社会医学基本理论双语.ppt

Chapter3 PrincipalTheoriesofSocialMedicine HuazhongUniversityofScienceandTechnologyTongjiMedicalCollegeFacultyofSocialMedicine Contents prefaceDefiningHealthandMedicineSociologicalPerspectivesonHealthandMedicineSocialCapitalandHealth Part1Preface Section1 1AStoryofSocialMedicineSeventeen year oldJimDavis apseudonym wascheckedintotherehabcentertwodaysagebythisparents Today heiscurledintoafetalpositiononthebedinhisroom hisbodyconvulsing Periodically hegetsupscreamingandtearsthesheetsoffhisbedorthrowsachairagainstthewall Jimisgoingthroughwithdrawal butfromwhat Isheaddictedtoheroin perhaps orcocaine alcohol orevennicotine No Jim spsychologistexplainsthatJimisanInternetaddict Ahighschoolseniorand untilrecently honorsstudent Jimspendsmorethansixhoursadayon line Hequitlong distancerunningandwithdrewfromotherextracurricularactivitiestohavemoretimefortheInternet Thenhebeganskippingclassesandcallinginsicktohispart timeemployer Hisparentsinsistedthathecutdownhistimeon line butJimcouldn tseemtodoit WhentheyremovedJim scomputerfromhisroom heatfirstbecomedepressed butthenhewentintoarage threateningtokillhimselfifhisparentsdidnotreturnhiscomputer This swhenthedecidedtoseekprofessionalhelp whicheventuallyledtoJim sadmissiontoarehabilitationcenterthatusuallytreatsdrugandalcoholabusers CliniciansreportthattheyareseeinganincreasingnumberofpeoplewithInternetaddiction acompulsivedisordersimilartouncontrollablegambling bingeeating anddrugandalcoholabuse Butsociologistsseethesereportasthelatestexampleofmedicalization theprocessofdefiningabehaviororconditionasanillnessinneedofmedicaltreatment Sociologistsbelievethatillnessisnotsimplyabiologicalorphysiologicalcondition Rather illnessissociallyconstructed Whatgetsdefinedasillnesshasasmuchtodowithasociety scultureaswithobjectivesymptoms Section1 2RelationsofConceptandTheory Thestructureofatheory concept variable proposition hypothesis ConceptAbstractofphenomenaRelationsofconceptandtheory conceptisasectionoftheory atheoryismadeupofagroupoflogic relatedconcepts VariableConceptwithmulti dimension PropositionAstatementaboutthecharacteristicofaconceptortherelationsofagroupofconcepts Categoriesofproposition axiom law hypothesis HypothesisAtentativestatementabouttherelationshipofrelated variable Part2DefiningHealthandMedicine Section2 1Whatishealth Somepeopledefinehealthassimplytheabsenceofillness butthisvaguedefinitionraisesmorequestionsthanthisanswers Forexample whenshouldweconsiderapersonisill whenthatpersonisunabletoperformnormalsocialroles Ontheonehand anindividual sassessmentcanbeproblematicbecauseresearchshowsthatwhilemostpeopleconsidertheirverygoodorexcellent onlyasmallpercentageiscompletelyfreeofphysicalailmentsatanygiventime U S Departmentofhealthandhumanservices 1996 Ontheotherhand ifwedefinehealthsolelyintermsoftheabsenceofdisabilityorincapacitation weoverlookthethousandsofpeoplewhoareillbutwhocontinuetocarryouttheirdailyactivitiesforavarietyofreasons suchaseconomicnecessary Astheseexamplesillustrate healthismultidimensional Inadditiontoaphysiologicaldimension healthalsohaspsychologicalandsocialdimensions Consequently wehaveadoptedtheWorldHealthOrganization sdefinitionofhealthasastateofphysical mental andsocialwell being Thisdefinitionmakesthepointthatwecannotconsiderapersonhealthyifsheorheisemotionallydistressedorlivinginahazardousenvironment evenifthepersonisfreeofphysicalillness Section2 2HealthandSociety Standardsofhealthvarycross culturally StandardsofhealthvaryovertimeStandardsofhealthreflectthedominantvaluesandnormsofasocietyHealthisaffectedbyasociety slevelofeconomicdevelopment Standardsofhealthvarycross culturally Whatisconsideredhealthyorwholesomeinonesocietymayberegardedasunhealthyorharmfulinanother Forinstance physicalconditionsthatwouldbediagnosedasseriousskindiseasesbyU S physiciansarenotconsideredevensymptomsofillnessbytheKubaofSumatra Definitionsofhealthandillnessmayalsobemanipulatedforpoliticalreasons Forexample inJapan wherethenationalgovernmentownsthecountry slargestcigarettesmanufacturingcompany anymedicalreportsthatwarnofthehealthhazardsofsmokingmustalsoincludeclaimsaboutcigarettes benefits suchashowsmokingcigarettescontributestocreativity Standardsofhealthvaryovertime Littlemorethanacenturyago physiciansbelievedthathysteriawascausedbytheuterusbreakingfreeandmovingthroughthebody Thus bydefinition allhystericswerewomen andthe cure wasremovaloftheuterus hysterectomy Hysteria whichistodaycalledhistrionicpersonality isstillamedicallyrecognizeddisorder butitisnotthoughttohaveaphysicalcause norisitonlydiagnosedinwomen 25to50percentofindividualswithhistrionicpersonalityaremen Standardsofhealthreflectthedominantvaluesandnormsofasociety ConsiderthatintheUnitedStates whereindividualismishighlyprized somepeopledevelopaphobiaofbeingembarrassed whereasinJapan wheregroupwelfareisvaluedovertheindividual somepeopledevelopafearthattheymightembarrassothers Healthstandardsmayalsobeusedtoenforcenorms InmanyWestAfricancountries forexample youngwomenareexpectedtobevirginswhentheymarry Toguaranteemarriageability parentsusuallyhavetheirdaughters circumcised theirexternalgenitalsareremovedandthevaginaissewnclosedexceptforasmallopeningtoallowthepassageofmenstrualblood eventhoughtheprocedureoftenresultsincomplications includingshock hemorrhage andtetanus Inthiscountries thecircumcisionservesasameansofsocialcontroltoensureyoungwomen sconformitytotheirsociety ssexualitynorms Healthisaffectedbyasociety slevelofeconomicdevelopment Economicallyundevelopedsocietieshavehighratesofillnessandhealth especiallyfrompreventableinfectiousdiseases Asasocietydevelops deathfrominfectiousdiseasesdeclinesdramatically sothatindustrializedsocietiesenjoythehigheststandardsofhealth Thisdoesnotmeanthatindustrializedsocietiesareillness free however Infectiousdiseasesmaybeundercontrol butindustrializationgeneratesotherhealthproblems Onlyinindustrializedsocieties forexample doworkerscontractlife threateningillnessesbecauseofoccupationalexposuretocottonfibers coaldust asbestos mercury andnumerouschemicals Section2 3Whatismedicine Medicineisthesocialinstitutionestablishedtoidentifyandtreatillnessandpromotehealth Goalsofmedicine preventionofdisease reliefofsuffering careoftheillandavoidanceofprematuredeath Section2 4MedicineandSociety Justashealthreflectsthecultureandstructureofasociety sodoesmedicine Weusuallythinkofmedicineafterthefact thatisoncewehavegottensick werelyonmedicinetomakeusbetter Thiskindofmedicine curativemedicine focusesontreatingpeoplewhoarealreadyill Incontrast preventivemedicineseekstoestablishconditionsthatkeepillnessfromoccurring IntheUnitedStates preventivemedicinehasbeengettingmoreattentioninrecentyears Weareallfamilywiththecurrentcampaignstoquitsmokingand eathearthealthy Butforthemostpart medicineinUnitedStateshastraditionallyemphasizedcurethanprevention anemphasisthatfollowslogicallyfromoursociety svaluesofindividualismandfreeenterprise Theindividualissupposedtodeterminehisorherownhealthneeds findasourceofhealthcare andpayforthatcareprivately Part3SociologicalPerspectivesonHealthandMedicine TheStructuralFunctionalistPerspectiveEvaluatingtheStructuralFunctionalistPerspectiveTheSymbolicInteractionistPerspectiveEvaluatingtheSymbolicInteractionistPerspective Section3 1Thestructuralfunctionalistperspective ThestructuralfunctionalistperspectiveonhealthandmedicinewasformulatedlargelybyTalcottParsons 1951 AccordingtoParsons ahealthypopulationisessentialtosociety Healthpeoplecanperformthesocialrolesnecessarytokeepsocietyfunctioningoptimally Illness then isdysfunctionalbecauseitpreventspeoplefromperformingtheirsocialroles atleasttemporarily Thus thesocialinstitutionofmedicineplaysavitalroleintheoverallfunctioningofmedicinebymakingmembershealthy Ofcourse everyonegetssicksometimesandwhentheydo Parsonsargued theyfollowasociallyprescribedrole Physiciansalsohavespecificroleexpectations Section3 1 1TheSickRole Parsonsidentifiedfourcharacteristicsofthesickrole thebehaviorsdefinedbyasocietyasappropriateforpeoplewhoaresick First sickpeopleareexcusedfromtheirusualresponsibilities suchasattendingclassorworking However whilesayingyou resickmightinitiallyevokesympathy youwon tbeexcusedfromyourobligationsforlongunlessyourillnessisverifiedbyarecognizedexpert suchastheschoolhealthserviceoryourphysician Second sickindividualsareconsidered worthy ofothers sympathyonlyiftheydidnothingtoprecipitatetheirillness Consider forexample therecentlawsuitsbroughtagainstthetobaccoindustrybysmokerswithseriousillnesses Jurieshavebeenreluctanttoawarddamagesbecausetheplaintiffsknewsmokingwasharmfultotheirhealth butkeptdoingitanyway Third thesickpersonmustdisplayasinceredesiretobewell Someonewhoclaimstobeilltoavoidwork getoutofasociologyexam orbepamperedbyothersisnotconsideredlegitimatelysickbysociety Finally thesickpersonmustdoeverythingpossibletogetwell Ifthesickpersonmakesnoattempttogetmedicalhelporignores doctor sorders heorsherelinquisheslegitimateclaimtothesickrole Thehelp seekingelementofthesickrolereadsustoconsidertheroleofhelpprovider thephysician Section3 1 2ThePhysician sRole AccordingtoParsons thephysician srolehastwocomponents Oneistoevaluatepeople sclaimsofillness assessingwhethertheyarereallysickand ifso determiningthecauseoftheirailment Thesecondcomponentofthephysicians sroleistocurethesicksotheycancarryouttheirnormalsocialroles Section3 1 3Therelationshipbetweenthephysician sroleandthesickrole thephysician sroleandthesickroleareinterdependent First patientsmustsupplytheirmedicalhistoryandsymptomsinorderforthephysiciantofulfillthefirstcomponentofhisorherrole Then tofulfillthesecondcomponents thephysiciandependsonthepatienttofollowinstructions Despitethisinterdependence thespecializedknowledgeofthephysicianmakesthephysician patientrelationshipunequal Thelevelofinequalityvariescross culturally butthephysicianalwayshastheuppershandintherelationship Parsonsdidnotviewpatient physicianinequalitynegatively though Thephysiciansimplyknowswhatisnecessaryforapersontogetbetter sothepatientshoulddefertohimorher Section3 2EvaluatingtheStructuralFunctionalistPerspective Parsons sanalysisofthesickroleshowshowsocialnormsimpingeonbothhealthandillness Parsonsalsocorrectlydepictsthephysicianasthegatekeepertothesickrole Butparsons sideashavealsobeencriticized Some forexample saythatParsons sconceptofthesickroleimpliesthatapersonasonlytemporarilyillandcanberestoredtonormalfunctioningrelativelyquickly Thisistrueifthepersonissufferingfromanacuteillness which thoughoftenserious iscurable Butchronicillness prolongedillnessthatmaybecontrolled butnotcured ispermanentlyincapacitatingandpreventsapersonfromeverresumingnormalsocialroles Parsonsisalsocriticizedforputtingtoomuchemphasisonindividualresponsibilitywhiledownplayingthesocialstructuralfactorsthatcanaffecthealth Forinstance Parsons sclaimthatpeoplewhocontributetotheirownafflictionhavenolegitimateclaimtothesickroleoverlooksthefactthatsocialstructuralfactorsalsoshapepeople sbehavioralchoices Advertising forexample promotesagreatdealofunhealthybehavior includingsmokingandalcoholconsumption Finally Parsonshasbeencriticizedforignoringthenegativeconsequencesofsocialinequalityforhealthandmedicine Sickpeoplemaywishtogetwell forexample buttheiraccesstomedicalcaremaybelimitedbytheirfinancialstatus Section3 3Thesymbolicinteractionistperspective Symbolicinteractionistsareprimarilyconcernedwiththemeaningspeoplegivetotheirsocialinteractions sotheyfocusonhowhealthandmedicinearesociallyconstructed Quiteapartfromobjectivesymptoms healthandillnessaresociallydefinedbythemembersofasociety InLithuania forexample thereareaboutasmanyrear endcarcollisionsasinNorwayandtheUnitedStates butLithuanianeverreportthelingeringneckpain calledwhiplash commonlyreportedbyNorwegianandAmericanaccidentvictims Lithuaniansdon thavestrongerneckmusclesandtheircarsaren tsafer sowhydon ttheygetwhiplash Researchersbelievetheanswerliesinhowthesituationsaresociallydefined InLithuania peoplearenotaccustomedtosuingoneanotherforanyreason letaloneaccidentliability Lithuaniansdonothavepersonalinjuryinsurance iftheyareinjuredinanaccident thegovernment spublichealthinsuranceprogrampaysthemedicalbills Whenarear endcollisionoccurs theydefineitasamajorinconvenience notbecausetheywillmissworkbecauseofneckpain butbecauseitissodifficulttogetsparecarpatsinLithuania Incontrast inNorway whichhasthehighestnumberofwhiplashcasesintheworld thereismuchtobegainedfromdefiningarear endcollisionasaninjury producingeventbecauseinsurancecompaniesgenerouslycompensateindividualsforchronicdisabilitycausedasinjurysuitsarecommonplace rear endcollisionsaredefinedasinjurieshealontheirownwithinafewdaysorweeksandrequirelittleornotreatment ThisisnottosaythataccidentvictimsinLithuanianeverexperienceneckpain orthatpeopleonNorwayandtheUnitedStatesonlypretendtobeinpain Rather accordingtosymbolicinteractionists thesocialexpectationsthatindividualsattachtoaneventshapehowtheyexperienceitandthemeaningstheygivetotheexperience Symbolicinteractionistsarealsointerestedinhowmedicaltreatmentissocialconstructed Thinkaboutyourmostrecentvisittoaphysician soffice Afterbeingseatedinthewaitingarea youwereprobablyescortedtoanexaminingroombyanurse whotooksomebasicmedicalinformation yourweight temperature andbloodpressure Oncethenursefinished youarelefttowaitforthedoctor Thedoctorwasn tdifficulttorecognizesincesheorhehadseveralpropsthatdesignatedthestatusdoctor Forexample thedoctorprobablyworeawhitelabcoatwithastethoscopeprotrudingfromthepocket Thetwoofyoumayhaveinitiallyexchangedsmalltalk buttheconversationwaslikelylimitedtoyouansweringthedoctor squestions Althoughthedoctormayhaveaddressedyoubyyourfirstname youinvariablyusedthetitle doctor whenaddressingherorhim Thedoctoralsoprobablyusedaspecializedvocabulary referringtoyoursorethroatas pharyngitis oryourswollenpinkyfingerasyour fifthdigit Eachelementoftheinteraction includingthepropsandthelanguage contributetothesocialconstructionofthestatusesphysicianandpatientandthephysician patientrelationship Therelationshipitselfisclearlyhierarchal withthedoctorassumingtheroleofauthority Section3 4EvaluatingtheSymbolicInteractionistPerspective Thesymbolicinteractionistperspectiveisvaluableforemphasizingthesocialnatureofhealthandmedicine whichwetypicallythinkofonlyinbiologicalterms Infact thedefinitionspeopleattachtoparticularbehaviorsorconditions labelingthemhealthyorunhealthy wellorsick oftenderiveasmuchfromnonmedicalfactorsasfrommedicalones Nevertheless thesymbolicinteractionistperspectivehasbeencriticizedfordownplayingtheobjectiverealityofhealthandillness Afterall peopledogetsickandsufferdebilitatingphysicalillness regardlessofwhethertheyareprofessionallydiagnosedorsociallylabeledsick Illnesscanalsoexitindependentofself definitions Forexample anunderweightwomenwhoconsidersherselfoverweightandrefusestoeatwillexperienceharmfulphysicalchangesthatcaneventuallycausedeath evenasshedefinesherdramaticweightlossashealthy Finally criticschargethethatsymbolicinteractionistsoverlookhowsocialinequalityaffectswhoandwhatgetsdefinedassickorwell Andhowapersonsodefinedistreatedbythemedicalcommunity Part4SocialCapitalandHealth Section4 1WhatisSocialCapital Socialcapitalreferstotheinstitutions relationships andnormsthatshapethequalityandquantityofasociety ssocialinteractions Increasingevidenceshowsthatsocialcohesioniscriticalforsocietiestoprospereconomicallyandfordevelopmenttobesustainable Socialcapitalisnotjustthesumoftheinstitutionswhichunderpinasociety Itisthegluethatholdsthemtogether Section4 2SocialCapitalandHealth NutritionandPopulation Therelationshipbetweensocialcapitalandhealthhasbeendocumentedsince1901whenEmileDurkheimidentifiedarelationshipbetweensuicideratesandthelevelofsocialintegration Sincethenresearchhascontinuedtodemonstratethathighersocialcapitalandsocialcohesionleadstoimprovementsinhealthconditions Recentresearchshowsthatthelowerthetrustamongcitizens thehighertheaveragemortalityrate HealthandNutrition Socialcapitalcanimpacthealthandnutritionthroughavarietyofmethods Trustcombinedwithformalandinformalsocialnetworkshelppeopleto accesshealtheducationandinformation designbetterhealthcaredeliverysystems actcollectivelytobuildandimproveinfrastructure advancepreventionefforts andaddressculturalnormswhichmaybedetrimentaltohealth SocialNetworksPromoteBetterHealthEducation Itiswidelyacceptedthateducationonnutritionandprenatalcareimproveshealthoutcomesforchildren Thereisalsoalinkbetweenincreasedgeneraleducationofgirlsandimp