THE RELEVANCE OF SOCIAL SCIENCE FOR MEDICINE

THE RELEVANCE OF SOCIAL SCIENCE FOR MEDICINE

CULTURE, ILLNESS, AND HEALING Studies in Comparative Cross-Cultural Research Editor-in-Chief: ARTHUR KLEINMAN University of Washington, Seattle, Washington, U.S.A. Editorial Board: LEON EISENBERG Harvard Medical School, Boston, Massachusetts, U.S.A. NUR YALMAN Harvard University, Cambridge, Massachusetts, U.S.A. MORRIS CARSTAIRS Postgraduate Institute of Medical Education and Research, Chandigarh, India VOLUME 1

THE RELEVANCE OF SOCIAL SCIENCE FOR MEDICINE Edited by LEON EISENBERG Harvard Medical School, Boston and ARTHUR KLEINMAN University of Washington, School of Medicine, Seattle D. REIDEL PUBLISHING COMPANY DORDRECHT : HOLLAND / BOSTON : U.S.A. LONDON : ENGLAND

library of Congress Cataloging in Publication Data Main entry under title: The Relevance of social science for medicine. (Culture, illness, and healing) Includes bibliographies and index. 1. Social medicine. I. Eisenberg, Leon, 1922- II. Kleinman, Arthur. III. Series. [DNLM: 1. Sociology, Medical. WA 31 R382) RA418.R44 362.1 80-24965 ISBN-13: 978-90-277-1185-4 e-isbn-13: 978-94-009-8379-3 DOl: 10.1007/978-94-009-8379-3 Published by D. Reidel Publishing Company, P.O. Box 17, 3300 AA Dordrecht, Holland. Sold and distributed in the U.S.A. and Canada by Kluwer Boston Inc. 190 Old Derby Street, Hingham, MA 02043, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322, 3300 AH Dordrecht, Holland. D. Reidel Publishing Company is a member of the Kluwer Group. All Rights Reserved Copyright 1981 by D. Reidel Publishing Company, Dordrecht, Holland No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any informational storage and retrieval system, without written permission from the copyright owner

T ABLE OF CONTENTS PREFACE ix 1. LEON EISENBERG and ARTHUR KLEINMAN I Clinical Social Science SECTION 1: HOW ACADEMIC PHYSICIANS VIEW THE SOCIAL SCIENCES 2. ROBERT G. PETERSDORF and ALVAN R. FEINSTEIN I An Informal Appraisal of the Current Status of 'Medical Sociology' 27 SECTION 2: SOCIAL SUPPORTS: INFLUENCES ON HEALTH AND ILLNESS 3. LISA F. BERKMAN I Physical Health and the Social Environment: A Social Epidemiological Perspective 51 4. JOHN B. McKINLAY I Social Network Influences on Morbid Episodes and the Career of Help Seeking 77 SECTION 3: ILLNESS BEHAVIOR 5. ANDREW C. TWADDLE I Sickness and the Sickness Career: Some Implications III 6. MARILYN BERGNER and BETTY S. GILSON I The Sickness Impact Profile: The Relevance of Social Science to Medicine 135 7. GILBERT LEWIS / Cultural Influences on Illness Behavior: A Medical Anthropological Approach 151 SECTION 4: CULTURE, MEANING, AND NEGOTIATION 8. BYRON J. GOOD and MARY-JO DELVECCHIO GOOD / The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice 165 9. JOHN-HENRY PFIFFERLING / A Cultural Prescription for Medicocentrism 197 10. JOHN D. STOECKLE and ARTHUR J. BARSKY / Attributions: Uses of Social Science Knowledge in the 'Doctoring' of Primary Care 223

vi T ABLE OF CONTENTS 11. IRVING KENNETH ZOLA / Structural Constraints in the Doctor- Patient Relationship: The Case of Non-Compliance 241 12. WAYNE KATON and ARTHUR KLEINMAN / Doctor-Patient Negotiation and Other Social Science Strategies in Patient Care 253 SECTION 5: SOCIAL LABELING AND OTHER PATTERNS OF SOCIAL COMMUNICATION 13. NANCY E. WAXLER / The Social Labeling Perspective on Illness and Medical Practice 283 14. LINDA ALEXANDER / The Double-Bind Between Dialysis Patients and Their Health Practitioners 307 SECTION 6: SOCIOPOLITICAL AND SOCIOECONOMIC ANALYSES 15. HOWARD WAITZKIN / A Marxist Analysis of the Health Care Systems of Advanced Capitalist Societies 333 16. M. HARVEY BRENNER / Importance of the Economy to the Nation's Health 371 LIST OF CONTRIBUTORS 397 NAME INDEX 399 SUBJECT INDEX 406

To Carola and Joan

PREFACE The central purpose of this book is to demonstrate the relevance of social science concepts, and the data derived from empirical research in those sciences, to problems in the clinical practice of medicine. As physicians, we believe that the biomedical sciences have made - and will continue to make - important contributions to better health. At the same time, we are no less firmly persuaded that a comprehensive understanding of health and illness, an understanding which is necessary for effective preventive and therapeutic measures, requires equal attention to the social and cultural determinants of the health status of human populations. The authors who agreed to collaborate with us in the writing of this book were chosen on the basis of their experience in designing and executing research on health and health services and in teaching social science concepts and methods which are applicable to medical practice. We have not attempted to solicit contributions to cover the entire range of the social sciences as they apply to medicine. Rather, we have selected key approaches to illustrate the more salient areas. These include: social epidemiology, health services research, social network analysis, cultural studies of illness behavior, along with chapters on the social labeling of deviance, patterns of therapeutic communication, and economic and political analyses of macro-social factors which influence health outcomes as well as services. Particular emphasis is placed on patient-oriented teaching of social science in clinical training programs, teaching which attempts to translate knowledge and skills from anthropology and sociology in order to conceptualize sickness more adequately and to care for patients more successfully. We have chosen the chapters to reflect distinctive, clinically relevant examples of this new and potentially very important field of research. We have in mind a primary audience of medical and other health science students, physicians and other health workers in practice, and clinical investigators and teachers who wish to learn what is relevant in social science. We have asked our contributors to write for such an audience and where possible to spell out the practical significance of their work. While the chapters vary in their accessibility to a clinical audience, we believe all of them can be read with profit and that many will have immediate value for the applied interests of clinicians. In addition, we believe that a number of the chapters in this book will be of use to social scientists whose field of interest includes health and the health professions. The Editors share the view that social science has much to contribute to medicine, but that its practical implications need to be more precisely defined; strategies must be developed by which the new understanding can be more L. Eisenberg and A. Kleinman (eds.), The Relevance of Social Science for Medicine, ix-x. Copyright 1980 by D. Reidel Publishing Company. ix

x PREFACE effectively applied in medicine's distinctive domains. The chapters that follow disclose both successful examples and the difficulties in the process of transfer across disciplines. While some of the obstacles to this process arise within medicine, others emanate from social science. Although this volume does not pretend to have provided a recipe for the removal of these barriers, we believe that some of the major problems facing the integration of social science within medicine are identified and experiences in efforts to resolve them are shared. Quite clearly, there is at present no rigorous and systematic means for deciding what is most relevant, how it can be applied and how its efficacy can be assessed. In the absence of a common agreement on strategy, the best. that we can do is to share "state of the art" experiences and to compare outcomes critically. Many of the chapters in this book will advance this process and thereby indicate to readers significant directions for future collaboration. At the same time, others suggest (either explicitly or tacitly) where the limits of social science contributions may lie. In preparing a book for a non-specialist audience, we have attempted to avoid lengthy expositions of highly technical questions of interest primarily to the separate social science disciplines themselves. At the same time, this is no mere primer. We take our readers seriously and ask them to join us in confronting issues at the critical juncture of sociology and anthropology with health problems. We hope that the chapters will be sufficiently exciting that readers will be impelled to use the extensive bibliographies appended to them in order to consult original sources as well as general reviews. The Editors wish to acknowledge the outstanding secretarial assistance of Carla Millhauser and Marge Healy, and the editorial assistance of Leslie Morris. We would also like to thank our students and colleagues at Harvard and at the University of Washington whose sometimes jaundiced responses to our own early efforts to relate social science to medicine prompted the concerns which resulted in the creation of this volume. The undergraduate and graduate students who attended our seminars and conferences most always took the position: "I'm from Missouri; prove it to me." While we did not always succeed, the demand to "prove it" resulted in sharpening our own awareness of the limits of our understanding and of the need for a clearer and more logical exposition of what we thought we understood. We hope they profited from our interchange; we know we did. Boston and Seattle April 1980 LEON EISENBERG ARTHUR KLEINMAN