Public Health Programs as Social Change: Ambiguities and Conflicts

Public Health Programs as Social Change: Ambiguities and ConflictsAuthor(s): RODNEY K. CROOKSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 57, No.7 (JULY 1966), pp. 299-305Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41983910 .

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Public Health Programs as Social Change:

Ambiguities and Conflicts

RODNEY K. CROOK,1 Ph.D.

TN this paper an attempt will be made to suggest areas of sociological theory and

research which might be of significance to the professional working in the field of public health. After suggesting at the most general level an approach to health and illness within a sociological frame of reference, consequences of this view for the public health field will be noted. Some discussion of social characteristics with respect to illness and therapy will be offered and contributions of sociology to effective programs in public health will be suggested.

By illness will be meant a situation in which a member of any society through no fault of his own is rendered unable to meet normal role expectations in which he is involved. This view of illness is clearly based on Talcott Parsons' analysis (1, 2). It is such reciprocal relationships in a system of roles which make up what the social scientist speaks of as social structure. It follows from this view of illness that we have in mind a conception of maxi- mum efficiency in role performance against which standard in any society the desirable, the usual, and the limits of tolerable performance are located with respect to role performance.

Since the level of biological functioning of any population poses limits within which patterns of social organization must occur, it follows that every society has some conception, if not of health, then at least of illness, and develops methods of dealing with such illness. The institutional varia- tion shown by different societies in coming to terms with illness constitutes an area of considerable sociological interest. If illness is regarded as taking up a degree of "efficiency" slack in any society so it serves to reduce the effectiveness of the adapta-

1Associate Professor of Sociology, Dalhousie Uni- versity. Halifax, N.S.

tion of that society to its setting, then it poses a threat to the continued existence of the society at its current level of complexity if it is not contained within some arbitrary limits.

The definition of illness in any society depends on the conceptions within which experience itself is categorized, and always involves a point of recognition by the ill person himself, or by some other person, that there indeed does exist a state of affairs beyond his conscious control which renders him unable to meet normal expectations in social relationships, including performance of daily tasks. In addition to recognition there is always present what has been called the "sick role," a defined type of temporary identity with its own rules of reciprocity which allows the ill person to move out of the usual complexity of his daily life into a situation with less complex and heavy demands (3). It is to be noted that this incumbency of the sick role is always on a temporary basis since included in the legitimation of incumbency is the insistence that the sick person seek to return (or someone acting on his behalf seeks to return him) to normal functioning as soon as possible.

The implication of illness and the threat posed to the continued existence of any society at a given level of complexity require that, quite early in the division of labour by which tasks are differentiated, there develop medical practitioners whose task it is to handle sickness and to intervene in order that the patient is returned to health. It should perhaps be clarified that one does not equate the efficiency of modern medical practice with the old woman of traditional Mexico or with the shaman, but at any level of social structure the same process is occurring. What may differ is the sophistication of the diag- nostic categories and their linkage into

299



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systems of theoretically based therapeutic intervention. A glance at comparative life tables serves to clarify this point.

In western society the usual process through which incumbency of the sick role is legitimized and through which the patient seeks to return to normal functioning is by consultation with a medical professional. In this relationship between professional and client, the patient, as client, voluntarily seeks the advice of the professional, or, in the case of the old or young, a member of kin acts on his behalf in seeking professional help. The relationship between physician and patient, since it is one case of the relationship of professional and client, is structured in such a way that the professional acts within his specific areas of training and competence in the best interests of his client. The client, for his part, looks to the professional for advice which he voluntarily accepts as being "in his interests".

The central feature of the voluntary nature of the contract between professional and client is stressed since it is a crucial defining criterion of the relationship that the client be viewed as a moral agent capable of acting in appropriate ways. To illustrate the point, we might note the extreme difference between the process of committal to a mental hospital and agree- ment to accept the advice of a trusted professional in agreeing to undergo recom- mended in-hospital therapy. Inasmuch as a person is placed without his consent into the role of patient in a mental hospital, he is being stripped of the social bases of his identity as an adult member of the society through the removal of his rights as a moral agent (4).

In terms of this emphasis on the voluntary contract between the professional and his client, it follows that a person does not seek professional help unless he views his own activities in such a way that there appears to exist a state of affairs in which his normal activities are hindered. Beyond this general recognition it is further necessary that the potential client also con- ceptualize this experience in terms of at least gross symptoms which seem to him to lead to seeking the help of a physician. To clarify: the decision to seek professional help is a complex and highly sophisticated decision requiring as a mini- mum that the adult recognizes that (a)

there is indeed something wrong, ( b ) that it is the sort of experience which he has learned falls into the general categories of illness in his society, and (c) that he then perceives the physician as the appropriate person to consult, as opposed to his mother, the family medical book, a wise aunt, a spiritualist, a chiropractor, or merely de- cides to go to bed for the rest of his life.

Since part of medical science always deals with uncertainty, and to articulate between the profound concern of the individual for his own condition and the general rules which apply clinically to cases like his, there is always a religious component in the relationship of physician and patient. The awe in which the client holds the physician reduces his uncertainty and helps in meeting the anxiety involved in his existential situation. One theoretically useful way of looking at the activities of the medical profession is in terms of the strategies adopted which heighten the religious component of the role.

Role Ambiguities and Dilemmas of the Public Health Officer

The traditional relationship between client and professional discussed above, although it follows socially defined rules, nevertheless involves an extremely individualistic view of illness. Within this conception illness is something which affects one individual and reduces his personal effectiveness. Yet, from the sociologist's point of view, illness may also be viewed as a threat to society and not only to individual happiness and well-being. The development of social or preventive medicine has shown increasingly that the conception of individualism involved in illness, while it may be useful and necessary at the level of therapeutic intervention in the single case of a given illness, is not appropriate to large-scale intervention to reduce the prevalence of a given type of illness.

The very basis for preventive medicine is involved in by-passing certain of the stages noted above in considering the process by which a person seeks help from the physician. In the case of public health medicine there is no recognition by an individual, or someone acting on his behalf, that there is indeed something wrong. In this case, it is precisely the point that there is nothing wrong at a level which leads to seeking professional help. The person does



July 1966 SOCIAL CHANGE 301

not link his normal functioning to a set of conditions which can be best maintained by the intervention of professionals. If we do not voluntarily seek the advice of the professional, then his attempts at intervention must be seen as unwarranted meddling by experts. Health, except for the very sophisticated, is seen merely as the normal situation which is unquestioned. Illness is something which happens to individuals who then do something about their condition.

There is an absence in most people's minds of any basic appreciation of the purposes of public health services. "They" are the people who do something about gross health hazards but there is no real understanding of any sustained idea of maintaining a social situation which is least likely to result in the onset of illness. When, for example, a public health nurse seeks to gain information about all new- born babies, she is often treated with indignation by middle-class mothers, since any attempt to suggest that there may be health problems of which the mother is not aware is to threaten her conception of herself as a good mother. For someone to call uninvited to discuss health is to suggest that she is in need of charity, that she is being confused with the lower class who do need things done to and for them since, as every middle-class person "knows", they are incapable of looking after themselves.

The public health worker is precisely the opposite of the traditional physician standing in a warm, personal relationship to his client (if only in ideal terms). The public health worker is interested in the distribution of specific illnesses in a given population and the social conditions which favour the development of such illness rates. His focus is not individualistic and he acts, not on behalf of the patient as client, but on behalf of a community as his client. Whereas, in our society, the physician typically meets his client in his own office, where he alone determines the structure of interaction that develops and is totally able to act as "stage master" in the situation, the health officer does not consult with his client in this way. His role is less personal, less filled with awe, less legitimized, and more complex.

What is being suggested, then, is that knowledge of the social aspects of illness

has developed more rapidly than the insti- tutionalized arrangements in our society for handling the implications of this knowledge. Yet, if the health officer is to be effective, he is forced to come to terms with the present idea systems and values within which the population handles illness. Telling a community that the use of fluorides is desirable is not the same type of activity as telling a client in a consulting room that a specific medication should be taken "as instructed on the bottle". The sources of decision at the level of the individual have already predisposed him toward accepting his physician's advice - his presence in the office would make little sense otherwise. At the community level, the decision to introduce fluorides into the water supply is a more complex issue which must come to terms with both the power and influence structure of the community, and also existing modes of con- ceptualizing the world in different segments of that community.

The public health officer treads a tight- rope between arbitrary authority, which may be self-defeating, and the necessity of educating a public which he may not understand. At the same time, the very different activities of professionals in public health and the traditional medical prac- titioner do not always allow for the most sympathetic relationships. The public health officer's relationship with his client is nearer to that of a professor in a university setting than to the independent physician. He is, at the same time, both professional and also employee, while he is in some sense given a mandate to act on behalf of a whole community. Clearly, only as notions of extreme individualism in their more inappropriate areas continue to dis- appear can the public health worker be- come able to work more effectively.

Some Social Correlates of Illness , Preven- tion and Therapy

The discussion of the relationships between social characteristics of a population and the distribution and frequency of specific types of illness is not new, and indeed, quite sophisticated discussions of issues such as diet were carried on long before the advent of modern medicine. In Britain, for example, studies of the relationship between socio-economic class and age-specific death rates from various causes



302 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 57

have been carried on for many years and were effective in facilitating both legisla- tion and social and economic change.

Studies which serve merely to indicate the relationships which exist in a given population at risk between socio-economic status, or any other social characteristics, such as ethnicity, age, sex, and the incidence of a given illness, can be made within a general view of the nature of illness itself which retains the individualistic notions of the past. Such studies may be most useful in altering attitudes towards social change, particularly when the illnesses concerned threaten middle-class populations, and thus can facilitate the development of meaningful policies of social and preventive medicine. They do not, however, contribute greatly either to social science itself or to a real understanding of illness.

To illustrate, let us assume that there is a direct relationship between socio- economic status and the frequency of visits to a physician, such that the higher the socio-economic status the more frequent the visits. On the basis of this, we cannot give either a theoretical account of the relationships existing between the two variables or intervene to change the situation with any probability of success. There is, however, in the way in which such studies have been undertaken and the results used, an assumption that "naturally" all people would seek medical advice if given equal access to that advice through either equalization of income or making the service free or nominally priced. The model of man as entirely rational and entirely motivated by economic considerations may be seen as stemming from the days of the nineteenth century when a more sophisticated social science was unavailable, and indeed, its very possibility denied.

Studies made in Britain since the advent of socialized medicine have indicated that people do not necessarily utilize access to medical attention even when that attention is freely available (5). This leads back to the earlier discussion of the nature of illness in any society, in which it was suggested that it was required that recognition take place (itself a function of education in that society) and such recognition was linked to categories concerning illness and the appropriate avenues for the legitimate adoption of the sick role. It may well be

the case in communities and neighbour- hoods characterized by lower socio-economic levels and having a moderate continuity and stability that the process of defining illness, and the avenues which exist for dealing with it, do not accord with those which are prevalent in the middle class. This does not mean that there is an absence of any conception of illness or of therapy such that the health worker has to go into a neutral situation and offer the pearls of modern medical science to a delighted and receptive public - a position which would from the point of view of the health worker be anticipated. Rather, it follows from earlier comments that there already do exist in any community or neighbourhood modes of con- ceptualizing and dealing with illness and with its disruptive effects. These modes may not accord with those of the public health worker and may appear to him to be harmful, ignorant, superstitious or ex- hibiting sheer indifference. They are to that community, however, just as important and embedded into the structure of everyday life as the public health worker's are to him.

Preventive medicine involves the capacity for the highly sophisticated act of prepar- ing now for an eventuality in the future which may not, in any case, happen. This type of "time-binding" activity is clearly related to the middle-class value system in modern industrial societies, and one source in our own society lies in the prudence deeply ingrained in Protestantism. Time- binding requires, however, in addition to the style of child-rearing which charac- teristically reproduces the pattern in any new generation, that there is some reason for believing that tomorrow may be controlled, and that one's future life history is open to conscious intervention in the present. In many parts of the world in pre-industrial societies, there has been no reason ever to think in this particular way involving as it does a view of individualism, freedom, and power which would be mean- ingless. Similarly, in relatively large segments of western society there is less stress on future orientation, less stress on individualism, and more emphasis on the role of the family and neighbourhood in meeting eventualities as they occur - "enough for the day is the evil thereof". The economic powerlessness of large numbers




of people leads to resilience in the face of change rather than to active intervention.

In suggesting this relationship between the development of medical science and the utilization of facilities by a population, it also may be noted that even with middle- class populations, and at the level of the individual, something rather strange appears to intervene to obstruct preventive programs. If asked how often a person should have medical check-ups, the usual response in middle-class people would be once a year. However, the evidence suggests that very few do have such check-ups, and only then because of necessities such as insurance policy requirements. This suggests that there are other forces operat- ing to reduce the probability of effective preventive programs.

It is possible to be perfectly well aware that unnecessary weight increases the risk of many illnesses and continue to overeat, or to know the risk factor of lung cancer, yet continue to smoke cigarettes. In human affairs it seems extremely difficult even to apply probability statements about a given class of persons to ourselves in a syste- matic way. In the face of uncertainty, even when the odds of any trained observer are against us, we seek to defend ourselves against the implications. Our own life history, centering on this moment of experience, is somehow qualitatively different from that of any other person who ever lived. We somehow believe that in the absence of all or none predictions (and probability statements are precisely the opposite of all or none predictions) what is left over is somehow accounted for in terms of "luck". Since it is always most difficult to accept the certainty of our own death phenomenologically, so we always seek the escape hatch of being the one to whom the events cannot really occur. Such intrapsychic games make perfect existential sense (without introducing notions about the death wish); they do, however, make preventive medicine more difficult.

Another area for comment concerning the relationship between programs in the area of public health and the structure of society is the problem of the sabotaging of such programs through the existence of taboos. While the situation is changing rapidly, particularly since the Second World War, venereal disease reflects directly on the sexual activities of a given

population. The consequences of this involve both a lack of preparedness to support programs of medical education in this area, and also a pronounced reticence on the part of infected persons to reveal their condition because such a revelation would necessarily involve in some sense a public admission that their private lives do not accord with the public image they wish to preserve. Changing attitudes towards sex and large-scale publicity campaigns have rendered this aspect of the public health problem of venereal disease somewhat less serious.

Social Elements in the Development of Illness

It has been usual to see illness as falling on a continuum between somatic to totally related to the psyche. In the case of the somatic types there exist physical conditions which may be located through application of available measurement techniques at that level of the development of medical technology, and which would account for the role incapacity reported by the sick person. In this sense a broken leg would appear as a pure type of somatic difficulty. At the other extreme are those illnesses where the incapacity for normal role per- formances is reported by either the patient or by others although no discernible physical condition can be located at the present level of medical technology which could adequately account for that illness. Rather obviously, the so-called functional psy- choses are the most dramatic representa- tives of the non-somatic end of the continuum.

An alternative way of looking at any illness would not concentrate attention so much on the issue of the presence or absence of measurable physical malfunc- tionings but would take as given that every illness involves some state of the organism, yet also involves definite implications from the personality point of view (6) . A modern view of illness should be concerned with a multi-causal view which would emphasize the dynamic relationship between psycho- social variables and the presence or absence of established physical bases for illness. Within this approach it becomes possible to speak of both necessary and sufficient conditions for the development of specific modes of illness. Illnesses as varied as schizophrenia, rheumatoid arthritis, and



304 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 57

influenza, do not allow for simple mono- causal theories (7). There is apparently an interrelationship of genetic predispositions and specific environmental conditions, e.g., specific types of interpersonal tensions which act as sufficient conditions for the onset of illness.

Studies of the distribution of specific illnesses in a given population, particularly those relating incidence to social and social psychological variables, appear to be most useful in developing social medicine into what have been called "socio-somatic" areas of illness beyond the simpler type of epidemiological investigations. The information gained from such studies calls for a theoretical explanation of an interdis- ciplinary nature. Examples here might include the finding that Jews exhibit low rates of cancer of the cervix, Protestants exhibit a rate of cancer of the testes one- and-a-half times that of Catholics, and that those living with hypertensives tend to exhibit hypertension more often than those of the same family of origin living in different households (8). Clearly, the "facts" do not speak for themselves. One area of theoretical advance would be at the level of explaining the development of cancer cells in a manner which would allow for more active intervention in halt- ing or controlling the disease. A further area would be the elucidation of the role of genetic variations in setting predispositions. Social scientific inquiry would seek to clarify the relationships between gross social characteristics, such as religious affiliation, and the interpersonal relationships which provide an environment within which specific tensions develop, and the socially structured alternatives which exist for handling such tensions. Only quite complex studies of a multi-causal nature will eventually clarify the nature of types of physical manifestations, role conceptions, personal identity, and appropriate modes of therapy and prevention. Relevance of the Social Sciences for Pro- fessionals in the Public Health Field (9)

It seems most probable that future de- velopments in medicine will increasingly emphasize preventive medicine. It is pre- dictable, therefore, that the institutional arrangements which allow for the development and organization of public health

services will themselves change in the direction of increased acceptance and legitimation. This change will presumably go together with changes in the relationship between public health services and clinical medicine such that, either the misunderstandings and opposing points of view will increase as private medicine increases its claim to individual professional relationships with its patients, or else will be reduced as the trend moves towards a view of modern medical practice which accords more with the needs of a population at risk. The important determinant here is the direction taken by general medicine. If this direction is towards seeing medical services as a crucial requirement of the modern community, rather like education, so that services are centrally organized and controlled, and the individual physician is seen as both employee and professional, then the interrelationship with public health conceptions of medicine will be strengthened. If, on the other hand, entre- preneurial conceptions of general medicine continue to be maintained and professional responsibility is seen as directly linked to reciprocity in a traditionally defined relationship with patients, then the gap between public health services as a form of activity and general medical practice will increase and misunderstandings will also increase.

The type of information and theory available through modern social science is indispensable to the effective operation of public health services. The areas for this dependence are as follows:

1. The application of sociological and demographic research techniques in work in epidemiology.

2. Increasing stress, not merely on gross social characteristics in relation to the distribution and frequency of illness, but also on the type of theoretical account which sees illness as not merely a physical event with definable single physical causes but as involving a whole view of man as a bio-social organism in an environment which includes the social relationship systems in which his identity is embedded. That is to say, increasing stress on the behavioural component of etiology, prevention, and therapy.

3. Increased awareness that the effectiveness of public health services depends on an understanding of existing attitudes towards




illness and therapy in that community, and a consideration of the most useful strategies to be adopted in moving these attitudes in directions appropriate to the successful achievement of public health goals. This problem involves a view of community activities which can be taken over from the social sciences and can most usefully take advantage of knowledge in areas such as community power structure, public opinion formation and change, and the role of opinion leaders. We know, for example, that the conception of the modern neighbourhood as an amorphous mass of anonymous individuals "tuned in" directly to the mass media of communication is not a particularly useful model and has little explanatory payoff. At the local level, people clearly relate their activities and beliefs to other persons and reference groups which are the source of ideas, values, and the reaffirmation of these central guides to identity. It has been dis- covered that in different areas of information there are opinion leaders who mediate between the mass media and the formation of attitudes. It is also clear that messages are never received in wholes but rather tend to be interpreted in terms of pre- existing conceptual systems which may be virtually closed to conventional types of argument (10, 11). Effective programs of fluoridation, for example, would seem to require this type of knowledge to allow for successful intervention and change.

4. Not only existing knowledge but also sociological modes of investigation are of

direct relevance in aiding public health programs. The location of specific sources of support and opposition in the community and the identification of the variables which appear to be relevant can be aided through sociological inquiry. For example, the work of Clausen (12) and his associates on receptivity to Salk vaccine in the school system was able to indicate that favourable response was related to educational level and also to the source of information by which the parent learned of the program. Parents who learned of it through such avenues as radio (the role of the "open-line" type of program cannot be over-emphasized here since ascribed magi- cal qualities transform the most ill-educated prejudice into the voice of good sense), or through their children, tended to be opposed to the program.

5. A sociological view of the role of the public health worker is in itself useful in clarifying areas of daily frustration and opposition, and also in suggesting that the truths of the public health worker are not so self-evident as he sometimes thinks.

The implementation of public health programs is always a type of social change. Change always creates opposition and tensions of which the person who wishes the changes may be unaware and which he may find difficult to understand. It further creates other changes which he may not even find desirable. Social scientific knowledge and modes of inquiry can aid in increasing the effectiveness of public health programs at all stages.

REFERENCES 1. Parsons, Talcott: The Social System ,

The Free Press, Glencoe, Illinois. 1951, Chapter 10.

2. Parsons, Talcott: in Patients, Physicians, and Illness , E. Gartly Jaco, Editor. The Free Press, Glencoe, Illinois, 1958, Chapter 20.

3. Parsons, Talcott: The Social System , pp. 428-479.

4. Goffman, Erving: Psychiatry, 1959, 22. 5. Political and Economic Planning, Family

Needs and the Social Services , George Allen & Unwin Ltd., London, 1961.

6. Parsons, Talcott: Patients, Physicians , and Illness , pp. 165-188.

7. King, Stanley H.: in Handbook of Medi- cal Sociology , H. E. Freeman, S. Levine,

and L. G. Reeder, Editors. Prentice-Hall, Inc., Englewood Cliffs, N.J., 1963, pp. 99-121.

8. Graham, Saxon: op. cit. pp. 65-98. 9. Suchman, Edward A.: Sociology and the

Field of Public Health , Russell Sage Foundation, New York, 1963.

10. Katz, Elihu and Lazarsfeld, Paul F.: Personal Influence , The Free Press, Glen- coe, Illinois, 1955.

11. Dexter, Lewis A. and White, David M. (Editors) : People, Society, and Mass Communications , The Free Press, Glen- coe, Illinois, 1964.

12. Clausen, John, Seidenfeld, Morton, Deasy, Leila: Amer. J. Public Health, 1954, 44 : 1526.



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Public Health Programs as Social Change: Ambiguities and Conflicts