Quite by chance, the other day I came across a very useful diagrammatic representation of the debate between biomedical and social approaches to health and illness. Probably when I was looking for something else. You know how it is.
The diagram is based on the American County Health Rankings National Findings Report created by The University of Wisconsin Population Health Institute and while it has obvious applications to American health care, its basic conclusion holds broadly true for both the UK and Western Europe: of the factors contributing to health care, a relatively consistent 80% are social in some shape or form, with the remaining 20% the result of biomedical clinical care.
And if you want to explore the issue in a bit more detail, I’ve added some general notes on the biomedical and social approaches to health. I’m nice like that.
For that dwindling band among you who study the Sociology of Health, one of the key debates is the different approaches to understanding health encapsulated by two opposing models: the biomedical and the social.
Most of us will already be familiar with the former approach, the dominant medical discourse in Britian and America for 200 years or more. It focuses on the clinical care and treatment of illness with the doctor-patient relationship being central to the model. It is sometimes characterised as a “curative” model of illness in the sense that it focuses resources on curing patients through a variety of medical interventions.
The social model, on the other hand, is an oppositional discourse on the nature of health and illness. It challenges biomedical assumptions concerning both the way to promote health (and well-being) and the doctor–patient relationship. It is, in this respect, sometimes seen as a “preventative” model in the sense that the causes of health and illness are seen to be located in wider social processes – such as clean air and water.
While this debate may seem fairly academic, it actually has a range of important real world consequences, not the least being the funding of health care and treatment in countries like Britian with it’s socialised medical system and the United States with its privatised insurance system.
If you want to expand your understanding of the biomedical and social models I’ve written some basic notes that allow you to do just that..
The Biomedical Model
Sociologically, we can outline the model in terms of its underlying assumptions, the social relationships that devolve from these assumptions, and its general strengths and weaknesses.
Health is defined as a negative state – the absence of disorder (such as disease). In terms of causality, Blaxter (2004) argues that this model is shaped by the ‘doctrine of specific aetiology’: every disorder has a single observable cause that can be identified, isolated and (once we have sufficient scientific knowledge) treated. Ill health is seen as the result of two medical processes:
- External processes: The normal, healthy body is ‘invaded’ by viruses, bacteria and so forth that cause particular types of disorder.
- Internal processes: The normal functioning of the body breaks down because of physical changes or because of genetic disorders and predispositions.
As a result, this approach is sometimes characterised as a mechanical model of order. Just as a machine like a car has a ‘normal state’ where the parts work as they should, so too does the body. When a machine breaks down – through normal wear-and-tear or because something has caused it to malfunction – the cause can be established, the problem fixed and normal functionality returned. Similarly, the cause of ‘mechanical breakdown’ in the body can be established and treated, such that the body returns to its normal, ordered state. Malfunctions, therefore, are engineering problems capable of resolution by skilled technicians.
If ill health has clear, definable causes, it follows that a scientific approach to understanding causality must be based on objectivity. Our understanding and treatment of ill health are based on clear and incontestable rules of evidence that have to be followed if treatment is to be successful. The subjective beliefs about disease that may be held by those who treat it (such as a doctor) or those who seek treatment (the patient) are largely irrelevant – health cannot be restored on the basis of things like prayer, faith, charms or rituals.
A further aspect of objectivity is the idea that disorders are largely random events – disease doesn’t strike people because they are ‘evil’ or ‘sinful’, or because someone has worked a ‘magic spell’.
These assumptions shape the social relationships surrounding health and illness in a range of ways, in terms of roles and power.
The objective view of disease leads to an objective relationship between a doctor (someone medically qualified to diagnose and treat illness) and their patient (the person who is treated). This relationship has the following qualities:
- Formal: While the patient’s role is to describe their symptoms, the doctor’s role is to correctly interpret and treat those symptoms.
- Distant: While the doctor–patient relationship can be friendly, how they interact socially is largely irrelevant in terms of diagnosis and treatment. The objective nature of the process means that a treatment will work regardless of the relationship between those involved.
- Instrumental: The relationship is based on what each individual needs and can provide in return. The patient needs treatment and expects the doctor to provide it; the doctor needs the patient to cooperate in their diagnosis and, in return, suggests a treatment for their disorder.
There is a clear power difference between doctor and patient based on differences in knowledge (about the cause of illness) and skills (in treating a disorder). Health, in this respect, is something medical professionals:
- Define: on the basis of scientific observation
- Police: to ensure that only those properly qualified can make diagnoses
- Measure: in order to determine effective treatments
- Health is simple to define and measure.
- The model is evidence-based. In basic terms, it works; it has what Keat and Urry (1975) call instrumental utility — it works successfully even though a patient may not know exactly how or why a cure works. Cause-and-effect relationships can be reliably tested and established — for example, we know that malaria is caused by a parasite passed on to humans through a mosquito bite.
- Knowledge of causality leads to knowledge about prevention. For example, one of the greatest life-savers of the twentieth century was clean water — and we understood why clean water was important because of our scientific knowledge of deadly bacteria.
- A simple cause-and-effect analysis, whereby exposure to a particular virus causes a particular disorder, for example, doesn’t always hold true. Two people exposed to the same influenza virus don’t always both fall ill — which suggests that health and illness sometimes have a complex causality which is not simply and easily established.
- Modern medicine is centred on technology rather than the patient. In other words, it has become focused on finding more and better ‘cures’ rather than seeking to prevent disease occurring in the first place. While this has made the medical profession powerful and produced huge profits for private transnational pharmaceutical companies, the overall health of the population has not greatly improved beyond a certain minimum level.
- The focus on technology (more and better medical machines) and drug-based cures has made medicine increasingly expensive. In private health systems even basic forms of medical care have been priced beyond the reach of many citizens; Smith et al. (2011), for example, note that in 2009 around a quarter (26%) of all American citizens ‘experienced at least 1 month without health insurance coverage’. In the UK, where the National Health Service is funded from taxation, the cost has increasingly risen each year.
Another issue is iatrogenesis – illness caused by the medical profession. According to Illich (1976), there is a general assumption (advanced by an increasingly powerful medical profession) that medicine represents an inevitable progression from ignorance about disease to enlightenment about the nature and causes of illness, but this assumption ignores the fact that people can be ‘made ill’ by the medical profession in three main ways:
- Clinical iatrogenesis refers to the use of ineffective, toxic and unsafe treatments.
- Social iatrogenesis refers to the way social life is increasingly ‘medicalised’: a wide range of ‘disorders’, from children misbehaving to adult criminality, are seen as having a medical cause, and requiring a medical response (such as the application of new drugs). This process also leads to an increasing rate of ‘discovery’ of new conditions (especially, but not exclusively, those of the mind) that can be ‘cured’ using drug-based technology.
- Cultural iatrogenesis refers to the hegemonic (or leadership) role of the medical profession: alternative forms of treatment or ways of dealing with pain, illness and so forth are marginalised or brought under the control and oversight of the medical profession.
Richardson and Peacock (2003) concluded that an increase in the number of doctors resulted in increased mortality rates: ‘The hypothesis that iatrogenic effects may more than off-set the direct beneficial effects of additional, and largely unregulated, medical services must be contemplated seriously. Maybe Ivan Illich got it right!’
The Social Model
Health is a positive state that, for Seedhouse (1988), involves something more than the ‘absence of illness’: ‘health’ is given a much wider interpretation, based around the idea of ‘human potentials’. In this view, healthy individuals are those able to fully participate in the groups, communities and societies to which they belong. The (functional) emphasis, Wolinsky (1980) notes, is on the individual’s ability to perform particular roles and tasks in their everyday life. Seedhouse argues that health is determined by two central conditions:
- material conditions such as food, shelter, warmth and peace – the basic prerequisites for health
- non-material conditions that include access to information about health and disease and the ability to understand and use such information to promote a healthy lifestyle
The social model assumes that health and illness have multiple causalities, ranging from individual factors (such as age and genetic inheritance) through group factors (such as lifestyles) to wider community factors (such as the quality of water and air supplies). It also assumes that health involves a combination of individual and wider social relationships.
Healthcare is a matter not simply for individuals, based around a doctor–patient relationship, but for societies as a whole. A range of individual, social and environmental factors and relationships combine to create healthy or unhealthy individuals. As an extreme example, people living in a war-zone without access to clean water, food and shelter will have demonstrably worse health than people living peacefully with access to the basic necessities.
The focus of this model, therefore, is not professionals and their patients (although these roles may be part of the overall health equation) but rather demographic factors – how, in basic terms, individuals and groups interact with their natural and social environment.
The biomedical model sees health as primarily a private concern – the health of the individual normally plays no part in the health of the community (except in the case of highly contagious diseases). In contrast, the social model sees health as mainly a public concern – the health of the community goes a long way towards determining the health of the individual.
Dahlgren and Whitehead (1991) represent the relationship between the individual, their social environment and health in terms of layers of influence. These layers capture the relationship between two types of asset: fixed and modifiable.
At the bottom of the diagram are the fixed assets: those that can’t be changed, including personal factors such as age and genetics. (Consider, for example, the greater vulnerability to illness of the very young and the very old, and the effect of hereditary diseases.) Above the fixed assets, the diagram shows several levels of modifiable assets. These are assets that can be changed and include the following:
- lifestyle choices (such as heavy alcohol use) that impact directly on the health of the individual
- social and community influences determining the levels of mutual support that contribute to, or minimise the likelihood of, ill health
- living and working conditions (e.g. the condition of people’s housing and the nature of their work environments)
- general social and economic conditions which affect a whole society (e.g. the wealth or poverty of a society, whether it is peaceful or war-torn, levels of medical knowledge).
- Responsibility: The responsibility for a population’s health is shared throughout a community; illness is a ‘collective problem’ related to a range of social and economic conditions, some of which are the individual’s responsibility (such as smoking and drinking), while others relate to community responsibilities (such as waste disposal, safe working conditions and the like). The model also highlights how large-scale social inequalities (such as extremes of wealth and poverty) contribute to individual health problems.
- Community: Government behaviour impacts on individual health. The provision of proper sanitation or adequate housing are factors beyond individual control that have significant impacts on individual health. Governments also have a role in ensuring that drugs and medical services known to injure health are controlled.
- Diminishing costs: The general health of a population improves as social and economic conditions improve (e.g. through the provision of clean water and air, or the banning of unsafe working conditions). Health is not based on constant technological developments in medicine.
- Causality: This approach focuses on the ‘causes of the causes’ of ill health: the social conditions (poverty, malnutrition, unsanitary conditions and so forth) that cause disease which, in turn, causes individual ill health.
- Responsibilities: Where health is seen as a collective problem, the question arises as to who is ultimately responsible for ill health — the individual? the community? some combination of both? It’s not clear from the model where responsibility ultimately lies.
- Entrenched interests: Where a medical system is based on private profit, there is little incentive for health prevention because profits mainly lie in curing illness (through expensive individual treatments).
- Victim blaming: Where health is conceptualised as a community problem, it ironically becomes easier – once certain ‘community responsibilities’ have been met, such as the provision of clean water – to attribute ill health to the individual and their personal lifestyle choices.