporary medical sociology appears to be doing
precisely that as part of the next stage of its development.
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