7.2 The Social Construction of Health
Amy Huskey and Elizabeth B. Pearce
“It is health that is real wealth and not pieces of gold and silver.”
—Mahatma Gandhi
Health is the “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” as defined by the World Health Organization (2005) in its Constitution. The organization goes on to state that families and communities are able to thrive when individuals are able to maintain health. Our employment, finances, mental and emotional functioning, and spiritual lives all interact with our overall health.
The United Nations Universal Declaration of Human Rights Article 25 identifies health as a human right:
1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control.
2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection (United Nations, 1948).
While the status of health is very real, it is also important to examine the aspects of health and illness that are socially constructed. As members of society, we share assumptions about reality that define both health and illness. Illness has a biological component, yet it also embodies an independent element that is experienced by the person and observed by those outside of the illness. Societies construct the idea of “health” differently from place to place and over time. For example, many societies consider health and health care to be a human right that all human beings are entitled to, but this is not universally true (figure 7.1). What is your viewpoint?
The social construction of the idea of family, as discussed in Chapter 1, plays a special role in the health of families in the United States. In all other industrialized countries, health care is considered a human right, and all individuals can access comparable care regardless of family status. But in the United States, health care insurance is accessed through a variety of systems, all of which have age, income, employment status, and family relationships as criteria. How do definitions of “family” impact the access of any individual to health care?
Social Stigma and Family Health
Society informs the definitions for when an illness can be considered a disability, how eligibility for insurance and medical coverage are determined, what illnesses are perceived as legitimate, when the reality of an illness is questioned, and what illnesses are stigmatized (Griffiths & Keirns, 2015). These social constructs can, in themselves, contribute to differentiation in individual health as well as stereotypes, prejudice, and discrimination. Stigma, the social process whereby individuals who are taken to be different in some way are rejected by the greater society in which they live based on that difference, operates in the world of health, ability, and illness. Sociologist Erving Goffman said, “Stigma is a process by which the reaction of others spoils normal identity.” A disease or illness that is stigmatized is one in which there is some societal disapproval or questioning of the integrity of people who have the disease, which can also include medical professionals and the person with the disease stigmatizing themselves (figure 7.2).
In Focus: Families, Health, and Stigma
Mental health is a state of mind characterized by emotional well-being, behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish relationships and cope with the ordinary demands and stresses of life.
It deserves a specific mention when it comes to stigma, as society has long considered it to be something that individuals can fix, rather than needing medical attention. Someone struggling with depression that causes weight gain or weight loss due to a lack of appetite or excessive hunger is an example of the relationship between mental health and stigma. Obesity and emaciation are both stigmatized in our culture, while the underlying health condition may be ignored. Mental illness is a wide range of mental health disorders that affect your mood, thinking, and behavior. Although we have seen a shift in media about mental illness from known celebrities coming forward, such as Demi Lovato, Chrissy Teigan, Steve Young, and Dan Reynolds, there is still a social stigma against mental illness. When a family member is diagnosed with a physical illness such as cancer or heart disease, we see communities and families coming together. Unfortunately, we rarely see mental illness struggles come to the surface without holding a place of shame or guilt; individuals, families, and communities are often more reluctant to talk and come together in the same way. Figure 7.3 expresses the concern that mental health is often hidden or pushed aside.
When we speak about stigma, we speak of two different types: the social stigma, meaning the prejudiced attitudes others have around mental illness and self-perceived stigma, which is an internalized stigma that the individual who suffers from the mental illness has. Not only may the stigma around mental illness create painful emotions and a sense of invalidation for the individual, but it can also result in a reluctance to seek treatment, social rejection, avoidance, isolation, and direct harm to psychological well-being. Stigma is reinforced by common cultural misconceptions, social stereotypes, popular media representations, the politicization of health care, and even some medical professionals and health care institutions.
There are many socially stigmatized diseases, including HIV/AIDS and other sexually transmitted diseases, substance use disorders, skin conditions, and diseases that are less understood by the medical community, such as autoimmune disorders and chronic fatigue syndrome. Individuals may be less likely to seek treatment when experiencing symptoms of a stigmatized condition. In the United States, health insurance, paid for by the consumer or another entity, covers a portion of the risk of a person incurring medical expenses is the norm, rather than universal health care. Insurance creates another layer of bureaucracy, and less understood illnesses and treatments may not be covered by some insurance companies.
Even if a person with a stigmatized disease accesses health care, they may have fewer social supports and greater chances of isolation and discrimination in the health care setting and beyond. Management of a disability because of the deterioration of health due to a stigmatized illness can prove to be a tremendous hardship (Sartorius, 2007). It is important to consider how marginalized groups experience health inequities, including those experienced due to the stigma and prejudices linked with the societal perception of specific illnesses.
In Focus: Lung Cancer and Stigma
In a 2014 report, “Addressing the Stigma of Lung Cancer,” the American Lung Association (ALA) described how stigma can contribute to patients avoiding or delaying care when symptoms are experienced and how they may resist disclosing health information to providers. Patients could also experience fewer social supports, feel more distress related to the disease, experience additional conflicts in relationships, and receive lower-quality health care. The report then explained how the stigmas around lung cancer related to lung cancer being hard to detect early, being seen as a death sentence with little hope for survival, and being labeled “a smoker’s disease.” This could contribute to society’s feeling that people with lung cancer are to blame for their disease and ought to feel ashamed.
According to the ALA survey, the public lacked knowledge regarding the prevalence and mortality of lung cancer, as well as knowledge about the funding levels for research. Responders also lacked knowledge of factors other than smoking that contributed to the development of lung cancer, such as genetics and occupational or environmental exposures. Lack of knowledge could play an important role in perpetuating some of the negative associations with and assumptions related to lung cancer (figure 7.4).
Lung cancer stigma has real consequences. People with lung cancer may hide their condition and experience anxiety and depression. They may believe that health care providers are judgmental and biased toward them. Research, advocacy, and public policy are also dimensions in which stigma can have negative consequences for advancing progress toward the treatment of this disease. For instance, lung cancer kills far more people than any other cancer type and contributes to over 25% of all cancer deaths per year (American Cancer Society, 2020). Yet, a study of nonprofit research funding by cancer type determined that lung cancer ranked fourth in its level of funding and is underfunded in relation to its burden on society (Kamath et al., 2019). Not only are funding levels influenced by stigma, but celebrities, community leaders, and volunteers may be less likely to lend their names or volunteer their time due to negative associations with this disease (American Lung Association, 2014).
After reading this, you may want to reflect on or discuss these questions:
- Notice if you blame or hold people more responsible knowing that they have lung cancer than if they have another cancer such as breast or prostate cancer.
- What effects could stigma itself have on people who are sick and the health care that they receive?
- Is the stigmatization of lung cancer a social problem? Or a personal problem?
Structural Power and Family Health
One’s status in society, or structural power, can complicate the experience of social stigma related to medical conditions. For example, cisgender men hold more power in the United States than women or people outside the gender binary. What role does that play in the diagnosis of real health concerns and the social construction of those concerns?
We know that, overwhelmingly, men are the subjects of the majority of medical studies and research. That affects what is thought of as “typical” or “normal.” Women have more often been told that their symptoms are “all in your head” or related to “female troubles.” While this is less common than in the past, it likely continues to play a part in the misdiagnosis of serious illness in women and people with nonbinary gender identities. We also know that women experience diseases such as chronic fatigue syndrome and fibromyalgia in much higher numbers than men. The medical community describes these syndromes in overly broad terms that make diagnosis difficult. We must ask ourselves: How do these multiple complex factors serve to continue to reinforce the existing power dynamic in the United States? What systemic changes in health care would reduce this inequity?
In Focus: The Overlapping Demands of Work, Family, and COVID-19 Testing
Carmen Quinero, a 35-year-old essential worker who works at a distribution center that ships N95 masks in California, developed a severe cough in late March 2020. Her workplace’s human resources department told her to stay home until she was tested for the virus. Quinero has health insurance coverage through her employer, but she has a $3,500 deductible.
Tests were not widely available in March 2020, so she was directed by her doctor to go to an emergency room. She went to the closest one, a for-profit hospital owned by Universal Health Services, one of the largest health care management companies in the United States. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) had passed the week before, and it had been widely publicized that coronavirus testing and treatment would be free to individuals and covered by the federal government.
Unfortunately, the legislation was full of loopholes, including for people like Quinero who needed a test but were unable to get one due to the low supplies. Although she was given a chest x-ray and prescribed an inhaler, she was not tested. That means that not only was she responsible for the $1,840 in hospital and doctor fees, but she had to miss a week of work (mostly unpaid), putting a considerable financial strain on Quinero and her family.
Quinero’s case is not isolated and is not specific to the coronavirus. Access to and coverage for the test for COVID-19 illustrates how the patchwork of insurance, government programs and laws, and private payments inequitably affect lower-income people, whether or not they have health insurance coverage.
If you want to hear more about Carmen’s story, listen to this 4-minute recording from the NPR-KFF series Bill of the Month.
In this chapter, we will examine the overall health of families in the United States, with attention to comparisons among families’ experiences with health, illness, injury, and diseases, as well as comparisons with other countries. We will describe the daily life factors and resources that affect health, including the effects of stigma, prejudice, and discrimination. We will look closely at how families access health care services, including the health care insurance system. We will discuss the question of health care as a human right.
Every time an individual is considered part of a marginalized group, including illness status, it intensifies the effects of discrimination and resulting health disparities, which are preventable differences in the burden of disease that are experienced by those groups. Considering disparities and social stigma provides a way of thinking about the social construction of illness. Someone from the LGBTQIA+ community, for instance, already faces challenges in finding health care providers who are culturally competent and have knowledge of LGBTQIA+ health (U.S. Dept. of Health and Human Services, n.d.). If they are also dealing with a stigmatized illness, then they have multiple obstacles that stand in the way of them receiving quality health care.
One could also examine how socioeconomic status (SES) may further complicate this scenario by realizing that people living in poverty are more likely to have no health insurance, therefore restricting access even more (U.S. Census Bureau, 2019). Even geographical location, like living in a rural area or in the Southern portion of the United States, will reduce accessibility to health care (Warshaw, 2017).
Institutionalized inequities have been amplified during the coronavirus pandemic, as illustrated in figure 7.5. Some of the factors that contribute to greater numbers of Black, Indigenous, and Latinx families being affected by the COVID-10 virus include the following (Centers for Disease Control and Prevention, 2020):
- Crowded work environments such as meat-packing facilities
- Food deserts
- Less health insurance
- Less access to health care and virus testing as measured by geography and transportation options
- Greater likelihood of experiencing discrimination, stress, and lack of sleep
In Chapter 4, we illustrated the ecological systems theory. When families are viewed as a system, it is easy to imagine how health challenges of one family member impact the whole family. Imagine that a parent of young children is sick and can’t care for their children. In addition, what if they lack health insurance or have to take two buses to get to their doctor’s office? Not only is the parent unable to care for their children, but they must also weigh whether to try to see a doctor, how to provide childcare, and how to pay for the visit. As you read this chapter, consider how each of the health challenges described may affect a family system, as well as the surrounding societal functions.
Comprehension Self Check
Licenses and Attributions for The Social Construction of Health
Open Content, Original
“The Social Construction of Health” by Elizabeth B. Pearce and Amy Huskey, with the exceptions noted below. License: CC BY 4.0.
“In Focus: The Overlapping Demands of Work, Family, and COVID-19 Testing” by Elizabeth B. Pearce. License: CC BY 4.0.
Open Content, Shared Previously
Figure 7.1. “Chalking the Universal Declaration of Human Rights 2015″ by University of Essex. Licensed under CC BY-NC 2.0.
“In Focus: Families, Health and Stigma” adapted by Elizabeth B. Pearce. License: CC BY 4.0.
“In Focus: Lung Cancer and Stigma” adapted by Elizabeth B. Pearce from “Health and Medicine” in Introduction to Sociology 2e.
Figure 7.2. “Lung Cancer Awareness” by Steve Thompson/Air Force Medicine. Public domain.
Figure 7.3. “Right on” by LizSpikol. License: CC BY-NC-ND 2.0.
Figure 7.4. “Stigma – Social and Self | Individuals and Society | MCAT” by Khan Academy and AAMC. License: CC BY-NC-SA 3.0.
All Rights Reserved Content
Figure 7.5. “COVID-19 Update for April 21, 2020” © American Medical Association. License: Standard YouTube License.
References
American Cancer Society. (2020, January 8). Lung cancer statistics: How common is lung cancer. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.htm
American Lung Association. (2014, April). Addressing the stigma of lung cancer. https://www.lung.org/lung-health-diseases/lung-disease-lookup/lung-cancer/living-with-lung-cancer/how-to-talk-about-your-cancer/addressing-lung-cancer-stigma
Griffiths, H. & Kerins N. (2015, April 24). Introduction to Sociology 2e. OpenStax. https://openstax.org/books/introduction-sociology-2e/pages/19-1-the-social-construction-of-health
Kamath, S. D., Kircher, S. M., & Benson, A. B. (2019). Comparison of cancer burden and nonprofit organization funding reveals disparities in funding across cancer types. Journal of the National Comprehensive Cancer Network, 17(7), 849–854. https://doi.org/10.6004/jnccn.2018.7280
Sartorius, N. (2007). Stigmatized illnesses and health care. Croatian Medical Journal, 48(3), 396–397.
U.S. Department of Health and Human Services (2020) Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health#31
U.S. Census Bureau. (2019, May 23). Who are the uninsured? https://www.census.gov/library/stories/2018/09/who-are-the-uninsured.html
Warshaw, R. (2017, October 31). Health Disparities Affect Millions in Rural U.S. Communities. https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities
World Health Organization. (2005, September 15). Constitution. https://www.who.int/about/who-we-are/constitution
the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
an international document adopted by the United Nations General Assembly that enshrines the rights and freedoms of all human beings.
the developmental changes and transitions that come with being a child, adolescent, or adult.
meaning assigned to an object or event by mutual agreement (explicit or implicit) of the members of a society; can change over time and/or location.
the unequal treatment of an individual or group on the basis of their statuses (e.g., age, beliefs, ethnicity, sex).
a negative or discriminatory attitude toward others related to a specific characteristic or difference, often of a marginalized identity.
a state of mind characterized by emotional well-being, behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish relationships and cope with the ordinary demands and stresses of life.
the shared meanings and shared experiences passed down over time by individuals in a group, such as beliefs, values, symbols, means of communication, religion, logics, rituals, fashions, etiquette, foods, and art that unite a particular society.
a wide range of mental health disorders that affect your mood, thinking, and behavior.
can include the emotional significance of an action or way of being; the intention or reason for doing something; something that we create and feel; closely linked to motivation.
a type of insurance, paid for by the consumer or another entity, that covers the whole or a part of the risk of a person incurring medical expenses.
a method by which sociologists gather their data by asking questions.
a systematic investigation into a particular topic, examining materials, sources, and/or behaviors.
a large issue that affects many people, can threaten the health and well-being of society, is recognized as a problem by many, includes multiple causes and effects, and needs a systemic solution.
a person who identifies in accordance with their gender assignment.
a socially constructed expression of a person’s sexual identity which influences the status, roles, and norms for their behavior.
a social construct composed of two parts that are framed as absolute and unchanging opposites.
preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.
a population census that takes place every 10 years and is legally mandated by the U.S. Constitution.
a framework that looks at individuals within their environments.
usually used to refer to non-parental care of a young child, often in a paid provider’s home or in a childcare center.