Barry Goldlist, MD, FRCPC, FACP
Director, Division of Geriatric Medicine,
University of Toronto
Health, Illness, and Medicine in
Canada 3rd Edition
Juanne Nancarrow Clarke
Oxford University Press Canada 2000
I am unsure of the origins of this text, but it reads as though it was adapted from a course on the sociology of health, illness, and medicine. This might explain the clarity of the language and the fact that enough background about sociology and its jargon is given to make the text completely accessible for a neophyte such as myself. In her writing, Professor Clarke, a professor of sociology at Wilfred Laurier University, shows herself to be a gifted teacher.
The book is divided into three parts. The first part, "Sociological Perspectives" explains ways of thinking and studying about health, illness and medicine from the perspective of sociology. The four central sociological perspectives, structural functionalism, conflict theory, symbolic interactionism and feminist theory, are clearly explained with examples given. Structural functionalism and conflict theory are useful in studying and understanding large societal 'systems', which is to say social and political groups (including interest groups), and private and government-run institutions and corporations. Symbolic interactionism, with its stress on individuals and their interactions, is useful for understanding the more intimate interaction between a patient and her doctor (or between a patient and any other practitioner). Feminist theory can be a useful tool for analyzing both 'systemic issues' and individual interactions. This part also explains, and clearly illustrates, the tools that each sociological perspective uses. A physician might object to some of the concepts expressed. For example, epidemiology is called "the study of the causes and distribution of diseases" and AIDS research is given as an example. I would argue that "correlation" would be a better word than "cause" to help explain epidemiology. In my opinion, epidemiology suggested a virus as the cause of AIDS, and basic laboratory research proved it. The comment that silicone breast implants are associated with numerous health problems is based on a quote from a 1993 paper; unfortunately, the author seems to be ignoring the overwhelming and more recent epidemiological data that shows that there is no correlation. This might reflect a lack of editorial updating of this edition.
The second part of the book examines the sociology of health and illness and includes chapters on disease and death, environmental disease, social inequity, on visiting the doctor, and on the experience of being ill. All are excellent. The sections on health and inequality may be particularly sobering for less experienced physicians, some of who are from relatively privileged backgrounds.
The third part of this book is the section, which may be of greatest interest to doctors&emdash;the sociology of medicine. Chapters on related topics include discussions of the development of medical and scientific knowledge, the 'medicalization' of society, that is, the institutionalization of the practice and teaching of medicine (in the forms of hospitals and university departments), and the development of private and government organizations and structures to regulate and support the delivery of medical care. These are chapters on nursing and midwives, alternative medicine, and the medical industrial complex. As a physician, I am always concerned that medicine seems to be held to a higher degree of accountability than are some of its 'competitors'. I feel this has occurred in this book to some degree. Moreover, there are certain internal inconsistencies. We are informed at the beginning of the text that the major determinants of health are non-medical (although in some cases, as with clean water, medi-cal science played a crucial role in terms of identifying them as determinants of health). Then in chapter 11, we are informed that remunerating doctors on a capitation basis will provide an incentive for doctors to keep people healthy. Does the author feel the determinants of health are medical or non-medical? Chapter 13 examines the relationships between the male medical profession and the female nursing profession. This chapter would have been stronger had the approach been a comparative one; the provision of some examples or analysis of the relations between female doctors (half the current graduates) and nurses, who are still overwhelmingly women, would have been helpful. However, the biggest flaw in this section, is that the sole focus is on a sociological perspective. This area, in my opinion, requires a combined historical and sociological approach. Doctors, nurses, and health care are part of a much larger social picture, and understanding the development of modern medicine cannot be done without understanding the broader historical context.
Despite the few issues I have mentioned, I consider this to be an excellent text. It is clearly written and contains information relevant to the practice of medicine. It is worthwhile reading for all doctors, particularly those in primary care.