Life expectancy and illness are strongly influenced by ecological and social factors. The way people respond to and treat different illnesses varies from country to country and for different groups within one society. The same physical ailment may be treated by witchcraft, prayer, the laying on of hands, or radiation and chcmotherapy, or some combination of these, dcpending on the culture in which the illness occurs.

In addition, people in different societies around the world die of very different causes. In preindustrial and developing societies, people may weaken and die of tuberculosis, starvation, and parasites such as tapeworms. Many young children die of malnourishment, typhoid, or diphtheria. In industrial societies, most of these causes of death have been eliminated. Moreover, previously stubborn diseases such as smallpox, polio, German measles, tetanus, diphtheria, mumps, and measles have been controlled.

People in industrial societies generally live to be much older, on the average, and die of quite different causes than people in preindustrial societies. Cancer, heart disease, and stroke are the chief killers in industrial societies.

The Health of Americans

American health patterns are consistent with these trends. Americans are much more likely to die from chronic illness now than they were at the turn of the century (Figure 18.8). Deaths from infectious diseases have dropped over the last 80 years. Accidents continue to account for about 10 percent of deaths, and these are particularly likely to involve Americans under age 30. Wide dif ferences remain within the United States in death rates and types of illness according to social class, race, and sex. There also are cultural differences in reaction to pain, with some cultural groups such as those of Anglo Saxon or Asian origin talking less about their pain than other cultural groups (Zborowski, 1981). As noted in Chapters lO and 11, whites have a longer life expectancy than blacks, and women live longer than men. The life expectancy of women has increased dramatically in the last 60 years. It was 56, only two years longer than that for men, in 1920, but by 1987 it was 78.3, seven years longer than men's (U. S. Bureau of the Census, 1989a).

Figure 18.8 The Changing Contribution of Chronic and Infectious Conditions to Total Mortality (Age- and SexAdjusted), in the United States, 1900-1973. In this century, increasing numbers of people have died from chronic conditions rather than infections. Source: McKinlay and McKinlay, 1986, p. 16.

How can we explain the dramatic drop in mortality rates, the shift in the causes of death, and the persistence of gender, race, and socialclass differences in death and disease in the United States? A likely answer seems to be the progress and availability of modern, scientific medical care. Throughout this century, medical practitioners armed with increasingly powerful tools and techniques have attacked and wiped out many diseases. But because some social groups have not had access to physicians or hospitals, they have been more likely to get sick and to die at younger ages.

Figure 18.9 The Fall in the Standardized Death Rate (per 1000 Population) for Four Common Infectious Diseases in Relation to Specific Medical Measures, for the United States, 1900-1973. Mortality from these discascs had already dropped dramatically before vaccines or treatments were discovered. Source: McKinlay and McKinlay, 1986, p. 2.

Continued differences in health and death rates for different groups in the United States today result from both social and medical causes. People in higher social classes tend to be healthier than those in lower social classes. This phenomenon seems to be due to better nutrition, lower likelihood of smoking, lower exposure to health hazards and stressful situations, more knowledge about health, and greater access to superior health care (Kitagawa, 1972;Syme and Berkman, 1981). Both medical and social factors seem to affect gender differences as well. Among young adults, males are more likely to succumb to accidents. At older agcss, heart and kidney diseases and lung cancer contribute to the higher mortality of men. Women, in turn, have become less likely to die in childbirth or of uterine cancer in recent years (Waldron, 1981). Cultural factors play a role in the lower mortality rates among married rather than single or widowed males, particularly from such causes as cirrhosis of the liver (associated with heavy drinking). Gove (1973) argues that married men receive better physical care than single ones and have a greater sense of psychological well-being.

Diseases that are on the increase in the United States also appear to have important social causes. More than 53 million people in the United States-over one-quarter of the population-will develop some form of cancer. Why, in the face of improved techniques of identifying and treating cancer, has the rate of death due to this disease increased? Some argue that rising levels of industrial chemicals in our environment and the exposure of large numbers of people to those chemicals over the last four decades are related to these increases (Epstein, 1981). Experts suggest that up to 90 percent of human cancers are environmentally induced.

Life expectancy is related to a rising standard of liVillg which enables people to buy more nutritious food. Better nutrition, in turn, increases resistance to disease and the chances o f surviving illness.

This conclusion is supported by evidence showing that the incidence of cancer varies geographically (Epstein, 1981). It is already known that about 50 percent of long-time asbestos-insulation workers die of cancer; the rates of bladder cancer are very high in dye and rubber industry workers; lung cancer is up in uranium miners of Colorado and coke-oven workers. Other cancers are associated with certain occupations: skin cancer in shale-oil workers, nasal sinus cancer in woodworkers, liver cancer in workers making polyvinyl chloride, leukemia in benzene workers, and cancer of the pancreas in organic chemists. Lung cancer is demonstrably higher in smokers than in nonsmokers and possibly in their spouses and children as well.

Such cancers are ultimately preventable if the specific causes can be pinpointd. Spotting cancer-causing agents is sometimes difficult because cancers crop up 15 or 20 years after workers or residents are exposed to the agents (Selikoff, 1980). Not only are workers exposed, but vast areas of the world are in danger of contamination from the chemical wastes produced by many manufacturing processes (Magnuson, 1980). Industry seems unconcerned with the issue. When additional regulatory standards limiting environnaental and occupational exposure to toxic agents are proposed, industries often respond by forecasting major economic distress and unemployment as a result of the regulations. Such calculations overlook the fact that the economic (not to mention the human) costs of cancer are at least S15 billion a year (Epstein, 1981). The scourge of cancer calls for major social, economic, and political solutions at least as much as medical ones.

Other serious diseases, such as AIDS, have no known medical cures. Changes in social behavior are the only available ways to prevent infection. (See box in Chapter 21 for more on AIDS.)

Sophisticated medical technologies can help sustain the lives of very premature babies such as this one.

The Medical Profession in America

Why, if social features appear to be so important in health and illness, do Americans tend to think primarily in terms of physicians, hospitals, and medical cures? Perhaps the reason lies in what we see around us. We see large hospitals with sophisticated technology like CAT scanners, doctors trained in rigorous medical schools, and a host of supporting professions and personnel. Although these aspects of care are taken for granted today, doctors have not always offered effective cures or had an exclusive monopoly on medicine. Less than 100 years ago, they offered bleeding and strong emetics or purgatives as their major forms of treatment. Until the latter part of the nineteenth century, various groups, including midwives, shared medical practice with doctors. But by the 1920s, virtually only M.D. physicians had the legal right to practice medicine in the United States (Conrad and Kern, 1981). Their monopoly extends over the right to define illness and its treatment, the right to limit and evaluate other medical care workers, and the supervision of childbirth.

American medicine has not always enjoycd thc prospcrity and profcssional esteem that havc markcd its position sincc thc middlc of this century. In his award-winning book, The Social Transormation of American Medicine, Paul Starr (1989) traccs thc roller coastcr history of thc mcdical proScssion sincc thc ninetccnth contury.

The Nineteenth Century

In this pcriod physicians had an insecurc and ambiguous status and reccived low pay The lack of a solid scicntific basc for diagnosis and trcatment mcant thcy could do littlc to hclp thc sick othcr than to offer rcassurancc and moral support. Thc ficld of mcdicinc was in a statc of unccrtainty and disagrecmcnt.

The Early Twentieth Century

Aftcr thc Flcxncr report in 1910 mcdical education was completcly rcvampcd to bridgc thc gap bctwccn scicntific knowlcdgc and mcdical practicc Mcdical education camc to bc rootcd in basic scicncc rescarch and clinical instruction. Studcnts wcre cxpectcd to have some collegc training or even a collegc dcgrce bctorc attending mcdical school. Mcdical graduatcs had to pass a liccnsing cxam. As admission to thc profcssion becamc increasingly restricted thc numbcr of physicians dropped and thcir social charactcristics changcd. In particular thc numbcr of black and women's medical schools plumetted in this period (Ehrcnrcich and English. In 1900 20 pcrccnt of doctors in some American cities had becn women (Walsh 1977) but as recentlv as 1960 women reccivcd only 7 5 percent of all mcdical dcgrecs (U. S. Burcau of thc Census 1987a p 179) Although thc Flcxncr rcport and thc ensuing ccrtification requircmcnts for doctors cnhanccd thc scicntific status of mcdicine they also gcncrally restrictod access to a mcdical carcer to whitc malcs.

1945 to 1965

Thc post-World War Il ycars saw thc growth of an imcnsc medical rcscarch establishmcnt thc cxpansion of scicntifically advanccd hospitals and a trcmcndous incrcase in thc sizc of thc mcdical work forcc and thc amount of hcalth carc cxpcnditurcs. Physicians becamc prosperous socially privilcgcd and highly influential profcssionals who complctcly dominated thc health care markct. Univcrsity medical schools became ticd in with major hospital systcms in large mctropolitall arcas. Powcr was held by chairmcn-chicfs who chaircd thc major mcdical school department and wcre chiefs of mcdicinc surgcry and other departments in thc tcaching hospitals.

1970s and 1980s

Along with many othcr Amcrican institutions in thc l970s mcdicinc expcricnccd a stunning loss of public confidcnce. Scicntific progrcss in mcdicine capturcd public attention at mid ccntury but by thc 1970s and 1980s pcoplc were increasingly conccrned about costs and moral problems. The womens movement raiscd qucstions about the authority and powcr of doctors particularly in rcgard to childbirth practiccs and canccr surgery. As Starr notcs physicians found their political influence, economic powcr, and cultural authority all being challengcd.

At least four developmcnts willl strongly affect thc mcdical systom for thc rcst of this ccntury: thc incrcasing supply of physicians thc continuing cffort by government and cmploycrs to control the growth of mcdical cxpcnditurcs thc risig cost of mcdical malpractice insurancc, and thc growth of corporatc enterprise in hcalth scrvices. Changes such as thcsc will limit thc mcdical profcssion's control of markets and hcalth organizations, and they will affect thcir standards of judgement too.

As Starr (1982) suggests: In the future, more doctors will be in group practicc; more hospitals will bc in multihospital systcms; and morc insurance companics will bc dirccrly involvcd in providing mcdical carc through HMOs" (p 440).

The American medical profession is among the most independent and powerful of its kind in the world, and the organization of American health care is characterized by the monopolistic control physicians have over medical practice. Doctors have an exclusive state-supported right, apparent in the licensing of physicians, to practice medicine. They are the only ones who are legally entitled to prescribe restricted drugs, cut into the human body, and sign a certificate giving the cause of death. While each country grants slightly different privileges to its physicians, the medical profession in all modern countries stands in a dominant and influential position. In the United States, however, the professional's rise to dominance brought considerable control over the organization and financing of medical care. This was not typical of other countries.

Financing Medical Care

Perhaps the most striking feature of health care organization in the United States is the way it is financed. Medical care is considered a service available to those who can pay for it or who have insurance to do so-just as, say, the services of an auto body shop are available to people who can afford them. The price of medical care depends on market forces. This market model of medical care stands in sharp contrast to the organization of medical services elsewhere. In virtually all other industrial countries, medical care is viewed more as a right of citizenship than a service to be purchased. Health care systems received subsidies from the state. Hence, the kind and quality of the medical care received may depend on the nature of the illness, not on a person's income (Freidson, 1978). In recent years, financial barriers to adequate medical care in the United States have fallen considerably (Dutton, 1978; Rundall and Wheeler, 1979).

A team of medical researchers at Harvard was surprised to find that a significantly higher proportion of white people admitted to Massachusetts hospitals have coronary bypass operations and other heart surgery than do blacks (Stevens, 1989). This difference in medical treatment by race existed even when the study took into account other factors such as income, age, sex, and insurance status. The authors urged caution about concluding that black patients are underserved, however, suggesting that whites might undergo more unnecessary procedures than do blacks. Other researchers have found that black Americans significantly underuse medical care in the United States, and other studies report that blacks and women are less likely than white men to receive kidney transplants, even if they have similar incomes, insurance coverage, or states of health (Stevens, 1989). Such results suggest the need for further research on how social factors and health care are interrelated.

Problems in the Health Care System

The high level of professional autonomy and reliance on market forces has created problems in the U.S. health care system. As early as 1970, then-President Nixon announced that there was a "health care crisis" in the United States. This included the inability of many Americans to obtain medical care; the spiraling costs for people and government; and concerns about the success, priorities, and methods of medical treatment.

For example, the market model and the relative autonomy of doctors have led to problems in the distribution and type of doctors available. Physicians are very unevenly distributed throughout the nation. In 1985, Washington, D.C., had 573 active physicians per 100,000 population, compared to 119 per 100,000 in Mississippi (U. S. Bureau of Census, 1987a). Thousands of towns and counties in America have no doctor at all.

Another difficulty has been the increasing specialization of modern medicine. Until World War II, most physicians were family doctors, practicing general medicine and making house calls. Now, all but 14 percent of the nation's doctors are specialists (U. S. Bureau of the Census, 1989a) . This specialization may lead to higher costs, loss of perspective on a whole human being, and lack of continuity of treatment. This specialization, some argue, leads to higher costs, loss of perspective on the patient as a "whole person," and a lack of continuity in medical care for the individual.

Even when medical care is available, many Americans delay seeking care because of its high cost. Although 87 percent of the population had some kind of private health insurance in 1985, that still left 13 percent of Americans without any coverage at all (U. S. Bureau of the Census, 1989a). Moreover, many who have coverage find that it is limited as to the kind and amount of payment. The result is that some people can pay high prices to see private physicians, whereas many have only crowded public clinics and hospital outpatient facilities. Some even use the emergency room as a last resort when their medical condition worsens.

Even the staunchest defenders of the medical profession express concern about runaway medical costs. Although the cost of medical care in the United States is higher than almost anywhere in the world, we do not have the lowest infant mortality rates or the lowest death or disability rates. Health care costs increased more than 35 times between 1950 and 1986, as Figure 18.10 shows. In the latter year, they were about $458 billion (or 10.9 percent of the GNP). This was up from $13 billion (4.5 percent of GNP) in 1950 (U . S . Bureau of the Census, 1989a).

Figure 18.10 Rising Costs of Health Care, 1950-1986. Health care expenditures in the United States rose steadily between 1950 and 1986; in 1986, they represented 11 percent of the GNP. Source: U.S. Bureau of the Census, 1982a, p. 101; 1989a, p. 92.

Another major consequence of the current organization of health care is the relatively greater emphasis on the treatment rather than the prevention of illness. Yet some activities actively create illness and injury; for example, occupations such as logging, mining, chemical handling, or proScssional football have much higher rates of illness or injury than do many other occupations. Certain behaviors-such as being competitive, aggressive, and impatient- may be encouraged and rewarded in our socicty and yet be linked to higher rates of heart attack and high blood pressure. Various foods and drugs are widely advertised around the world (for instance, sugar-rich soft drinks, alcohol, coffee, cigarettes, and tranquilizers), although growing evidence suggests that they may be harmful to our health.

Despite the overwhelming hints that environmental causes of cancer might be a fruitful area for further investigation, the National Cancer Institute's expenditures on environmental cancer agents have been estimated at only 5 to 20 percent of the total (Epstein, 1981). Medical treatment has been very effective in preventing and treating acute infectous diseases suc. 1 as pneumonia, which lends itself to treatment with antibiotics. But long-tcrm chronic illnesses such as heart disease, cancer, and stroke are more likely to affect people in industrial societies. Therefore, an improved understanding of ways to prevent these diseases may produce more benefits (Torrens, 1978).

Responses to the Problems

Responses to the growing problems in American medical care have come from the public, "alternative" healers, the government, health care insurance companies, and the medical community itself.

Opposition to the rising costs of health care has been growing, both among private health insurance companies and in the federal government. Blue Cross and Blue Shield, among the largest private health insurance programs, set limits on the fees they will pay to doctors and hospitals. In 1983 Medicare (the government sponsored health insurance program for the elderly) began paying hospitals a preset amount based on the problem a patient was diagnosed as having, rather than simply reimbursing hospitals for itemized daily charges. Under this DRG (diagnostic related groups) system, hospitals face a cap on the amount they will receive for each patient. Therefore hospitals have urged physicians to cut unneccssary diagnostic tests and prescribe only essential care. This places physicians in a precarious position, because they also face increased pressure, from the rising number of malpractice suits, to run diagnostic tests. Despite the American Medical Association's bitter opposition, thc government began in the 1970s to reimburse charges by chiropractors through Mcdicarc and Mcdicaid (government sponsored mcdical insurance for the poor).

HMOs. The development of health maintenance organizations (HMOs) represents another organizational effort to trim health care costs. Members of an HMO pay a set fee each year to belong. In return, they receive a full range of health services. Some HMOs have been criticized for denying membership to poor health risks, so the reductions in cost may be offset by social costs.

HOSPICES. Hospices were started as a way of responding more humanely to the needs of terminally ill people, first in England and then in the United States (DuBois, 1980). The goal of a hospice is to help people with fatal diseases spend their last days in as little pain and as much comfort as possible and to provide them and their loved ones with emotional support. They may also help to reduce health care costs. Hospices may be part of a hospital or they may be independent. Some are mobile units of doctors, nurses, and social workers that help families care for dying patients at home. In general, hospices are designed to be as homelike as possible. Painkilling drugs are used as needed for relief, and no extraordinary efforts (such as resuscitation) are made to prolong the process of dying. Dying is treated as a natural part of the life cycle rather than as a "failure."

The U.S. public has not passively accepted problems in the medical care system. As early as the mid-seventies, a substantial portion of the American population was willing to question the authority and medical expertisc of physicians (Haug and Lavin, 1983, p. 69). Americans also gave more negative evaluations to government efforts in the mcdical-care system than did the citizens of six European countries (Pescosolido, Boyer, and Tsui, 1985). A grwing consunzerism in medicine has led to increased interest in selfcare, other types of medical practitioners (for example, acupuncturists), and physical fitness. In recent years, many residents of industrial societies, especially the United States, have joined health clubs, taken up exercise programs, or embarked on programs to ensure better nutrition.

Three changes in the delivery of health care have challenged physicians' professional dominance. The first two have already been mentioned. They are the greater involvenacnt of the government because of Medicare and Medicaid and the rise of consumerism in health care. The third is the corporate takeover by business conglomerates of a significant portion of the health market (Starr, 1982). By the mid 1980s, one out of five U.S. hospitals was owned by for-profit corporations (Cockerham, 1988, pp. 592-593).

Analyzing and changing the social origins of illness requires a different approach than that practiced by the health profession. It involves efforts to understand and change the ecological, political, and social forces affecting health and disease in our society.

The kind of medical care needed in a society depends partly on its age structure. A society's population, age structure, health care, and food production are all interrelated. When children do not regularly die of malnutrition or disease, parents tend to have fewer children. If such a decline follows a period of numerous births and life expectancy increases, the proportion of elderly in the population will increase. Such an increase has occurred in the United States, and it has numerous significant social consequences.