Discussion 6

Using the sources provided only in APA Style 550 words answer the following question:
What approaches to the study of poverty does economic sociology offer? More specifically, what might sociologists studying poverty focus on besides poor households, neighborhoods, and individuals?
sociology
ATTACHED FILE(S)

Economic
Sociology

Fabio Rojas, Indiana University

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Economic Sociology

F A B I OR O J A S ,I N D I A N AU N I V E R S I T Y
THE SOCIOLOGICAL APPROACH TO THE ECONOMY
WORK AND PAY IN THE MODERN ECONOMY
Human capital and income gaps
Discrimination and income gaps
Social closure
Native Americans and Latinx people in the American economy
CORPORATIONS, MONEY, AND OTHER ECONOMIC
INSTITUTIONS
Corporations as institutions
Bureaucracies
Money
THE 1%, THE 50%, AND THE99%
MARKETS: THE BIG PICTURE
REVIEW AND CONCLUSION

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THE SOCIOLOGICAL APPROACH TO THE ECONOMY

 How do sociologists look at economies?
 What is workplace discrimination? What does it mean for a job to be segregated by
gender or race?
 How is the economy “inside” society?
In 2009, Heidi Wilson, a bank services manager for Citigroup, sued her employer for
gender discrimination. When she was promoted to be the manager of her service center, she
was paid about $75,000. The man who held the position before her was paid $129,000. She
later asked her company for a raise and didn’t get it. She then asked the company to
conduct a study of pay levels inside the company. Soon after, she was fired. Wilson turned to
the courts. After suing Citicorp, she received a settlement of $340,000.1
Wilson’s case raises an important question about work: Why do some people get paid
more than others? A casual glance at income statistics shows consistent differences in pay
between social groups. According to numerous studies, spanning decades, women make less
money than men – depending on the study, about 15% less. This is the gender wage (or pay)
gap.2
Many factors explain why women make less money than men. Sometimes, employers
simply like certain workers more than others and reward them more highly. This is discrimination
in pay, and it happened in Wilson’s case. Men and women are also over- or under-
represented in different occupations. For example, women are overrepresented in nursing but
underrepresented among doctors. These are important differences because some jobs earn
more income and are seen as more prestigious or valuable than others. If women are less likely
to be in high-income jobs, like medicine, they will, on average, make less money than men.
Thus, the gendered segregation of work—the concentration of men and women in different
jobs—is a factor that partially explains the pay gap.3
The question of why men and women are paid differently is a great way to start thinking
about the economy sociologically. People are not interchangeable cogs in an economic
system. We bring our backgrounds and personal identities to work. When a boss is about to
hire someone, they are not only looking for skills; they’re also thinking about this person as a
potential friend, colleague, or ally at work. Some employers may not care about the gender
or race of job applicants, while others may care a great deal. An employer may ask, “Does
this person have the skills needed for the job?” But they also have emotions and gut reactions
related to social categories. The owners of a Silicon Valley company may feel that women
shouldn’t lead high-tech companies. Or maybe men avoid a job because it isn’t “manly
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enough.” Even though nursing is a field open to everyone, many men feel that they wouldn’t
fit into a job held mainly by women. When a job is perceived to be appropriate for either men
or women, but not both, the job is
gender typed.4 This is an example
of how gender “frames”
interactions. When people work
together, they often use gender to
guide their actions—thinking that
only women, for example, are
supposed to do certain jobs, like
nursing or teaching kindergarten.
Sociologists such as Cecilia
Ridgeway argue that this type of
framing happens in almost all
human interactions and
contributes to inequality at work
and in other settings.5
Understanding how “social things” are wrapped up in what we buy, who we hire,
and how we run businesses is the core goal of economic sociology.6 In the rest of this chapter,
we’ll think about issues that motivate economic sociology. First, we’ll discuss workplace
inequality and why some people get paid more or are promoted more often than others. Do
some people get paid less because they are less productive or because employers and
clients dislike them? Second, we’ll discuss economic institutions,7 the rules and systems we use
to organize our economic lives. I’ll talk about two economic institutions: money and the
corporation.
Third, we’ll discuss two big-picture approaches to the economy. What does it all mean?
Is our system of private profit a good one? Sociologists call this kind of analysis political
economy.8 We’ll start with the more positive view of the classical economists, who saw the
economy as a vast and sprawling social order that coordinates buyers and sellers. I will also
talk about the critical approach, which stems from writers such as Karl Marx; from this view,
markets are inherently unfair and exploitative, generating inequality, corruption, and social
instability. This leads to the final section, about high and low points in the American economy.
What do sociologists and other researchers know about poverty and what do we know about
the very wealthy and those who are poor?
How do people factor gender into the decision to hire someone for a
job? (Source)
https://pixabay.com/en/beard-brainstorming-business-2286440/
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REVIEW SHEET: THE SOCIOLOGICAL APPROACH TO THE
ECONOMY
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

WORK AND PAY IN THE MODERN ECONOMY

 How are barter economies and cash economies different?
 Why do we have a division of labor?
 What does human capital theory try to explain?
 What is the difference between statistical discrimination and taste-based
discrimination?
 What are some occupational groups that maintain high pay because they have been
able to exclude others from their type of work?
Take a moment and think about how you get your food. It’s almost certain that you
don’t live on a farm and grow all of it. You probably don’t till the soil, plant wheat, and then
harvest it. You likely don’t grind it and take a few hours to bake bread. Instead, like most
people, you go to the grocery store and use money to buy bread. And the people at the
grocery store then use the money to buy things they need.
This chain of cash and work defines the modern economy. Very few people make
everything they need. Instead, we work at jobs and try to get people to pay us for what we

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do. We use our income to buy a wide assortment of goods and services: food, smartphones,
Netflix subscriptions, and trips to the dentist. Adam Smith, an 18th-century economist, called
this the division of labor.9 As societies develop and grow, people can no longer do every type
of labor. They divide the labor up, specialize, and become more efficient. The division of labor
is the basis of the economy that we experience every day.
Sociologists have long had a special interest in the division of labor. When economists
first thought about the division of labor, they were mainly interested in efficiency: Was it better
for people to specialize in a specific job? Did specialization lead to wealth? Sociologists had
different questions: Who gets the best jobs in the division of labor? Do people get equally
rewarded if they do the same job? These differences in income and jobs are called economic
inequality.10
Inequality is a central concern of sociology. Societies tend to be unequal; there is no
society where everyone makes exactly the same amount of money or has exactly the same
amount of status. Even in non-industrialized societies, like tribes living in remote parts of the
Amazon or central Africa, some people are more popular than others and occupy the best
land. Inequality certainly characterizes the United States. Some people live below the poverty
line (the U.S. Census measure of the income needed to buy a minimally-sufficient amount of
food and shelter) while others have incredible amounts of wealth.11
Human capital and income gaps
How do we explain how much money people make? Human capital theory suggests
that skills lead to income. If you have a skill that is highly desired, you will make more money
than people with less-desired skills.12 This might explain why doctors make more money than
poets: While poetry has its own value, few people desire poetry so badly that they will pay lots
of money for poems. But most of us are willing to pay large sums for medical services that
relieve our pain or extend our lives.
Human capital (your skills and knowledge that allow you to be productive at work and
produce economic value) is an important tool for thinking about income inequality. For
example, ethnic groups vary in their average yearly incomes. African Americans and Latinos
make less money than the average White person in the U.S. According to the 2017 Current
Population Survey, the median income for an African American family was $41,000; for Latinos,
it was $50,000. In contrast, the median White household earned about $68,000.13 This is a very
large difference and it matters a great deal. How do we explain this gap in income between
ethnic groups?
Human capital theory points to education. People with college educations generally
make much more money than those without college degrees. College graduates make
almost double what people with only high school degrees earn. The extra money that college
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graduates make is called the college premium. This has indicated to sociologists that
education might be one explanation for differences in income.14
The data on
education, race, and
ethnicity is consistent with
this view. About 36% of
Whites have a college
degree, while only 23% of
Blacks do.15 This is an
important gap because
many of the best jobs
require advanced
educations; some, such as
medicine and the law,
require multiple college and
graduate degrees. Other
jobs that require a college
degree may not pay as
much, but they offer high levels of job security. Teaching is one example; public school
teachers don’t make as much as doctors but they often have tenure, which means their
contract is automatically renewed as long as they do a satisfactory job. Not surprisingly, most
states require that teachers have college degrees.
Not only are there differences in how much people are willing to pay for skills (e.g.,
people want doctors more than poets), but some groups have systematically different access
to skills, which impacts their long-term earnings. Let’s think about the case of doctors. To
become a medical doctor, you need to accomplish the following: First, you need to complete
high school and enroll in college. Second, you have to complete a four-year college degree
with a high GPA. Then you must get a high score on a standardized test (the MCAT) and earn
admission to a medical school. Finally, you have to find the money to pay for medical school.
At current rates, you need about $200,000 for a private school or $100,000 for a public one.
Most medical students take out huge loans. As you can see, becoming a doctor is a difficult
and expensive process. If some racial or ethnic groups start with low incomes or have little
access to good high schools, it will be harder for them to begin the process of becoming a
doctor. We would expect those groups to have lower levels of educational achievement,
which would later lead to lower incomes.
According to human capital theory, manual work, like house painting, doesn’t
pay as much as some other jobs because the skill is very common. (Source)
https://pixabay.com/en/worker-wash-window-man-service-1215278/
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Doctors earn a lot of money because their skills are rare, as suggested by human capital theory.
But there are also laws that restrict the total number of medical school graduates. (Source)
Discrimination and income gaps
Human capital theory isn’t the only explanation for why some groups make less money
than others. A second theory is that employers and customers discriminate. Remember the
case of Heidi Wilson, who sued Citicorp. She argued that women were not paid the same
money for the same work. This is an example of the discrimination theory of income
differences. Women and men are capable of performing the same management tasks at
Citicorp, but perhaps the bank’s leaders simply like men more than women and so they pay
men more. When an employer or customer pays more to some groups than others for
providing the same service or good, they’re engaging in taste-based discrimination. In other
words, if a boss pays a White worker more than a Black worker when they’re equally
productive, it reflects the boss’s subjective “taste,” or preference, for White employees.
In an interesting experiment, Devah Pager and her colleagues had matched pairs of
men give (fake) resumes to employers to see how much employers cared if applicants have a
criminal record. This was another audit study, which you’ve read about in previous chapters.
Some of the men participating in the study were White and some were Black. The resumes
they presented to potential employers were matched in terms of work experience and skills for
the jobs; however, some mentioned a minor criminal record (a conviction for a non-violent
https://pixabay.com/en/medic-hospital-laboratory-medical-563425/
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drug offense) while others didn’t. And not surprisingly, they found differences: employers were
less likely to call those with a criminal record and invite them for a job interview. But there was
an even larger gap based on race; in fact, a higher percentage of Whites with a criminal
record (17%) got a call for a follow-up interview than Black applicants without a criminal
record (14%)!16 This experiment shows that taste-based discrimination is real and that it
emerges even at the point of screening job applicants. If such biases in hiring and pay occur
at many stages of hiring and evaluating employees, it’s not difficult to imagine how race- and
gender-based differences in income would emerge.
However, a difference in income doesn’t always mean that employers or customers
dislike a group of people. It may indicate a genuine difference in skills or job-related abilities
that exists, on average, between groups. Statistical discrimination occurs when an employer
pays people from a certain group less because members of that group in general do not
perform as well as others; this is a form of discrimination because bosses are distinguishing
between workers based on group membership rather than their individual skills.17 Consider an
example from When Work Disappears, by William Julius Wilson.18 Wilson asked a common
question: Why is it hard for people from poor neighborhoods to find jobs? He answered this
question with an in-depth study of a poor Chicago neighborhood. He and his team of
researchers visited homes, interviewed people, and talked to employers around the city.
The story is complicated. Wilson found some evidence for human capital theory. High
schools in poor neighborhoods don’t prepare their students well for jobs. The schools are often
in such a poor state that students leave without a solid grasp of written English, which is
crucially important in an economy that depends on computers and handling information. In a
discussion with employers, Wilson asked why they didn’t bother to call people about a job
even if they had a high school degree, which indicates they might be prepared for an office
job. A number of employers suggested that people from these low-income areas probably
didn’t have the right personal skills—such as talking to customers or following directions at
work. Poor people from these areas of Chicago weren’t getting jobs because employers
thought it took too much effort to figure out who could work well in an office. They assumed
that the average person from poor neighborhoods wouldn’t fit. This is an example of statistical
discrimination; employers made decisions based on broad judgments about the abilities of
groups, rather than by evaluating individual job candidates.
Social closure
A third explanation of income differences is social closure. Often, one group will
actively try to exclude another in an attempt to defend its occupational “turf.” Consider
doctors. It’s certainly the case that doctors do well because their services are needed. But
part of their income derives from the fact that there are very few medical schools, and states
require doctors to obtain a degree from one. In fact, it’s illegal for non-doctors to perform
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many medical procedures, even those that require little medical knowledge.19 This makes
doctors relatively scarce.
To appreciate this point, take an example from my own life. Recently, my daughter and
I were at a mall and, like many young children, she started chewing on a small object she
found. She quickly wedged a small metal cap into her teeth. I couldn’t pull it out with my
fingers, nor could my wife. I eventually gave up; I needed someone who had a little skill in
taking care of teeth. I brought my daughter to an ER and told the nurse that my daughter had
a metal cap wedged in her mouth. A pediatrician took out a small tool and popped out the
cap in less than a second! The doctor was kind. She was used to children cramming all kinds of
odd things in their mouths, and she made me feel better.
What didn’t make me feel better was the doctor’s bill. For a procedure that took a few
seconds, I was charged over $600! What could account for such a high invoice? Human
capital theory suggests that the pediatrician had a valuable, and rare, skill that I really
needed. But the human capital answer is incomplete. Yes, the doctor had a valuable skill, but
couldn’t other people offer the skill of pulling metal caps out of children’s mouths at a lower
price? Many dentists could do it, many nurses could as well; many other health care
professionals, such as paramedics, could also complete such a simple procedure. But while
they probably could do it, they’re prohibited by law from doing so. In general, the only people
who can offer medical services, however minor, are doctors. Anyone who advertises medical
services without a medical degree will end up in jail. Thus, we shouldn’t be surprised when
even very basic medical services are expensive.
Doctors are only one example of social closure. For example, in the 1800s, many
southern states passed Black Codes, laws that banned newly freed slaves from entering
desirable trades.20 The goal was clear: state governments wanted the most desirable trades to
be reserved for White men. Today, we see a similar dynamic regarding migration: many
people want to exclude low-education workers from other countries in order to boost the
incomes of native-born workers.
Native Americans and Latinx people in the American economy
This chapter has focused on a number of processes that affect income and jobs such
as job skills, employer discrimination, and participation in labor markets. Here, we turn to a
discussion of how two different groups, Native Americans and Latinx people, fit into the
American economy. In some ways, they share much in common. The average income and
college graduation rate within each group are significantly below the national average. At
the same time, each has a unique history, and different institutions and characteristics
emerged that shape the way Native Americans and Latinx people earn income.
The story of Native Americans is essentially a story of conquest, forced removal, and
expropriation since the founding of the United States. Even though numerous treaties were
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signed to protect Native sovereignty and property rights, the treaties were routinely violated. In
many cases, Native Americans were forced to live on lands set aside for them called
reservations. By the 1900s, the situation had stabilized and the modern reservation system had
emerged. The 1934 Indian Reorganization Act passed by Congress established the basic legal
framework for reservations and allowed tribal leaders to exercise a significant level of control
over the economy of Native American communities.
Native American control over the economic institutions of reservations had far-reaching
implications that are still felt in the 21st Century. Specifically, Native American leaders had the
power to approve businesses that were limited, or even prohibited, outside of reservations. The
most notable example is gambling. Currently, about 200 Native American tribal groups
operate casinos, some in states where this type of gambling is otherwise illegal. In other cases,
reservations establish regulations that allow selected businesses to thrive, such as tourism and
specialized manufacturing. Thus, a key issue in understanding economic outcomes among
Native Americans is whether they find jobs in one of the industries that have emerged on
reservations or whether they seek employment in the rest of the American economy.
Like Native Americans, Latinx people are remarkably diverse and there is no single
“Latinx” experience that would explain all economic or employment outcomes. Still, a few key
factors often affect their outcomes. First, many people who identify as Latinx are immigrants or
have immigrant parents, and the context of their arrival in the U.S. is important. For example, a
large portion of migrants from Mexico find work in agriculture, which is generally low-paid. In
contrast, Cubans who migrated to Florida after the Cuban Communist Revolution of 1959
were often professionals such as teachers, doctors, and accountants. Not surprisingly, the
economic outcomes and options of Mexican agricultural laborers and Cuban professionals will
be vastly different.
Second, language strongly influences the ability of immigrants to earn income. The
ability to speak English greatly improves how much people earn. This draws attention to a very
important feature of work: getting a job is not merely about performing a specific task, it’s
about communicating with customers and employers and knowing how to fit in. Third,
migration status is also highly associated with income. American employment law makes it
difficult for people without proper documentation to find legal work, which means that their
wages are lower than might be expected otherwise. This is one reason why critics of the U.S.
immigration system often ask that the law be reformed to make it easier for people to legally
migrate here so their wages won’t be suppressed.
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REVIEW SHEET: WORK AND PAY IN THE MODERN ECONOMY
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

CORPORATIONS, MONEY, AND OTHER ECONOMIC
INSTITUTIONS

 What are the defining features of corporations? What types of laws govern corporations
in the U.S.?
 What is an economic institution? Are corporations formal or informal institutions?
 How do people use money to convey meaning? How might money change the way
people think about relationships?
Pacific Railway. Sears. General Motors. These titans of industry left their mark on
American history. At their peak, each of these corporations employed thousands of people
and built massive structures. The railroad companies laid thousands and thousands of miles of
railroad track, many of which are still used 150 years later. Drive through America and you still
see hundreds of Sears department stores. Even in decline, Sears managed to sell nearly $17
billion worth of goods and services in 2017.21 While people are shifting their purchases to online
retailers, the department store giant still brings in vast amounts of income. And General Motors
is doing quite well. It has weathered world wars and many economic recessions since its
founding in 1908. In 2017, General Motors employed 180,000 people and sold nearly 10 million
cars around the world.22

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Corporations—groups of people organized together by the owners to generate profit—
are a method of organizing the labor of millions of people. Corporations are so big that their
actions cause ripples across the economy. If General Motors went bankrupt, thousands of
auto-workers would be out of jobs. GM’s bankruptcy would also cause hardships for the
suppliers, dealers, and mechanics whose jobs depend on the sale and maintenance of
millions of cars. Not surprisingly, when the American auto industry has faced economic
problems, the U.S. government has often stepped in to help. In a very real way, the
corporation is a way of life in America.
Corporations as institutions
Corporations are an example of an economic institution, a set of formal and informal
practices meant to organize an activity. Corporations are formal institutions in the sense that
laws and other written policies govern what corporations may or may not do. For example, a
corporation must have a board of directors that appoints and monitors the company’s
leadership. If a corporation wants to raise money by selling stock, it must publicly report its
finances and tell stock owners what it has done each quarter.
Corporations are also
informal institutions governed
by social norms, unwritten rules
about what people expect.
Many people expect
corporations to “give back”
and help communities through
charitable work. This is one
reason you see corporate
sponsors behind a wide range
of activities. Corporations give
to the Girl Scouts, colleges and
universities, and hospitals. They
give money for Little League
baseball teams and cancer research. Why? Some business leaders truly support those causes.
Business leaders, like everyone else, would like to see medical researchers find a cure for
cancer. Sometimes the reasons are self-interested; how many of us wouldn’t feel pride and
high self-esteem if a university built a fancy library and named it after us? There are also social
expectations. A corporation that fails to give to charities might be viewed as heartless or
uncaring; just like other people, executives want to be seen as “normal” people who care
about their communities.
The skylines of many cities are corporate office buildings. (Source)
https://pixabay.com/en/singapore-river-skyline-building-243669
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Political activists (people who organize around a political issue) also shape corporate
behavior, which is a great example of how political pressures shape economic processes.
Protestors are a sort of stakeholder in a corporation.23 Stakeholders are the different people
who have a financial or political investment in a corporation. Many stakeholders are inside the
corporation: owners want to make profits and executives want high salaries; workers want
stable jobs and retirement benefits. But stakeholders also include people outside the
corporation, such as those who buy its products.
About thirty years ago, activists in
the anti-sweatshop movement started
targeting corporations because they
thought that corporations were treating
workers in developing countries badly. They
claimed that corporations paid low wages
in apparel factories in places like Mexico
and Vietnam. This led to a vigorous debate
in the 1990s about how clothes are made.
Protesters held rallies outside corporate
offices. In the press, they accused well-
known companies like Nike of employing
child labor and paying people unfairly low
wages. Student protesters asked university
presidents to disinvest from Nike and other firms that used sweatshops (meaning the universities
wouldn’t invest in companies that used sweatshop practices, and wouldn’t hire them to make
clothing branded with the university’s logo or mascot). The result? Many corporations,
including Nike, now promise consumers that they make shoes and clothes in ethical ways: they
pay more than they did before and avoid illegitimate business practices. Social protesters
changed the corporation by imposing new norms.24 Their influence is so notable that scholars
such as Stanford’s Sara Soule have begun to think of activists as stakeholders with a real voice
in the modern corporation.25
The corporation is such an important economic institution that it’s hard to find a
sector of the economy that hasn’t been touched by them. Consider computer software. While
you might think that popular software is written by small, ragtag groups of young software
engineers, most successful computer companies get larger and grow into corporations. The
Social Network, a movie about the early days of Facebook, illustrates this idea. Facebook was
founded by Mark Zuckerberg, who wrote the software and was assisted by his friend, Eduardo
Saverin. Much of the movie is about their attempts to run a small company out of a college
dorm. They had parties, drank beer, and tried to keep a small group of programmers and staff
together as they ran out of money. Once Facebook became very successful, things changed.
Protesters targeted apparel manufacturers to make them
produce shoes in more ethical ways. (Source)
https://pixabay.com/en/shoe-canvas-sneakers-casual-1433925/
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Zuckerberg had to become a more traditional leader for the company. They moved into a
large office and had to deal with investors, customers, and legions of employees. Today,
Facebook employs over 33,000 people in offices across the globe.26
Bureaucracies
What are the basic features of the corporation and why do we need them? Max
Weber answered this question over a hundred years ago. Noticing that modern life was filled
with large structures such as corporations and governments, Weber described bureaucracy as
an ordered system that provides structure and discipline for employees. Weber identified three
key features of bureaucracies: they have clear lines of authority, are run on written rules, and
are staffed by full-time employees who are experts in their field. Weber contrasted large
corporate entities like businesses with informal groups such as families or ethnic groups, which
are not clearly defined, lack an obvious “top-down” structure, and aren’t guided by a
professional group of managers.27
Weber’s definition of bureaucracy applies to all kinds of “big structures.” Take
government, for example. Most forms of government are organized into large bureaucracies.
In the U.S., the federal government is a vast system of employees organized into a massive
chain of command. The armed forces chain of command starts with the President, goes to the
Joint Chiefs of Staff, then to the individual branches of the military. Within each branch, there is
a chain of command from generals all the way down to privates. Educational organizations
share bureaucratic traits as well. Most colleges have a president and a board of trustees who
set policies. These policies are further developed and implement by a team of managers with
titles like “dean” and “provost.” The daily work of the university—teaching and research—is
done by a workforce of professors, graduate students, and part-time lecturers.
Weber’s description focused on the organization’s primary mission. An organization’s
structure, its chain of command and policies, flows naturally from its goals. However, later
sociologists came to see corporations and other organizations as open systems. That is, the
firm has loose boundaries that allow people and ideas to enter and leave the firm. A business,
a school, or a church doesn’t usually spring exclusively from the leadership’s ideas. Instead,
organizations respond to a larger environment that includes the government, investors,
customers, and rival organizations. People move in and out of a corporation and ideas flow
across the bureaucracy’s boundaries. Thus, corporations, and other bureaucracies, are more
like organic systems than rigid rational systems.28
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This organizational chart illustrates the concept of bureaucracy
as a rationally ordered system: boss at the top, managers in
the middle, and other employees below. (Source)

Facebook is a great example of this open systems view. Mark Zuckerberg didn’t invent
the concept of social media. In the early 2000s, numerous companies were experimenting
with websites that linked people together. There was Friendster and Orkut (owned by Google
and popular in South America). Probably the most popular was MySpace, which focused on
music. I’m not downplaying Zuckerberg’s skill in creating Facebook, but he and his friends
were responding to what was in the environment at the time.
As Facebook grew, it reflected that broader social environment. While Facebook
innovated many important features of social media, such as the scrolling “wall,” it also
mimicked ideas from or even entirely absorbed other companies. For example, at one point
Facebook added the ability to send money, copying companies like PayPal. Facebook’s
leaders also realized the importance of images for social media. Rather than spend the time
and effort to develop an entirely new system for sharing images, Zuckerberg bought
Instagram. Today’s Facebook reflects waves of innovation in the tech industry, the purchase of
firms like Instagram, and the development of its own ideas about social networking.
Money
A second key economic institution is money. Along with bureaucracy, it’s one of the
most distinctive features of the modern economy. Money is so ubiquitous that people measure
the worth of things with it. Companies are valued in terms of how much money would be
generated if the company sold all its assets. An education’s value is often measured in terms
of how much money a graduate will make. Even in love, we sometimes use money. Jewelry
https://pixabay.com/en/organization-chart-1989132/
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companies invented the idea that diamond engagement rings are the ultimate symbol of
love, and that the size of the ring indicates the amount of love. A successful jewelry ad
campaign even gave a clear economic value to a man’s love: he should spend three
months’ worth of his salary on an engagement ring.
Most social scientists treat
money as a method of recording
value. A dollar bill is simply a piece
of paper. What is valuable about it
is that other people treat the
piece of paper as a certain
amount of credit in a bigger
economic system. It may have no
value at all outside of that system.
In America, we use dollars issued
by the federal government. If I
went to France, I would need
paper that indicates credit in the
European economy. When a
government declares that specific
paper or coins are the official
money, it is called fiat currency (fiat means “command” in Latin). In other cases, money
represents specific items that are valuable, like gold. When money is literally a commodity,
such as a gold coin, or represents commodities, like old bank notes, it’s called commodity
money.
In theory, we could make money out of anything. We use paper and coins because
they’re convenient. When people lack paper and metal, they use other objects to record
value. People in island nations used sea shells as a form of money. Before the Spanish came,
the Aztecs of central Mexico used cocoa beans as currency. Using beans as money was
helpful because they are easy to carry and count, but they could also be eaten.
Perhaps the most fascinating form of modern money is bitcoin. A few years ago,
people realized that a purely electronic currency could be valuable. With an electronic form
of money, we wouldn’t need to produce paper bills and metal coins. But the real value of
electronic currency was that it could be created independently of any government. A
problem with most forms of money is that governments often try to control its value by issuing
more money. Inflation occurs when forms of money lose value in this way. But if a form of
money wasn’t tied to a government mint, its value could be controlled and stabilized by a
community of users.
British pounds, the currency of the United Kingdom. Like the American
dollar, they’re an example of fiat money, created by a national
government. (Source)
https://pixabay.com/en/banknote-business-cash-currency-15801/
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In 2009, an anonymous computer programmer released software that allowed people
to make bitcoins.29 You download and install the software on your computer; it performs a
mathematical operation and gives you credit for it. The program then records on a public
website that your computer performed this task and gives you a bitcoin that you can keep or
give to other people. An essential feature of the system is that it’s harder to “make” bitcoins
over time; there will be a fixed, but large, number of bitcoins. When you trade them, there is a
public record of the bitcoin exchange. The bitcoin system has been highly successful; bitcoins
are now accepted as money by many companies, and in June 2020 one bitcoin was worth
over $9,000.
Even though money is enormously useful, it still has complex and ambiguous
consequences. For example, money often transforms social relationships, as Israeli psychologist
Uri Gneezy demonstrated. His children were in daycare, and parents were supposed to pick
up their children at 4:00 pm. The daycare center relied on parents to stick to the schedule,
and it worked. Most kids were picked up around 4:00 pm, and few parents were late. But
Gneezy and his colleagues wanted to see what would happen if they attached money to the
“don’t be late for pick-up” rule. They asked the school to fine each parent who was late. The
result? More parents started coming late! Money encouraged parents to compare the cost of
being late with the cost of what they were doing at the time. Charging parents a price
encouraged them to make a specific comparison with other activities. In this case, they often
judged that their kids could stay in daycare a bit longer. In the more informal environment
where parents were simply expected to respect the daycare center’s rules, they were more
reluctant to be late. Gneezy’s experiment has an important lesson: when you attach a price
to an activity, you invite comparisons that may lead to unintended consequences. Money
changes social norms.30
Money is also a way of creating and managing social relationships. A fun example
comes from the work of Olav Velthius, a sociologist who took a deep interest in art. He wanted
to know what prices “say” about an artist. In his research on art dealers, he found many
interesting patterns. For example, art dealers don’t like to decrease prices on an artist’s work,
because that says that the artist is no longer artistically relevant. This is less common for normal
commodities like cars or floor tiles; if there are too many cars or floor tiles, businesses will
announce a sale just to get rid of them quickly. In contrast, prices for paintings are a statement
about the worth of a painter and her reputation. Thus, prices for art tend to be “sticky” – they
reach a level and stay there.31
However, dealers will often get permission from artists to reduce prices for special clients
they may want to cultivate. Dorothy and Herbert Vogel were working-class people who loved
art. Dorothy was a librarian and Herbert was a postal worker. Over the course of their lives, the
Vogels became friends with many famous artists and amassed one of the most extensive
collections of modern art in the world. Many artists wanted to become part of the “Vogel
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collection.” Artists, and their dealers, often had to massively discount the price of the work so
they could maintain a relationship with this humble, but highly respected, couple. The history
of the Vogels, and how artists and dealers responded to them, shows that money is an
expression of a social relationship.32

REVIEW SHEET: CORPORATIONS, MONEY, AND OTHER
ECONOMIC INSTITUTIONS
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

THE 1%, THE 50%, AND THE99%

 How much income inequality is there in the U.S.? What is the median income?
 How do social scientists determine what counts as poverty?
 How do the lives of the rich and poor in the U.S. differ? What types of jobs are common
among each social class?
In 2011, political activists met in Zuccoti Park in downtown Manhattan to protest
economic inequality. They noted, correctly, that the top 1% of income earners have been
receiving more and more of the total income in this country. Soon, this dogged band of
protesters attracted the attention of the national media and the world. This movement, now
known as Occupy Wall Street, protested inequality and political corruption. They thought Wall
Street had too much influence on government, which allowed corporations to get tax breaks
and favorable regulations and decreased the well-being of average Americans. This

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movement made a big impact by telling Americans that the “1%” was gaining an unfair
advantage over the “99%,” language that has since become widely understood as a way of
talking about income inequality.33
If nothing else, Occupy Wall Street drew attention to a very important fact—there are
vast inequalities in how much money people make. Earlier in this chapter, we discussed
income inequality and how education, skills, and status all contribute to some groups making
more than others. But Occupy Wall Street focused heavily on “the 1%” and the
disproportionate amount of income they get each year. Recent research suggests that the
top 1% of American income-earners get about 20% of the entire nation’s income. If we
stopped looking at income (money received in a year) and looked at wealth (the total value
of all assets someone owns), the top 1% is estimated to own about 35% to 43% of the entire
country’s wealth!34

An Occupy Wall Street poster about income inequality. (Source)

https://archive.org/details/flickr-ows-IfUSLandMassWereDividedLikeitsWealth-6282778330
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What do sociologists and other social scientists know about the top 1%? What about
the bottom 1%? How do we learn about people at these different income levels? Much of our
knowledge comes from surveys and government records where people are asked how much
money they make.
In 2018, the U.S. Census Bureau announced the findings of its most recent Current
Population Survey (CPS), a yearly study of the American population that provides the
government and the public with important data about the country. It found that in 2017, the
median annual household income was about $61,000. That means that 50% of people in the
survey lived in a family that made $61,000 in combined wages and salary or less, while 50%
made more.35
What about the very poor and very wealthy? When social scientists ask about the poor,
they often use the poverty rate—the percentage of people who are classified as falling below
the poverty line. The U.S. Census Bureau defines poverty as earning less income than the
estimated amount a family would need to purchase food, shelter, and other basic needs; this
is the poverty line (or poverty threshold). A poverty threshold is not meant to be an exact
measurement, but a guess about the amount needed to avoid extreme hardship.36 Poverty
disproportionately affects minority groups, and many sociologists have spent considerable
time trying to understand the consequences of poverty for minorities. For example, sociologists
Scott W. Allard and Mario L. Small have argued that when people are poor, they rely on their
social ties and local institutions, like churches, to provide services.37

Poverty is still a serious issue in the U.S. (Source)

https://pixabay.com/en/abandon-squatting-trash-squat-1901087/
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There is good news and bad news about poverty in America. The good news is that
poverty is declining, at least according to the Census definition. Since 1959, when the U.S.
Census Bureau began measuring poverty using this method, the percentage of people who
qualify as poor has decreased. In 1959, about 23% of people were poor by this definition; in
2016, that number had dropped to 13%. This is definitely a vast improvement. The bad news is
that a large number of people remain impoverished. In a nation of over 300 million people,
roughly 41 million live in poverty. 38 The reasons are complex. Some are migrants from poor
countries, like Mexico, who work in low-wage industries like agriculture. Others live in regions
like Appalachia with very limited economic prospects. Yet others may have very limited
earning potential because they are not well educated or work in industries such as food
services that traditionally have low pay.
What about the other end of the spectrum – what do researchers know about the very
wealthiest in our society? Unfortunately, the U.S. Census doesn’t define a category called
“rich,” which would help this discussion. To make things worse, the very wealthy are small in
number, so if you survey a random sample of Americans, you will get very few “Zuckerbergs.”
To address this problem, researchers have examined IRS tax records; they contain data on
almost all Americans, and tax returns usually contain basic information, such as the tax filer’s
occupation, which can tell us about who the 1% might be.

The highest-earning Americans have increased their share of national income. (Source)
https://pixabay.com/en/governor-s-mansion-montgomery-1612734/
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Economist Emmanuel Saez and his collaborators at the University of California, Berkeley
examined tax records to understand who was at the top of the U.S. economy. They
discovered huge changes in the top 1%, especially if you look within the top 1%, at the
wealthiest 10% of the 1%—the few thousand highest income earners in the United States. In the
early 1900s, the wealthiest Americans tended to be leaders of industry and rentiers (people
who inherited land and lived off rents).39 By the 2000s, the situation had changed drastically.
The wealthiest Americans were no longer primarily titans of industry, though those individuals
did appear in the data. Instead, the super-rich now work in finance—as bankers, hedge-fund
managers, and so forth. One of the largest changes in the economy is the move from income
gained through labor and industry to income generated by managing money. Social scientists
call the modern economy financialized because so much wealth is generated from banks,
mutual funds, and investment firms, organizations whose main purpose is collecting and
investing vast sums of money.40
Taken together, these studies suggest a complex picture of poverty and wealth.
Overall, Americans have been doing better. During the 1900s, poverty rates declined and
median household income increased. However, starting in 2008, a serious recession resulted in
lower household incomes and increasing inequality. A new group of people—those in finance
and related industries—account for a larger share of the national income. Perhaps Occupy
Wall Street activists were mistaken when they suggested that Americans were spiraling
downward economically, but they were correct that the 1% is getting more of the pie than
before.

REVIEW SHEET: THE 1%, THE 50%, AND THE 99%
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

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MARKETS: THE BIG PICTURE

 What is a capitalist society?
 What are the major arguments in favor of market-based economic systems? What are
some arguments against market-based systems?
 In what ways is the U.S. a market-based economy? In what ways is it not?
So far, we’ve talked about work, money, and corporations. We also looked at poverty
and wealth. But we can take a step back and ask bigger questions about the economy. The
large-scale analysis of markets is called political economy. As we noted before, the modern
economy is a system based on exchange. It’s ruled by money and decisions are made in
terms of their profitability. Is this a good system?
In general, there are two responses to this question. The first was articulated by the
economist Adam Smith and his followers. The vast decentralized world of the market economy
is very valuable. According to this view, markets are complex systems of interactions that
match buyers and sellers. In a famous passage in The Wealth of Nations, Smith noted that the
baker doesn’t provide bread out of the
goodness of his heart. He makes food for
others because he expects to be paid. Thus,
Smith saw markets as large, decentralized
arenas where people get what they need
through the pursuit of profits.41
Smith viewed markets as beneficial
because they allow people to specialize
and exploit the division of labor. As people
concentrate on activities that are more
profitable, they learn to produce in better
ways, thus creating more material goods.
Other economists, following Smith, argued
that market transactions are valuable
because they provide information about what people want. If housing in San Francisco is
expensive, it’s a sign that people probably need to build more housing in San Francisco. If
housing is cheap in downstate Indiana, we probably don’t need much more of it there.
The picture of markets that Smith presents is one where buyers and sellers discover what
is needed through exchange. But sometimes markets are violently disrupted. Consider Uber, a
company that allows virtually any individual to become a taxi driver. For nearly a hundred
In Smith’s view, markets are places where people make a
profit by bringing valuable goods and services to
consumers. (Source)
https://pixabay.com/en/business-buy-cds-man-market-music-1850085/
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years, the taxi business in America was heavily regulated, which reduced the number of
people who drove taxis. New York City, for example, has a well-known medallion system; the
city government issued a fixed number of licenses that could be bought and sold, and it was a
criminal offense to drive a taxi without owning a medallion. Uber disrupted that system using
smartphones. A person who wanted to make money driving people around downloaded an
app for their phone, verified their identity, and used a map to pick up customers. Once
people got used to getting rides from Uber drivers, cities found it difficult to ban them, and the
taxi industry was disrupted.
Joseph Schumpeter, a prominent economist in the mid-20th century, called this sort of
process creative destruction.42 In his view, markets may be effective in delivering goods and
services, but they tend to become rigid. Workers and capitalists get used to doing things a
certain way. But once in a while, somebody comes along and learns how to do things in a
new way that undermines the old order. An entrepreneur takes a risk on a new idea and, if
successful, can topple an industry. Cars displaced the horse and buggy. The smartphone
displaced older cell phones. History is filled with other examples. The world described by Smith
and Schumpeter is a good one. The desire for profit motivates us to produce valuable things
like food and shelter. Entrepreneurs bring us innovation after innovation.
A rival school of political economy is more skeptical of markets. The skeptics note that
markets don’t treat everyone equally and often have negative consequences. Perhaps the
most well-known advocate of this view is Karl Marx. In his view, markets are not about
satisfying consumer needs. Rather, they’re about exploiting workers. The market system, in
Marx’s view, turns people into machines that produce economic benefits for the owners of
capitalist firms.
The exploitation inherent in market economies had drastic consequences, according to
Marx. In the short term, workers may have their immediate necessities met. By working in a
factory, they receive a paycheck and can satisfy their needs. But the long-term
consequences are bad. Marx predicted that sooner or later, wages would fall as company
owners became better at capturing the revenue from their businesses and driving down
worker pay. Marx argued that corruption is also a natural consequence of private business;
business owners gravitate toward the government and try to control it for their own ends.43
In this situation, workers would suffer, leading to political unrest. Marx predicted
organized struggle, not sporadic conflict. He argued that there was a deep contradiction
within market economies.44 It simply wasn’t sustainable for a society to be so reliant on
exploited labor. People would eventually push back and topple the market society and
replace it with a system that would benefit all workers, not just business owners. This social
system, called socialism, would be governed by a state composed of workers and there
would little, or no, private industry. For this reason, Marx is a revolutionary thinker. He believed
that market economies were inherently unstable and led to crisis, which could only be
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resolved through political struggle. Many political parties were inspired by his writings and
gained power in nations such as China, Russia, and Venezuela.

In the Marxist view, workers are exploited by business owners. (Source)

Who is closer to the truth – the defenders of markets or the skeptics? The skeptics, in my
view, offer a number of valuable points. In the short term, workers and owners are indeed
locked in a zero-sum game. If one group gets more, the other gets less; raise wages and profits
fall. Many firms do treat their workers as little more than an expense whose cost needs to be
minimized. For example, the apparel industry relies on workers who make very little and work in
poor conditions. Activists argue that apparel companies treat workers poorly in order to save
money and increase their profits. Workers in many countries do create labor parties and try to
reform or revolutionize their nation. In Venezuela, for example, a socialist party came to power
and implemented socialist policies, such as nationalizing industries (having the government run
them).
The skeptics also make a valuable point when they say that poverty is a serious
problem, even in wealthier capitalist societies, where people privately own firms and seek
profits. As we noted in the last section, poverty is still a persistent feature of the American
economy. Though it has declined since the 1950s, about one in eight Americans are still poor.
Wages have also flattened: wages for people in the middle of the income range have stayed
constant over time. They haven’t gone up or down very much, even though the size of the U.S.
economy has increased over time.
The defenders of markets make strong points as well. In terms of material well-being,
Western societies enjoy an incredible amount of wealth. Millions of Americans have access to
https://pixabay.com/en/work-factory-industry-equipment-1713103/
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automobiles, cell phones, and televisions. These consumer goods are simply amazing, far
superior to anything that kings of previous ages had. While poverty still exists and is a serious
problem, it has declined drastically around the world, starting with Western nations and in
nations such as China and India. In fact, two sociologists estimated that the decline in global
income inequality is due to China and India opening up their economies to more capitalist
investment.45
My view is that market-based economies are imperfect but desirable. Western nations
have notable degrees of inequality and corruption, but standards of living tend to increase
over the long term. As we noted earlier in this chapter, poverty is a serious problem in America,
but it has decreased over several decades. Furthermore, market-based economies tend to be
the places where social and political rights are expanded first, such as women’s voting rights in
America, which suggests that a certain degree of material wealth promotes and sustains
these rights. Finally, nations that completely abandon markets do not do well in terms of
material conditions or political freedoms.

REVIEW SHEET: MARKETS: THE BIG PICTURE
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

REVIEW AND CONCLUSION

This chapter has examined the economy from a sociological perspective. We focused
on a few major topics: sources of income inequality, economic institutions, wealth and
poverty, and political economy. When we looked at work and pay, we encountered some
very important explanations of income differences. Human capital theory says that people
have skills that others find valuable. This helps us explain why some groups make, on average,
less than others. They lack job skills or may have limited educational opportunities. Then there

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are theories that focus on discrimination—when people choose to pay more to groups they
like. I used the term “economic institution” to describe broad ways of organizing economic
activities. We looked at money and corporations as examples of institutions. In addition to
being useful, these institutions also reflect our values and affect our society. Our discussion of
wealth and poverty, and of capitalism in general, drew a complex picture. American society is
in many ways better off than before, but poverty and inequality remain serious issues.
The sociological study of the economy teaches deep lessons about sociology
itself. No part of society is separate from the rest. We might, for example, think that people just
earn what they deserve. But we’ve seen lots of examples where social status—race and
gender, for example—affect what people get paid. We might also think that money is a
neutral vessel for transferring value among people. But that isn’t true either. How we make
money, how we distribute it, and how we let it affect our perceptions of value reflect our
moral sensibility. That is perhaps the most important lesson of all: sociology is not about “the
social,” it’s about how “the social” affects everything we do.

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http://www.tampabay.com/news/tampa-woman-wins-lawsuit-against-citicorp-for-pay-discrimination/1225359
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http://www.oxfordbibliographies.com/view/document/obo-9780199756384/obo-9780199756384-0132.xml#obo-9780199756384-0132-bibItem-0001
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23 King, Brayden. 2008. “A Political Mediation Model of Corporate Response to Social Movement Activism.”
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27 Weber, Max. 2015. “Bureaucracy.” P. 114 in Weber’s Rationalism and Modern Society, translated and edited by
Tony Waters and Dagmar Waters. New York: Palgrave-Macmillan.
28 Pfeffer, Jeffrey. 1997. New Directions for Organization Theory: Problems and Prospects. New York: Oxford University
Press.
29 You might enjoy this news article about Bitcoin: Popper, Nathaniel. 2017. “What is Bitcoin?” The New York Times.
https://www.nytimes.com/2017/05/15/business/all-about-bitcoin-the-mysterious-digital-
currency.html?rref=collection%2Ftimestopic%2FBitcoin&action=click&contentCollection=timestopics&region=strea
m&module=stream_unit&version=latest&contentPlacement=6&pgtype=collection Retrieved July 11, 2017.
30 List, John and Uri Gneezy. 2013. “What Makes People Do What they Do?” Freakonomics Blog.
http://freakonomics.com/2013/10/23/what-makes-people-do-what-they-do/
31 Velthius, Olav. 2006. Talking Prices: Symbolic Meanings of Prices on the Market for Contemporary Art. Princeton
University Press.
32 You might enjoy this documentary about Herb and Dorothy Vogel. “Herb and Dorothy.”
http://www.pbs.org/independentlens/herb-and-dorothy/film.html
33 You might enjoy seeing the documentary made by the movement: “99%: The Occupy Wall Street Collaborative
Film.” https://www.youtube.com/watch?v=FzJ4IpqmXwg
34 Jesse Bricker, Alice Henriques, Jacob Krimmel, and John Sabelhaus. 2016. “Measuring Income and Wealth at the
Top Using Administrative and Survey Data.” The Brookings Institution. https://www.brookings.edu/bpea-
articles/measuring-income-and-wealth-at-the-top-using-administrative-and-survey-data/#recent/ Retrieved July 12,
2017.
35 Fontenot, Kayla, Jessica Semega, and Melissa Kollar. 2018. “Income and Poverty in the United States: 2017.”
Washington, D.C.: U.S. Census Bureau. Retrieved from
https://www.census.gov/library/publications/2018/demo/p60-263.html
36 For analysis of the poverty rate, see: Bernadette D. Proctor, Jessica L. Semega, and Melissa A. Kollar. 2015.
“Income and Poverty in the United States: 2015.” Washington, D.C.: U.S. Census Bureau.
https://www.census.gov/library/publications/2016/demo/p60-256.html Retrieved July 11, 2017.
37 Allard, W. Scott and Mario L. Small. 2013. “Reconsidering the Urban Disadvantaged: The Role of Systems,
Institutions, and Organizations.” The Annals of the American Academy of Political and Social Science 647(1): 6–20.
38 U.S. Census Bureau. 2017. “How the U.S. Census Bureau Measures Poverty.” Washington, D.C.: United States
Census Bureau. Retrieved from https://www.census.gov/library/visualizations/2017/demo/poverty_measure-
how.html
39 Saez, Emmanuel. 2016. “Striking It Richer: The Evolution of Top Incomes in the United States.”
https://eml.berkeley.edu/~saez/saez-UStopincomes-2015.pdf
40 Krippner, Greta. 2005. “The Financialization of the American Economy.” Socioeconomic Review 3(2): 173-208.
41 Smith’s famous phrase is the “invisible hand of the market” – things get done, even without a designated leader.
Smith 1776 (above). https://www.adamsmith.org/adam-smith-quotes/
42 Schumpeter, Joseph. 1942.Capitalism, Socialism, and Democracy. New York: Harper.
43 Marx, Karl. 1967[1867]. Capital: A Critique of Political Economy, vol. 1. New York: International Publishers.
44 Ibid.
45 Ho-fung Hung and Jaime Kucinskas. 2011. “Globalization and Global Inequality: Assessing the Impact of the Rise
of China and India, 1980-2005.” American Journal of Sociology 116(5): 1478-1513.

Cover Photo Source; Creative Commons License
https://newsroom.fb.com/company-info/



http://freakonomics.com/2013/10/23/what-makes-people-do-what-they-do/
http://www.pbs.org/independentlens/herb-and-dorothy/film.html

Measuring income and wealth at the top using administrative and survey data

Measuring income and wealth at the top using administrative and survey data


https://www.census.gov/library/publications/2018/demo/p60-263.html
https://www.census.gov/library/publications/2016/demo/p60-256.html
https://www.census.gov/library/visualizations/2017/demo/poverty_measure-how.html
https://www.census.gov/library/visualizations/2017/demo/poverty_measure-how.html
https://eml.berkeley.edu/~saez/saez-UStopincomes-2015.pdf
Barter..
https://creativecommons.org/licenses/by/2.0/

Health & Illness

Margaret T. Hicken, University of Michigan
Hedwig Lee, Washington University in St. Louis

Health & Illness (Fall 2021)

Page 2
Health & Illness

M A R G A R E TT .H I C K E N ,U N I V E R S I T YO FM I C H I G A N
H E D W I GL E E ,W A S H I N G T O NU N I V E R S I T YI NS T .L O U I S
INTRODUCTION
Defining the Boundaries of health & illness
Early sociological studies of health
Social control and definitions of health & illness
HEALTH CARE IN THE U.S.
Health care as a system
Current debates about health care
SOCIAL DETERMINANTS OF HEALTH & HEALTH INEQUITIES
Perspectives for studying health
THE FUTURE OF THE SOCIOLOGY OF HEALTH & ILLNESS

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INTRODUCTION

 Why should sociologists care about health?
 How does the study of health differ for sociologists and epidemiologists?
Nandi Edmonds was 31 when she became pregnant for the first time. She and her
husband, Miles, were so excited about welcoming their twins into the world. On July 11, 2010,
at 30 weeks into her pregnancy, she and Miles were at a childbirth class when Nandi
developed a severe headache and started vomiting. They went home so she could rest; she
woke in the middle of the night in a pool of blood and then passed out. Miles called 911 and
Nandi and their twins were rushed to the emergency room with placental abruption (when the
placenta separates from the uterus too early in the pregnancy) and pre-eclampsia (a set of
symptoms that includes high blood pressure, headache, dizziness, and protein in the urine).
Their son was stillborn; their daughter died three days later.
Nandi was discharged from the intensive care unit (ICU) only four days after this
traumatic birth experience, even though she had nearly died herself during the birth. At home,
her health didn’t improve, but her doctor told her to take her prescribed medication and rest.
When she told her long-time friend, an internal medicine resident, about her symptoms, he
immediately picked her up and took her to the hospital. Nandi had extremely high blood
pressure and likely would have suffered a stroke had she followed her doctor’s orders and
remained at home.
Discussions of health are generally the purview of medicine or public health, which
focuses on describing and preventing disease and illness. We think of doctors and
epidemiologists (who study the frequency, patterns, and causes of health and illness) as the
health experts. Indeed, on the surface, Nandi’s experience appears to be medical in nature.
However, in this chapter, we will show how sociology provides unique and critically important
information about health and illness. While both epidemiology and sociology can describe
who is more likely to become ill or die, epidemiology focuses on biomedical mechanisms and
individual health behaviors; sociology, on the other hand, can clarify the aspects of society
that lead to social patterns in morbidity (having a disease) and mortality (death).
Nandi and Miles are Black Americans, which has social meaning that is reflected in
health. For example, infants born to Black women are substantially more likely to die before
their first birthday than infants born to White women. Figure 1 shows the infant mortality rate (a
measure of deaths during a child’s first year) for the United States and the countries of the
Organization for Economic Cooperation and Development (OECD), a group of countries
committed to global trade and economic development. We also included the infant mortality
Health & Illness (Fall 2021)

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rate for different racial and ethnic groups in the U.S. Epidemiologists may first note that the rate
for the total U.S. is by far the highest among the wealthy OECD countries; even the rate for U.S.
infants born to White women is high. Second, they may note that the mortality rate for infants
born to Black women is more than twice the rate for infants born to White women. As
sociologists, we will discuss these health inequities – differences in health that are due to
unequal social patterns – and focus on the social forces that are likely responsible for them.

Figure 1: Infant Mortality Rate by Country, 2014

(Source: OECD and National Center for Health Statistics)

Sociology can also help us understand how society shapes the definition and
experience of illness (the subjective experience of a disease, condition, or set of symptoms). In
recent years, growing media attention has focused on maternal morbidity, or illnesses and
disabilities related to pregnancy or childbirth, and, in particular, the treatment of Black women
during pregnancy, labor, and the postpartum period. These stories are supported by data
0 2 4 6 8 10 12 14
S l o v e n i a
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Infant death within first year, per 1000 live births
https://data.oecd.org/healthstat/infant-mortality-rates.htm
Health & Illness (Fall 2021)

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showing that physicians construct their views of who requires medical attention (in others
words, who is sick) around race and gender.1
Viewed through a medical lens, we might focus on the pre-existing conditions or health
behaviors of pregnant woman during the perinatal period (the time immediately before and
after birth) to explain health inequities. Black women do, in fact, have higher rates of high
blood pressure and diabetes compared to White women. However, neither these pre-existing
conditions, nor any health behaviors such as alcohol use or smoking, fully explain the different
rates of infant mortality.2 Viewed through a public health lens, we might focus on racial
inequities in access to high-quality prenatal care or adequate health insurance. However,
research indicates that these conventional public health concerns also don’t explain racial
inequities in infant mortality.

Left to right: Tressie McMillian Cottom, PhD; her baby girl died
during her preterm labor delivery (Source).
Serena Williams; she nearly died after returning home after
delivering her baby girl (Source).

Using a sociological lens, we widen the scope of our questions to understand how
Nandi’s and Miles’s life course social circumstances – the interconnected sequence and
timing of socially-defined life events that unfold over a person’s through their own actions and
behaviors – and the circumstances of their family and friends and even of their broader racial
group, impacted their chances of experiencing the death of their babies.
Public health and medicine can benefit from sociological insights into the social forces
that drive patterns in health – a state of complete physical, mental, and social well-being, not
merely the absence of disease. Sociologists also benefit from studying health. Health is
essential for quality of life and a sensitive indicator of the social forces in a society. In a
https://commons.wikimedia.org/wiki/File:Tressie_McMillan_Cottom_PhD_THICK.jpg
https://commons.wikimedia.org/wiki/File:Serena_Williams_US_Open_2013.jpg
Health & Illness (Fall 2021)

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statement to the National Commission to Prevent Infant Mortality, pediatrician Marsden
Wagner outlined the interconnected nature of social forces and the health of our most
vulnerable citizens, our children:
Infant mortality is not a health problem. Infant mortality is a social problem with
health consequences. It is analogous to traffic accident mortality in children: the first
priority for improving traffic accident mortality in children is not to build more and better
medical facilities, but rather to change traffic laws and better educate drivers and
children. In other words, the solution is not primarily medical but environmental, social
and educational. The same is true for infant mortality: the first priority is not more
obstetricians or pediatricians or hospitals, nor even more prenatal clinics or well-baby
clinics, but rather to provide more social, financial and educational support to families
with pregnant women and infants.3
In this chapter, we share layers of Nandi’s experiences that are mirrored in data to show
that her pregnancy experiences can be linked to how American society is structured. We
focus on specific examples from maternal and child health, the field of public health focused
specifically on the health of mothers, infants, children, and adolescents; however, the
concepts we discuss are relevant to any area of disease or illness throughout the life span.
We have three goals for this chapter. We hope to show you that health and illness are
socially constructed concepts; the meanings of health and illness are created through social
norms and interactions. We will also give you the tools to understand why this is the case. We
illustrate the social nature of the medical profession and the health care system, which are
constantly shifting. Indeed, the medical profession has only recently begun to recognize the
role of society in health; in 2015, new sections on the social and behavioral sciences, including
sociology, were added to the Medical College Admission Test (MCAT). Finally, we show that
health and health inequities are not just shaped by differences in access to health care and
health behaviors, but are also determined by social forces embedded in where we live, learn,
work, play, and pray. We hope to convey that sociology provides a critically important lens
through which we can view health and illness.

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DEFINING THE BOUNDARIES OF HEALTH & ILLNESS

 How is disease different from illness?
 What does it mean to say that illness is socially constructed?
Health and illness are not objective states; their
definitions and experiences are socially constructed. While a
person may be diagnosed with a physical or mental disease
(a disorder) or impairment (a loss of function), social and
cultural values and norms give meaning to the illness
experience. Diseases and other medical conditions are not
inherently illnesses; rather, illnesses are the subjective
experiences of the person with the disease, condition, or
impairment. For example, a person may receive a diagnosis
of high blood pressure (also called hypertension), but this
diagnosis doesn’t reveal anything about their experience with
hypertension. Perhaps they haven’t had any major changes
in their daily life with this diagnosis and may not consider
themselves ill at all. In fact, many people who take
medication and are able to control their hypertension don’t
consider themselves to actively have high blood pressure.4
Similarly, mental and physical impairments are not inherently
disabilities, or limitations created when an impairment isn’t accommodated in the physical
and social environment. They become disabilities when a society doesn’t provide such
accommodations, and therefore prevents people with impairments from fully engaging in
everyday life. For example, people with visual impairments may not have difficulty carrying out
their everyday tasks as long as accommodations such as audio tracks are available. In this
section, we discuss how health is socially constructed by examining spatial patterns in health
and how the definitions and experiences of illness function as forms of social control.
Early sociological studies of health
Nandi grew up in the 1980s and 1990s on First Street in Washington, D.C., in a
neighborhood noted for two infamous sites: the Sursum Corda low-income housing
development and Hanover Place, a street that functioned as an open-air drug market. At the
time, Washington, D.C. was in the middle of a major crack cocaine and violent crime
epidemic, much of it centered in Nandi’s neighborhood. Drug use and violent crime (which
ATM with a headphone port for
people with visual impairments.
(Source: Authors)
Health & Illness (Fall 2021)

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are also socially constructed, as discussed in the Deviance and Crime chapter) are social and
public health issues that are not evenly distributed across all neighborhoods, cities, states, or
even countries.
In fact, early studies in demography (the study of patterns in human populations, such
as births, deaths, aging, and migration) and sociology demonstrated that many health
concerns have a spatial pattern. Émile Durkheim, studied suicide rates in France and several
other European countries and showed that different countries, and even different areas within
France, exhibited vastly different suicide rates.5 He argued against the dominant
understanding that suicide was caused by mental illness or personal shortcomings. Instead, he
suggested that social factors outside the individual affect suicide rates.
Similarly, in 1899, W.E.B.
Du Bois (pronounced doo-
BOYSS) published The
Philadelphia Negro, a study of
Black Americans in Philadelphia
that included a detailed
discussion of health.6 In 1906, he
expanded this study in The
Health and Physique of the
Negro American.7 Du Bois
argued that the poor health of
Black Americans compared to White Americans wasn’t due to any individual biological
limitations among African Americans but rather to social conditions. He supported his
argument by showing that mortality rates for Black Philadelphians varied widely by area,
explaining that the high mortality rates occurred specifically in neighborhoods with poor
housing and substantial crowding.
We continue to see that our health depends on where we live and work, and sociology
can help us understand why. As discussed in the Urban Sociology chapter, the U.S. is racially
and economically segregated, meaning families of different racial or ethnic groups and
different socioeconomic status (SES) – a measure of social and economic standing – live in
different neighborhoods of unequal quality.8 Living in racially-segregated cities is harmful for
the health of Black infants, but generally not for White infants, even after accounting for the
poverty level of their neighborhoods.9 This suggests that segregation is about more than just
the unequal distribution of poverty; it leads to the unequal distribution of other resources that
are important for health.10
Let’s return to Nandi’s neighborhood on First Street, in Ward 5. When her mother passed
away in 2008 at the age of 58, Nandi inherited her childhood home; she and Miles lived there
during her pregnancy and childbirth. While her neighborhood has experienced some influx of
“The Ward.” Philadelphia mural honoring W.E.B. Du Bois; painted by Willis
Humphrey in 2008. (Source)
101204-Phila murals-#17 - Mapping Courage - Honoring W.E.B. Du Bois and Engine #11 - 01
Health & Illness (Fall 2021)

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White residents and the demolition of several racially-segregated low-income housing
developments, it continues to be highly racially segregated. Nandi’s neighborhood also has
some of the highest rates of infant mortality in Washington, D.C. (Figures 2a and 2b).
In Ward 5, 65% of residents are Black. We also see spatial patterns in the availability of
resources. For example, after several of the few remaining hospital maternity wards in Wards 5
and 8 closed in 2018, many women who live there must now travel long distances for their
prenatal care and delivery (Figure 3a). On the other hand, group homes (Figure 3b) and other
social services such as methadone clinics (which treat those addicted to opiates) are over-
represented in these wards. All of these social and health services are important resources,
and ideally they would all be more equally distributed across the city.

Figure 2a: Infant Mortality Rates in
Washington, D.C., by Ward, Highlighting
Ward 5, 2014
Figure 2b: Infant Mortality Rates by Ward
in Washington, D.C., Highlighting Ward 5,
2014

(Source: DC Health Matters)
http://www.dchealthmatters.org/
Health & Illness (Fall 2021)

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Figure 3a: Distribution of Washington,
D.C., Hospitals and Ambulatory Surgical
Centers as of 2014, along with Two
Maternity Wards Closed in 2018
Figure 3b: Distribution of Group
Residences in Washington D.C.,
2014

(Source: DC Department of Health)
Social control and definitions of health & illness
Think about the last time you or one of your close friends or family members were very
sick. Did you visit a doctor? Was there a clear diagnosis? A clear treatment plan? Did your
friends and family understand your illness? Were you embarrassed to share your diagnosis? Did
you wonder if your illness was your fault? Sociologists argue that illness doesn’t reside in the
biological disease, condition, or impairment itself. Rather, social and cultural norms shape their
definitions, meanings, and experiences. This perspective is central to the field of medical
sociology, which focuses on how social control – a society’s efforts to influence behavior and
maintain social order – operates through the medical profession, both directly and indirectly.
When you think of schizophrenia, what comes to mind? Currently, the American
Psychiatric Association defines schizophrenia in biological terms as a chronic brain disorder.
However, there is also a subjective component, as it is characterized by an inability to
distinguish between real and unreal experiences. This makes the label of schizophrenia
vulnerable to being influenced by social and cultural norms. After reviewing hundreds of
patient charts at the infamous (and now closed) Ionia State Hospital for the Criminally Insane,
in Michigan, Jonathan Metzl found that the definition of schizophrenia changed over the 20th
century in ways that coincided with social changes in the U.S.11 Before the 1960s,
https://doh.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/Web-Health-Systems-Plan-5-8.pdf
Health & Illness (Fall 2021)

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schizophrenia was associated with White housewives who weren’t able to adequately fulfill
their duties as wives and mothers. During the 1960s, as the Civil Rights Movement emerged,
schizophrenia became associated with violence and Black men.
The social shift in how schizophrenia was diagnosed and described shows how the
medical profession can label a set of symptoms as a disease – labels that reflect what is and
isn’t socially acceptable. Eliot Freidson argued that labeling, the process of assigning a
disease or medical condition to a set of symptoms, is a form of power exerted by the medical
profession that can impact the illness experience.12 Indeed, people with contested illnesses
that are disputed or questioned by medical experts, such as chronic fatigue syndrome,
fibromyalgia, or Gulf War syndrome, are often met with skepticism. Their illness experiences are
dismissed as psychosomatic, caused by mental factors such as stress or anxiety.13 While each
of these conditions represents a collection of recognizable symptoms such as muscle pain,
headaches, or fatigue, they don’t have a known underlying biological explanation.
Social control is also exerted through the medicalization of everyday events.14 Irving
Zola argued that medicalization is the description of an aspect of cultural or social life in
medical or biological terms.15 Medicalization erases the cultural or social forces involved in the
situation, reducing it to individual choices and behaviors or biological processes. From this
perspective, health-related problems can be solved not by changing society, but by
changing the individual’s behaviors or discovering a cure.
Health & Illness (Fall 2021)

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Pregnancy and childbirth
aren’t illnesses or disabilities, but
ordinary life experiences.
However, the medical model
dominates discussions of them in
the U.S. In the medical model,
the obstetrician – not the
pregnant woman – is the expert
about the woman’s body.
Childbirth is no longer a natural
event but a medical
circumstance requiring a highly-
trained physician. Of course,
there are circumstances that do
require medical intervention,
such as Nandi’s situation.
However, pregnancy and
childbirth are natural events that
most often don’t require medical
intervention. In countries such as
the U.S., “obstetrician
involvement and medical
interventions have become
routine in normal childbirth,
without evidence of
effectiveness” (emphasis
added).16 On the other hand, in
many European countries, the
midwife-led model of pregnancy and childbirth is often just as common as the medical model.
For example, half of all babies in Great Britain are delivered by midwives. In the midwife-led
model, midwives provide individualized prenatal and postnatal care and support for women
in labor. Research shows that having a midwife present results in positive birth experiences.17
Social control can also be exerted by dictating how we should behave when we are
sick. American cultural norms dictate that we should work hard and be financially responsible
for our families without relying on public assistance. Those who are ill or disabled, however,
may not be able to fulfill these social obligations. For example, a person who is undergoing
chemotherapy for cancer may not be able to continue working or fully caring for their family.
They may be excused from their usual social obligations if they meet certain criteria and fulfill
(Source)
http://www.euro.who.int/__DATA/ASSETS/PDF_FILE/0005/309623/INFOGRAPH-NURSES-MIDWIVES-EN.PDF
Health & Illness (Fall 2021)

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new social obligations, as outlined by the sick role – a set of rights and responsibilities granted
to some ill people – described by Talcott Parsons.18
In order to be considered sick or disabled in a
socially legitimate way that conforms to social
norms and values, the illness cannot be the person’s
own fault. Some illnesses are considered socially
legitimate while others aren’t. In the U.S., illnesses
and disabilities that are perceived to stem from a
person’s poor lifestyle choices are often
delegitimized and stigmatized. For example,
cigarette smoking is known to cause lung cancer,
and though smoking is both physically and
psychologically addictive, in the U.S. it is often
considered to be a moral weakness and a personal
choice.19 The health consequences are then
considered the smoker’s fault and those with lung
cancer, but not, say, leukemia – which is considered
outside of an individual’s control – are often
stigmatized.20
Similarly, a common form of cervical cancer
is caused by the human papilloma virus (HPV), a
sexually transmitted infection (STI). In the U.S., the
sexual behavior of women is highly stigmatized and
under social control.21 American women are
socialized to avoid appearing highly sexual, and
terms like “slut” are used to punish those who break
this rule. Health problems linked to sexual behaviors
are delegitimized and, as the public learned of the
connection between earlier sexual behavior and cervical cancer, women with cervical
cancer have been stigmatized and may not receive the sympathy and understanding offered
to women with other types of cancer.22
Susan Sontag argued that illness is often explicitly seen as a reflection of personal
shortcomings or moral weaknesses.23 While both lung cancer and cervical cancer may be
delegitimized and stigmatized because they are seen as the person’s fault, Sontag explains
that these diseases may also be viewed as the result of a personal shortcoming such as low
self-control. From this perspective, it’s not just that a person could have avoided the disease;
they should have avoided it, and it’s a moral failure on their part that they didn’t.
Edited poster from a 2012 anti-stigma campaign
by the Lung Cancer Alliance. Original text:
“Crazy old aunts deserve to die if they have lung
cancer. Many people believe that if you have
lung cancer you did something to deserve
it…Lung cancer doesn’t discriminate and neither
should you…” (Source)
https://www.flickr.com/photos/gazeronly/7483536468
Health & Illness (Fall 2021)

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If a person has a socially legitimate illness (meaning it isn’t believed to be their own
fault), they must take on two responsibilities before they can adopt the sick role and be
excused from their social responsibilities. First, they must seek expert advice on how to either
overcome their illness (if it can be cured) or reduce the impact it has on their social
responsibilities (if it’s a chronic condition that can’t be cured). Second, they must follow the
expert advice and try to overcome their disease or condition.
Nandi’s story demonstrates that the sick role doesn’t apply equally to all social groups.
After the death of her babies and her own near death, she spent four days in the ICU and
then was discharged from the hospital. Soon after she returned home, she experienced
dizziness, nausea, vomiting, and severe headaches, and she was seeing spots. Her doctor told
her to continue taking her medication and rest. When her friend who worked at the hospital
took Nandi to the ER, her blood pressure was extremely high. If her friend had not brought her
in for immediate treatment, she would have likely suffered a stroke at home. Nandi fulfilled the
responsibilities of a sick person: she sought expert medical advice from her original doctor and
followed it by taking her medication and staying in bed to rest. However, her story highlights
the complexity around who is allowed to fully adopt the sick role; her doctor failed to
recognize her as having a serious medical condition, and the expert advice she received
didn’t help her get better.
Nandi isn’t alone. Currently, Black women are more than twice as likely to have severe
pregnancy-related complications and nearly four times as likely to die due to these
complications than White women are.24 These inequities persist even after we take into
account health insurance coverage and health problems that existed before the pregnancy.
Political scientist Melissa Harris-Perry explains that society often burdens Black women
with crude stereotypes that obscure their true selves, making it difficult to recognize and treat
them as individuals.25 Writing about the death of her baby, Tressie McMillan Cottom said, “I
was pregnant and in crisis. All the doctors and nurses saw was an incompetent Black
woman”.26 When Nandi received the death certificates for her twins (Figure 4), she was listed
as unmarried, having less than an 8th-grade education, and having attended only six of the
standard 12 prenatal medical visits – none of which was true. Nandi was married, completing
her doctoral degree at a highly prestigious university, and had attended all of her prenatal
care visits. The level of inaccuracy of her certificate reflects studies showing that pregnant
Black women are stereotyped as unmarried, uneducated, and poor.27
To have a socially legitimate illness, medical experts must recognize the illness. While
Black women – and others facing pregnancy-related complications – may require medical
technologies, the medicalization of pregnancy has placed the expertise about women’s
bodies and experiences into the hands of highly-specialized medical doctors. If those doctors
don’t recognize symptoms as a condition in need of medical attention – either because of
Health & Illness (Fall 2021)

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racial stereotypes or because a doctor thinks the symptoms are psychosomatic – women may
be unable to get the medical help they need.

Figure 4: Inaccurate Information on the Death Certificate for Infant Son of Nandi and Miles

(Source: Provided to authors by Nandi)
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In this section, we discussed the ways in which illnesses and the illness experience are
socially constructed. By examining the spatial patterns of morbidity and mortality, we can
understand that diseases are not conditions inherent in the individual but reflections of society.
Through labeling diseases, medicalizing ordinary phenomena, and dictating the behaviors of
a sick person through the sick role, the experience of illness is socially controlled to fit cultural
norms and values. These forms of social control can operate differently in different social
groups. By questioning their social construction, sociologists can contribute to public health
and medicine, clarifying the underlying social forces that result in poor health.

REVIEW SHEET: DEFINING THE BOUNDARIES OF HEALTH & ILLNESS
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

15: Health and Illness

15: Health and Illness


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HEALTH CARE IN THE U.S.

 What is a health care system?
 What are the health care debates in the U.S. about?
Throughout Nandi’s
pregnancy, she and Miles went to
all of their prenatal care visits and
created a plan for their delivery.
Because Miles had good health
insurance through his employer,
these prenatal visits didn’t cost
them anything. They were
relieved that the costs of labor
and delivery were also covered
by their insurance. You may not
question the need for health
insurance or that their health
insurance came through Miles’s
workplace because this is
standard in the U.S. However, it
wasn’t always this way, and many
other wealthy countries don’t
have the same approach to
paying for health care.
The importance of
insurance in the U.S. health care
system is illustrated by Nandi’s
delivery experience. When Nandi
and Miles arrived at the ER, with
Nandi bleeding uncontrollably,
Nandi was asked for her insurance card. Despite passage of the Emergency Medical
Treatment and Active Labor Act (EMTALA), which states that women in active labor cannot be
denied care regardless of their ability to pay if they are at a hospital that takes federal
insurance such as Medicaid, she wasn’t admitted until she provided her card. In fact, many
hospitals do not comply with this law.28
Example of ER sign required by EMTALA. (Source)
https://www.calhospital.org/resource/emtala-its-law-poster
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The American health care system is embedded in the broader society and reflects the
same underlying sociological themes. Health care systems are organized around social
structures and political institutions.29 They also incorporate our larger values and ideologies.
Disagreements about how we should deliver health care in the U.S. stem from differing
ideologies about whether health care is a right or a commodity. Do we view all citizens as
worthy of a healthy life? Or are only some deserving of this privilege? Does it depend on their
ability to pay, or how they behave?
In May 2017, late-night talk show host Jimmy Kimmel discussed his infant son. His
monologue sums up the idea that health care is a right:
We were brought up to believe that we live in the greatest country in the world,
but util a few years ago, millions and millions of us had no access to healthcare at all.
Before 2014, if you were born with congenital heart disease like my son
was, there was a good chance you’d never be able to get health insurance
because you had a pre-existing condition. You were born with a pre-existing
condition. And if your parents didn’t have medical insurance, you might not live
long enough to even get denied because of a pre-existing condition. If your
baby is going to die and it doesn’t have to, it shouldn’t matter how much money
you make. I think that’s something that whether you’re a Republican or a
Democrat or something else, we all agree on that, right? I mean, we do.
Whatever your party, whatever you believe, whoever you support, we
need to make sure that the people who are supposed to represent us, the
people who are meeting about this right now in Washington, understand that
very clearly. Let’s stop with the nonsense. This isn’t football. There are no teams.
We are the team. It’s the United States. Don’t let their partisan squabbles divide
us on something every decent person wants. We need to take care of each
other. I saw a lot of families there and no parent should ever have to decide if
they can afford to save their child’s life. It just shouldn’t happen. Not here.
In an interview on CNN, Republican congressman Mo Brooks from Alabama summed
up the counterargument. Instead of seeing health care as a right, from this perspective only
those who have led “good lives” and are sick through no fault of their own deserve affordable
health care coverage:
My understanding is that [a proposed health care law] will allow insurance
companies to require people who have higher health care costs to contribute more to
the insurance pool. That helps offset all these costs, thereby reducing the cost to those
people who lead good lives, they’re healthy, they’ve done the things to keep their
bodies healthy. And right now, those are the people – who’ve done things the right
way – that are seeing their costs skyrocketing.
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In fairness, a lot of these people with pre-existing conditions, they have those
conditions through no fault of their own and I think our society, under those
circumstances, needs to help.

Left: Jimmy Kimmel, host of “Jimmy Kimmel Live,” with former President Barack Obama. (Source);
Right: Republican Congressman Mo Brooks of Alabama with former Alabama Republican
Senator Luther Strange. (Source)
As we discuss health care systems and health care debates, keep these
underlying opposing ideologies in mind. Who deserves to live a healthy life? Who
deserves to receive high-quality health care when they need it? Should your ability to
pay or your past behavior affect whether you can get care? How you answer these
questions will affect the type of health care system you might support.
Health care as a system
Health care systems include the organizations that deliver care (e.g. health care
providers, hospitals) and fund that care (such as governmental programs and private insurers).
For over 100 years, the U.S. has tried to figure out the best way to deliver health care. Because
it’s expensive, many countries, including the United States, have created health insurance
systems. Without health insurance, we would pay “out of pocket” for all health needs. Health
care, and the method of paying for it, are so intertwined that to speak of health care,
particularly in the U.S., is also to speak of paying for health care.
Globally, health care systems can be classified based on the roles of health care
providers and the medical profession, the government, and the payer:30
 Out-of-pocket model: The patient pays all health care costs personally; there is no
health insurance. This model isn’t used by wealthy countries.
 Beveridge model: The government pays all health care costs and funds it through
taxes. Health care providers, including hospitals and doctors, can be employed by the
government or have their own private practice. It is named after economist William
Beveridge, who designed Great Britain’s National Health Service.
https://obamawhitehouse.archives.gov/sites/default/files/image/image_file/obamakimmel.jpg
https://commons.wikimedia.org/wiki/File:Luther_Strange_and_Mo_Brooks.jpg
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 Bismarck model: Everyone is required to have health insurance, which is funded jointly
by employers and employees and isn’t intended to make a profit. While health
insurance operates through employers, the government provides oversight of costs.
Health care providers are generally private. It is named after Chancellor Otto von
Bismarck, who designed the German welfare state.
 National Health Insurance model: Combines the Beveridge and Bismarck models. The
government provides insurance funded through taxes or premiums, but supplemental
private insurance may be needed. Health care providers are generally private.
 Semashko model: All parts of the health care system are controlled by the
government. This model was developed in the Soviet Union and is still used, in some
form, by countries in eastern Europe.
Many countries combine features from different models. The U.S. operates with a
patchwork of these models.31 We have two broad categories of health insurance: publicly-
funded and privately-funded. The major types of public or governmental health care
coverage include Medicare, which covers certain health care costs for Americans aged 65
and older, and Medicaid, which covers certain health care costs for low-income Americans.
Other programs cover specific groups, such as the Indian Health Services (for eligible Native
Americans) and the Veterans Administration (for eligible military veterans). People get private
health care coverage for themselves and/or their families through their employers or by
purchasing coverage directly from an insurance company.
Health care costs in the U.S. have reached $3.5 trillion each year – nearly 18% of the
total value of all goods and services produced in the U.S. We spend two to three times as
much per person on health care as any other wealthy nation. Yet our health falls far behind
other countries. In other words, while our health care is expensive, this higher cost doesn’t lead
to better health. This has resulted in many attempts to change our health care system,
including health care delivery and particularly health insurance.
Current debates about health care
In a recent report, sociologists Jason Beckfield and colleagues stated:
Boundaries and construction of exclusion and inclusion regarding healthcare
systems are key issues that are debated within and across countries. … [T]he threat of
illness is universal. Consequently, observing which individuals and groups are considered
worthy of assistance…provides researchers with insight into the broader culture of a
society and into what its members expect of their healthcare system (e.g., how it should
provide services and to whom).32
On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA; commonly
known as ACA or Obamacare) was signed into law. The goal was to make health care more
Health & Illness (Fall 2021)

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affordable and accessible for more Americans, particularly those who couldn’t easily cover
the costs themselves. Before the ACA was passed, 18% of Americans under 65 years old didn’t
have insurance, only 50% of poor Americans were covered by Medicaid, and most people
with pre-existing conditions (a condition you had before you enrolled with a particular health
plan) couldn’t afford the high premiums charged by insurance companies.33 The ACA
required a number of changes:
 It established “health exchange” marketplaces where people could shop for health
insurance.
 Insurers are required to cover ten essential services: ambulatory (outpatient)
services, emergency services, hospitalization, maternity and newborn care, mental
health and substance use services, prescription drugs, rehabilitative services and
devices (such as speech-language therapy or physical therapy), laboratory
services, preventive and wellness services and chronic disease management, and
pediatric services, including oral and vision care.34 There are higher premiums (the
annual cost for an insurance plan) for greater coverage.
 Insurers are required to cover people regardless of their health status. In other words,
relatively affordable health insurance was available to those with pre-existing
conditions (which in the past might have made them ineligible for health insurance
or limited what was covered).
 Income-based subsidies are provided for people who can’t afford the premiums.
 Medicaid was expanded to cover more people. The U.S. Supreme Court ruled that
requiring states to expand Medicaid was unconstitutional, so the expansion is
voluntary for states. Thirty-one states expanded Medicaid to cover more of their
residents.35
 All Americans were required to have health insurance, similar to the requirement
that drivers have car insurance. This element was removed by Congress in 2019, so
the “individual mandate” in the ACA is no longer enforced.
 Employers with more than 50 employees are required to provide health insurance
and to extend the coverage to employees’ families and their children until they are
26 years old.
However, the ACA did not achieve universal coverage (coverage for everyone) for
several reasons. First, the Supreme Court ruling that states could choose not to participate in
the Medicaid expansion means that roughly 4.5 million poor and near-poor people are still
uninsured.36 And undocumented immigrants aren’t allowed to purchase insurance on the
marketplace or to receive subsidies to help pay for coverage, so roughly 40% of this group are
estimated to be uninsured.37
Just as with political disagreements about other American institutions such as the
criminal justice system, debates about health care reflect underlying ideological differences. It
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may seem that the debates center on how we can pay for health care. What should the
government’s role be in covering health care costs? This divides the nation based on some
who believe that it is the government’s role to pay for health care versus those who believe
that these costs should be left to the market and individual consumers. More fundamentally,
these debates reflect differences in ideologies about who is worthy. The question isn’t simply,
“Is health care a right or a commodity?” because viewing health care as a right or a
commodity for sale may reflect an underlying value system. Thus the question is: “Who has the
right to live a healthy life?”
Since it was signed into law, the ACA has been the topic of political and dinner table
debates; some political groups have attempted to change the ACA or repeal it entirely.
Several left-leaning proposals attempted to expand the ACA to cover all Americans and
reduce or eliminate individual premiums, while several right-leaning proposals tried to remove
some features. This includes proposals to create separate high-risk pools (where people with
certain conditions would pay more for
coverage) so that healthy people who
“lead good lives,” as Congressman Mo
Brooks said, don’t share the costs of
those with higher health risks.
These disagreements and the
many protests on all sides of this issue
reflect underlying ideological
differences. Policymakers have fueled
the disagreements through political
rhetoric such as calling the ACA
“Obamacare,” which was intended by
opponents to link the bill to President
Obama and to people’s ideas about
him and about who deserves a healthy life. In fact, while the ACA was championed at the
national level by former President Obama, a Democrat, it was modeled after “Romney Care,”
developed by former Massachusetts Governor, and Republican, Mitt Romney. But in opinion
polls, people are more supportive of the ACA than of “Obamacare” – even though they’re
the exact same program. A key role for the sociological study of health care is to understand
these types of connections between political discussions about features of our health care
system and larger societal norms, values, and ideologies.
Former President Barack Obama at an Affordable Care Act
event in 2013. (Source)
https://obamawhitehouse.archives.gov/blog/2016/03/23/look-six-years-affordable-care-act
Health & Illness (Fall 2021)

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REVIEW SHEET: HEALTH CARE IN THE U.S
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LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

SOCIAL DETERMINANTS OF HEALTH & HEALTH INEQUITIES

 What are the major social determinants of health?
 How can the socioecological framework and life course perspective help us
understand social patterns in health?
Figure 5 is a map of life expectancy in different parts of Chicago for 2009-2010. Average
life expectancy for residents of the Loop area of downtown Chicago is 85 years. Residents of
Washington Park, just a few miles away, have a life expectancy of only 69 years. What might
account for this dramatic difference in life expectancy for people who only live a few miles
from each other? In the Loop, 15% of residents live in poverty and only 6% are unemployed. In
Washington Park, 48% of residents are poor and 29% are unemployed.38 These patterns in
Chicago mirror those in other cities, including Washington, D.C., where Nandi and Miles live.
Economic characteristics such as poverty and unemployment are social determinants
of health, a broad category of factors, including “a society’s past and present economic,
political, and legal systems [and] its material and technological resources…”, that drive social
patterns in health.39 The social determinants of health are often described as the “upstream”
determinants of health because they then impact “downstream” determinants, such as
behaviors like smoking and diet. As we have seen throughout this chapter, the health of

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15: Health and Illness


Health & Illness (Fall 2021)

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individuals is embedded within a larger social context. This embeddedness can be considered
in a few different ways. First, sociologists have focused particularly on three interrelated
characteristics when studying health: race and ethnicity, gender, and class (also called
socioeconomic status, or SES). More recently, the focus has shifted toward how racism, sexism,
and class inequality make these characteristics relevant to health. A second way that
individual health is socially embedded is illustrated by the socio-ecological model. According
to this model, a person is embedded within their social networks and relationships, which are
then embedded within their neighborhoods and communities, which are embedded within
larger socio-political contexts. Finally, people are embedded in their life course. Examples of
life course events include graduation, marriage, parenthood, divorce, and other key
milestones or transitions. Living in a poor neighborhood for many years will have a different
impact on the health of a child than on a young adult or an older adult. And living in poverty
for five years before finding stable life-long financial security has a different impact on health
than living in poverty for your entire life.

Figure 5: Life expectancy in Chicago, 2009-2010
Many of these social
determinants of health result in
health inequities; the
differences in health that result
from these social patterns are
often due to unequal and
unfair social conditions. For
example, race, ethnicity, and
class are considered
fundamental causes of health
because they can result in
health inequities due to the
unequal distribution of
resources such as adequate
housing or food and also
through stigma and stress.40
While we focus on the most
studied determinants, social
scientists are beginning to
study other social
determinants of health
(Source: Center on Society and Health)
https://societyhealth.vcu.edu/media/society-health/pdf/LE-Map-Chicago.jpg
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including sexual identity, religious affiliation, skin tone, and immigrant status.41
Race, ethnicity, structural racism, and health. Race and ethnicity are socially
constructed; race is “a system that humans created to classify and stratify groups of people
based mostly on skin tone” and ethnicity is “a common culture, religion, history, or ancestry
shared by a group of people”.42 In the U.S., racial and ethnic categories are developed based
on social norms of who is fundamentally American and seen as worthy of inclusion in
American society.43 Given this, it isn’t surprising that there are racial and ethnic inequities in
health, as different groups experience unequal social, economic, and political contexts. It’s
not race and ethnicity, themselves, that result in health inequities, but structural racism – a set
of beliefs and ideologies and the social structure that they create based on the idea that a
specific racial group is biologically or culturally superior to other groups – that drives these
unequal contexts.
Let’s return to racial inequities in infant
mortality. In recent decades, technological
advances, such as the development of pulmonary
surfactant therapy, have made it possible for infants
born prematurely to survive life-threatening
conditions such as respiratory distress syndrome
(RDS). However, fundamental causes theory
predicts that access to this life-saving technology
would differ along racial lines, as structural racism
leads to unequal access to the resources needed
for a healthy life – and that is in fact what we see.
Before the development of pulmonary surfactant
therapy, there were no racial inequities in infant mortality due to RDS. However, after this
technological advancement, infants born to Black mothers were more likely to die of RDS than
infants born to White mothers, because White parents have greater access to this medical
therapy.44 This suggests that in order to improve the health of all babies, we need to focus
more fundamentally on how our society is socially structured rather than on medical advances
alone.
Gender, structural sexism, and health. Sex and gender are also socially constructed. Sex
refers to the “biological and physiological characteristics of males and females” while gender
refers to the “norms, roles, and relationships among and between groups of women and
men”.45 Some sex-based differences in health, such as differences in breast or prostate
cancer, don’t reflect inequities because breast cancer is extremely rare in men, while only
men can get prostate cancer. Differences between men and women in who gets these
cancers don’t reflect unfair or unequal social patterns. However, there are gender inequities
related to chronic diseases. While women have longer life expectancies than men, they tend
A yawning newborn can breathe due to lung
surfactants. (Source)
https://pxhere.com/en/photo/164675
Health & Illness (Fall 2021)

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to experience more disabilities, poorer mental health, and a lower quality of life.46 Sociologists
suggest that it isn’t gender itself that drives these health patterns, but structural sexism.
Structural sexism is a set of beliefs and ideologies, and the social structure that they create
through policies and institutions, based on the idea that men are superior to women; it is
distinct from, and perhaps more important for health than, sex discrimination by individuals.47
Sociologist Patricia Homan measured structural sexism as, for example, the size of the pay gap
between men and women in a state, how many women versus men hold seats in the state
legislature, and how many abortion providers there are in a state. These indicators capture the
extent to which women’s lives are valued. While it may not be surprising that the wage gap
would be bad for women’s health because health is related to income, it may not be clear
why other measures of structural sexism are related to women’s health. It’s not necessarily that
women legislators always support gender equality or that there are so many women requiring
access to safe abortions. Rather, these indicators of structural sexism represent a lot of similar
policies and programs that promote gender equality. Homan’s work showed that women who
lived in states with less structural sexism had better health than women who lived in other
states.48 What may be surprising is that men also benefitted from less structural sexism. It’s likely
that empowering women comes with many institutional improvements such as better
education and more social programs, which can improve the health of everyone in the state.
Socioeconomic status (SES). SES, or social class, is one of the most studied social
determinants of health. Features of SES include education, occupation, income, and wealth.
Each represents a different aspect of SES and is related to health along a gradient. It’s not just
that there are health inequities between the rich and poor, but that health declines along the
entire income spectrum; at each level, people have better health than those with lower SES.
Roughly 50 years ago, sociologists Evelyn Kitagawa and Phillip Hauser showed that college-
educated adults had lower mortality than adults with less education.49 Since then, numerous
studies in the U.S. and around the world have shown a strong association between the level
and quality of education and health.
While we know that education and health are linked, it still isn’t clear what about
education is important for health. Public health researchers have focused on a lack of
knowledge about healthy lifestyles. For example, a recent epidemiology text states,
“…schooling may [develop] a set of enduring cognitive or emotional skills that foster health-
promoting decisions through life. Literacy [the ability to read] and numeracy [the ability to
work with numbers] are likely to help individuals make health decisions.”50
Sociologists have focused on a default American lifestyle that has become dependent
upon conveniences such as, for example, driving (replacing physical activity to get around)
and highly-processed and high-calorie food (replacing fresh food, particularly fruits and
vegetables). This American lifestyle also depends on medical interventions to address diseases
rather than focusing on preventing disease in the first place.51 More education may provide
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access to power, prestige, and resources that allow people to avoid the default American
lifestyle. For example, people with higher education may be able to live in neighborhoods and
have workplaces that support walking and biking through walking paths, bike lanes, and
places to park bikes, and may live within safe walking or biking distance of stores, businesses,
and workplaces. They may also be able to afford higher-quality fresh produce and other
healthy food options.
Increased education is also related to higher occupational prestige and income or
wealth. Some occupations have more social prestige than others, giving people with that
occupation higher social standing. Both education and occupation are related to income
and wealth. Higher incomes and wealth give people greater access to resources such as
high-quality housing and neighborhoods with key resources.
In reality, race and ethnicity, gender, and class intersect in many ways that create
complex health patterns. When Nandi was pregnant, she was working on her doctoral degree
in public health at a prestigious university; her husband already had a Master’s degree in
education and taught at a private middle school. Nandi’s mother earned her college degree
before she died at 58 years old, and Nandi’s grandmother was a nurse, a skilled and generally
highly-respected profession. Nandi and Miles owned their home, which they inherited from
Nandi’s mother. In fact, many recent media stories are about Black women with high levels of
education and prestige who still experience poor maternal health.

Figure 6: U.S. Infant Mortality Rate by Mother’s Race, Ethnicity, and Educational Level, 2016

Abbreviations: AIAN, American Indian or Alaska native; API, Asian or Pacific islander; CO, college; HL,
Hispanic or Latino; HS, high school; NHB, non-Hispanic Black; NHW, non-Hispanic White.
(Source: Calculations from Singh & Yu [2019].52 Data derived from the 2016 National Linked Birth/Infant
Death Period File.)

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These stories are reflected in national data. Even with a college degree, Black adults
have poorer health than White adults. More education is beneficial to the health of all groups,
but not as beneficial for Black Americans as it is for White Americans. Figure 6 shows infant
mortality rates by the mother’s race, ethnicity, and educational level. Higher levels of
education are related to lower infant mortality for all racial and ethnic groups. However, there
are racial inequities, with Black and American Indian/Alaska Native women experiencing the
highest rates. In fact, Black women have the least payoff for higher education; Black women
with a college degree or more have an infant mortality rate that is higher than White women
with only a high school diploma – and only slightly lower than White women who have not
even completed high school. Black women simply have to earn much more education to
attain the health outcomes that White women have.
Social networks and health. In Durkheim’s study of suicide, he noted that we are
integrated into society in two ways: through attachment to others and by accepting and
complying with society’s values, beliefs, and norms. Think about the people you know – your
family, friends, neighbors, classmates, coworkers. They make up your social network (a
structure of socially interrelated people) and likely affect your health. The growth of social
media platforms has changed the size and potential influence of our networks.53 Your social
network can affect your health in several ways. One of the more obvious is through contact
with a pathogen (such as a cold virus) or other health risk (for instance, second-hand cigarette
smoke). And through your attachment to the members of your social network, you may
receive social support, opportunities for social engagement, money, and access to
information on jobs or health care that can ultimately lead to better health. Your social
network also exerts social influence through its values, beliefs, and norms, which may or may
not match those of the broader society; your network may support healthy behaviors or might
encourage you to take risks that can harm your health (such as excessive drinking).
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Neighborhoods and health. Your neighborhood can also affect your health.
Neighborhoods are more than the collection of residents; while neighborhood poverty, for
example, is made up of all residents who have an income below the poverty line,
neighborhood poverty can have impacts on health that go beyond a person’s own poverty.
Even if your family isn’t poor, if you live in a neighborhood where many of your neighbors are
poor, the larger city and private businesses may not invest resources in your neighborhood.
These resources are part of the social and physical environment that affect your health, and
may impact you and your family regardless of your income – that is, the poverty of the
neighborhood has an effect that is separate from the income of individual families, and
affects even those who aren’t poor. The social environment – the social elements of your work,
school, or neighborhood – includes
norms, local institutions, social
connections, trust, and safety. The
physical environment includes built
features of the neighborhood such
as housing, green spaces such as
parks, services and amenities such
as grocery stores, and toxic
substances like air pollution.
Research suggests that chronic
diseases such as hypertension and
diabetes are related to numerous
features of the social and physical
environment.54
Neighborhoods don’t occur
naturally. They are planned and
built, meaning neighborhood quality
is subject to the same power
dynamics as other social
determinants of health. While the
U.S. has always been racially
segregated, certain policies have
increased and reinforced
segregation, concentrated poverty,
and increased racial inequities in wealth and neighborhood quality. For example, a new
system of home mortgages was created as part of the New Deal in the 1930s. However, these
programs were available almost exclusively to White Americans. Maps assigned color-coded
grades to different areas of the city based on their racial composition and other
Color-coded residential map of Atlanta developed by the
Homeowners’ Loan Corporation (HOLC), 1939. (Source)
https://catalog.archives.gov/id/85713707
Health & Illness (Fall 2021)

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characteristics. Areas of the city that included mostly Black residents were graded “D” and
coded red. Residents in those “redlined” areas couldn’t secure government-insured
mortgages and weren’t able to take part in the upward mobility offered to residents of White
neighborhoods.55 The impact of those historical policies can be seen in health today. For
example, the racial composition of a neighborhood continues to be the primary determinant
of where industrial polluters are located, and historically redlined neighborhoods have higher
rates of asthma and violence than other neighborhoods.56
Stigma and health. Over 50 years ago, sociologist Erving Goffman wrote about the
stigma of mental illness.57 A stigma is a mark or label that discredits a person as a form of social
control; people are pressured to accept and follow social norms out of fear of being
stigmatized. Sociologists have since refined the concept of stigma, particularly as it relates to
health.58 They note that social, economic, and political power inequities determine the
difference between a harmful stigma versus a stereotype (a widely-shared perception about
the characteristics or abilities of members of a particular group). For example, there are
stereotypes and jokes about lawyers; however, the prestige and power associated with the
law profession prevents these stereotypes from transforming into a stigma. Sociologists identify
several stages of the stigmatization process. First, society as a whole determines which marks
or features are important in distinguishing “us” from “them”; “they” are seen as problematic. In
general, these features characterize groups of people that society would like to control. For
example, a feature may be dark skin tone, specific clothing (such as a hijab), or an accent.
Stereotyping links these features or marks to characteristics such as being a criminal, poor, or a
terrorist. This stereotyping allows us to separate “us” from “them.” Finally, the stigmatized group
experiences discrimination and loses status. This is the key stage that makes stigma a powerful
form of social control.
Bearing the mark of a stigmatized
group, even without sharing the underlying
characteristics, can impact health, which is
called a spillover effect. The growing
stigmatization of Latinx immigrants through
stereotyping them as “illegal” or “criminal”
may cause health effects not only to
undocumented Latinx immigrants but also to
documented Latinx residents and citizens,
even those whose families have been U.S.
citizens for generations. For example, in May
2008, U.S. Immigration and Customs
Enforcement (ICE) suddenly raided a meat-processing plant in Postville, Iowa. Nearly 300 men
were arrested, charged with working in the U.S. without proper documentation, and deported
A meatpacking plant in Postville, Iowa. (Source)
https://commons.wikimedia.org/wiki/File:Agriprocessors_plant_Postville,_Iowa,_July_27,_2008.jpg
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after serving a five-month prison sentence. News of this raid and allegations of inhumane
treatment toward those arrested in the raid spread quickly through the Spanish-speaking
community in the state. After the raid, there were increases in low-birth-weight babies born to
Latinx mothers in Iowa, even among those who weren’t related to the men who were
deported, suggesting that the stress of a stigmatized identity has health consequences.59
Stress and health. Think about the last time you experienced something stressful. Maybe
you weren’t prepared for a test, or you got into an argument with a close friend. Perhaps a
close family member passed away, or you lost your job. Each of these appears to be an
isolated incident, but through a sociological lens, we can understand that they are
embedded in our broader social context.
How did you feel during that stressful experience? Did your heart rate go up? Did you
feel anxious? For decades, scientists have studied how the body reacts and adjusts to
environmental stimuli. The term “stress” was coined to refer to anything that challenges and
threatens the body’s internal stability and equilibrium, such as blood pressure or even cellular
processes.
Several disciplines, including psychology and endocrinology, pay particular attention to
individual perceptions of stress, coping processes, personality characteristics, and biological
pathways. While the body is resilient and designed to deal with stressful situations, chronic
stress wears away at the body’s stress response system, leading to problems in the immune,
metabolic, and cardiovascular systems. Chronic stress can develop not just from repeatedly
experiencing stressors. Anticipation and worry can transform even a momentary situation into
a chronic stressor.60
Stress has received increasing research and media coverage because of its link to
health. Stress compromises the immune system, whether it is acute stress about an upcoming
exam or the chronic stress of stigma.61 Additionally, major traumatic stress and chronic stress
are related to numerous chronic diseases and conditions including poor mental health,
cardiovascular disease, hypertension, and certain cancers, just to name a few.62
There are social patterns in stress, and social inequities in stress are related to social
inequities in health.63 Inequities in chronic stress are thought to drive many of the health
inequities between the rich and poor, between different genders and sexual identities, and
between different racial and ethnic groups. Early sociological work on stress and racial health
inequities focused on interpersonal discrimination, or unfair treatment of one person by
another, with some attention to structural racism.64 Many sociologists continue to study the
health impact of discrimination; however, some have turned to structural racism as a more
fundamental driver of racial health inequities.
A sociological lens on stress helps us understand the link between social forces and
health inequities. For example, Nandi’s traumatic birth experience was a single event that
cascaded into a series of stressful circumstances, including her inability to focus on her
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doctoral research, which then delayed her graduation and later employment (and the higher
income and health insurance that came with it). Sociologist Leonard Pearlin described this as
stress proliferation, when one stressful event leads to a series of other stressful events and
situations.65 We can go further back and look at the premature death of Nandi’s mother less
than two years earlier. Nandi and her mom had always been very close, so when her mother
fell ill, Nandi moved back to Washington, D.C., in the middle of her doctoral studies, to take
care of her. Could the stressful event of her mother’s death, with the connected stresses of a
major move, delaying her progress in her graduate program, and then caring for her mother’s
affairs, be related to the later death of her babies? Poet Claudia Rankine talked of “the
condition of [B]lack life [as] one of mourning”.66 Sociologists would note that Nandi, as a Black
woman in the U.S., is more likely to experience the death of friends and family as well as other
chronic stressors. These stressors are likely not separate events, but are interconnected,
building on one another to result in poor health.
More recently, sociologist Joe Feagin and anthropologist Philomena Essed have helped
us understand the stressful experiences of Black men and women as they negotiate everyday
American life. Marginalized social groups often anticipate potential prejudice or discrimination
or worry about previous problematic encounters. This anticipation or worry may stem from their
own personal interactions as well as encounters experienced by people in their social
networks – or just as importantly, from experiences of their larger marginalized group, as in the
raid on the meat-processing plant in Iowa. Vigilance includes the anticipation and worry stress
that comes with membership in a socially marginalized and stigmatized group. Vigilance is
consistently related to poor mental and physical health, and racial inequities in vigilance are
also related to numerous health inequities.67
Perspectives for studying health
One of the most widely-used perspectives for studying the social determinants of health
is the socio-ecological framework.68 In this framework, the individual is placed within their
interpersonal, community, and societal contexts. Some sociologists focus on the broadest level
and explain how societal-level factors affect health. Social epidemiologists, on the other
hand, may place more emphasis on the behavioral or biological mechanisms of the
individual. Let’s think about the childhood nutritional environment. Sociologists might focus on
school district policies and practices (which reflect the larger sociopolitical context)
throughout a city to understand differences in the nutritional value and quality of lunches
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served at schools in different
neighborhoods. A social
epidemiologist might instead
document what children
choose to eat in their schools,
focusing on the individual
health behavior. These
approaches target different
areas of the same issue; to
address childhood nutrition,
we can focus on school
district policies to ensure that
all schools provide nutritious
food or we can focus on
individual children (and their
families) to suggest better food choices.
The socio-ecological model has influenced research on public health and guided
interventions and policy recommendations. For example, a recent trend in health promotion
focuses on the social determinants of health more globally. The 8th World Congress on Health
Promotion, held in 2013, led to the “Health in All Policies” (HiAP) model. It addresses issues of
health inequities by recognizing that these inequities ultimately stem from numerous social
factors. The World Health Organization (WHO) stated,
Health and health equity are values in their own right, and are also important
prerequisites for achieving many other societal goals. Many of the determinants of
health and health inequities in populations have social, environmental, and economic
origins that extend beyond the direct influence of the health sector and health policies.
Thus, public policies in all sectors and at different levels of governance can have a
significant impact on population health and health equity.69
The National Academy of Sciences in the United States has also recognized the
importance of the HiAP movement, stating:
Medical services, while vitally important, play a lesser role in overall population
health improvement than the social determinants of health—the environments in which
people live, work, learn, and play. Economic status, educational attainment, structural
racism, and neighborhood characteristics are critical determinants of health and
health inequities. Improvements in a community’s economic, physical, social, and
service environments can help ensure opportunities for health and support healthy
behaviors. However, health agencies rarely have the mandate, authority, or
organizational capacity to make the policy, systems, and environmental changes that
An example of the socio-ecological model of the social determinants
of health. (Source: Authors)

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can promote healthy living through healthy environments. That responsibility falls to
housing, transportation, education, air quality, parks, criminal justice, agriculture,
energy, and employment agencies, among others.70
This means that we can’t address health inequities through conventional medical
approaches targeted at disease management, or with public health approaches that try to
promote better health. We must incorporate a sociological lens that understands how social,
economic, and political contexts ultimately drive health inequities. From this perspective, labor
policies are health policies; education policies are health policies; transportation policies are
health policies; and so on.
Often, health and illness are described in terms of a particular period in the life span –
childhood asthma, vaping among teenagers, hypertension among adults, and cognitive
impairments in older adults. In reality, our social experiences and health are interrelated
throughout our lives, which is a major principle of the life course perspective on health.
Sociologist Glen Elder outlined a theory of the life course related to child development, and
many sociologists have adapted this perspective to the study of health.71 Elder suggested five
basic principles that have been incorporated into studies of health and social structure:
 Life span development: Human development isn’t limited to a single period in the
life span, but is a continuous process throughout one’s life. The health of adults, for
example, represents a progression of health throughout their lives.
 Constrained agency: People make choices and take actions that shape their lives;
they are active participants in how their lives unfold. However, these choices and
actions are constrained by structural circumstances. For example, while we may try
to have more nutritious diets and exercise, our ability to do so depends on the
resources in our neighborhoods (are there safe places to jog?) and the norms of our
social networks (what kind of food is served at social gatherings?).
 Time and place: The course and trajectory of a person’s life is embedded and
shaped not only by their own lived history, but by the history of the spaces they
inhabit. Your health depends on where you live and at what point in your life you
lived there – living in a polluted neighborhood can have different effects on children
than on adults, for example. And the history of your neighborhood, even before you
lived there, can shape your health by affecting the quality of resources available
there now.
 Timing: The ways in which your life unfolds depend on your social experiences and
when in your life you had those experiences. For example, conventional American
norms of the life course are that a person completes their education, gets a job,
gets married, then has children, and later retires. Our social institutions are set up to
support this timing and ordering of the life course; high schools aren’t set up to
accommodate students with children, for instance. Due to structural constraints,
Health & Illness (Fall 2021)

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different social groups may not be able to adhere to these norms, with implications
for their health.
 Linked lives: Our lives are interconnected directly through our social networks and
indirectly through our place in history. Our health is related to the health of the
members of our social network. We are also connected as, for example, Americans
living at this point in time, as veterans of recent American wars, or as Black men and
women living during the Civil Rights era.
In this section, we introduced several social determinants of health that have been the
focus of sociology for many years. Sociologists have documented the health inequities among
different racial groups and among those with different levels of education. Recently,
sociologists have focused on the features of society that might drive these health inequities,
such as structural racism or unequal access to resources important for health. These social
determinants may impact health differently depending on when in the life course they are
experienced, as outlined by the life course approach. Finally, the social determinants of health
perspective suggests that, in order to improve population health and reduce social inequities
in health, we must focus on social factors rather than on primarily public health, health care, or
medical factors.

REVIEW SHEET: SOCIAL DETERMINANTS OF HEALTH & HEALTH
INEQUITIES
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LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS

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THE FUTURE OF SOCIOLOGY IN HEALTH & ILLNESS

 What role does the sociology of health and illness have in the genomics era?
 Is historical context related to contemporary social patterns in health?

An African-American boy at a segregated drinking
fountain in Halifax, North Carolina, 1938. (Source)

With the sequencing of the human genome (the complete set of genes needed to
build and maintain our bodies) in 2003 came the promise of boundless discoveries of cures for
diseases. Since then, it has become clear that health and illness are not simply the product of
our genes, but the likely result of a complex interplay between our genes and our social
experiences, which are ultimately shaped by cultural norms and values and our social
structure. We are witnessing the birth of a new interdisciplinary field of social genomics in
which sociologists and other social scientists work with geneticists to understand how the social
world might alter the structure and function of our genome and affect social patterns in
health.72 As we move into this field, we must be careful not to conflate socially-constructed
races with genetic ancestry, which is composed of specific parts of the genome.73
Physical barriers (such as oceans or mountains) and social forces (such as policies or
traditions that ban or encourage people from different social or cultural groups from marrying)
separate groups of people, and this separation is reflected in our genomes.74 How racial
categories are socially constructed in a particular society or country at a particular point in
time may or may not match the underlying genetic ancestries.75 And importantly, there is no
evidence that genetic differences among racial groups are responsible for the racial
https://en.wikipedia.org/wiki/Housing_segregation_in_the_United_States#/media/File:We_want_white_tenants.jpg
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inequities in common chronic diseases.76 In addition to the social forces that shape the
structure of our genomes, social forces can also affect how our genes are related to health.
For example, studies show that the effect that our genes have on health really depends on the
environment we are in.77 Sociologists have an important role to play in this genomic era, both
by continuing to clarify the social forces that shape health patterns and by working with
geneticists to understand how social forces and our genome contribute to social patterns in
health.
Sociologists have contributed important information about historical patterns in social,
economic, and political aspects of society; some have also linked historical social forces to
contemporary society.78 As the life course perspective highlights, we are linked to history –
which means that our health may also be linked to historical aspects of society. Indeed,
historical elements of structural racism, such as redlining, Jim Crow laws, lynching, legal (e.g.
police) and extra-legal (e.g. Ku Klux Klan) racial violence, and slavery, created racial
boundaries around access to resources, opportunities, and full citizenship that continue to
drive contemporary racial health inequities, such as the disparities in novel coronavirus 2019
(COVID-19) infection and the risk of death once infected.79
We have discussed only two possible future avenues for sociologists to study health –
social genomics and social history. In reality, as society changes, there are new roles for
sociologists, such as understanding the impact of social media on society and health and
using algorithms and artificial intelligence to model the complexity of society and health.
Common to all of these topics of research is the growing integration of sociology with other
fields to create interdisciplinary areas of study. Because sociology provides a unique and
important lens for the study of health, there will be exciting new ways to integrate it with other
social sciences such as economics or psychology, and also with biomedicine, humanities, and
computer science. Ultimately, given the critical ways in which social forces shape health and
the illness experience, the future of sociology and health is one that centers sociology while
extending into other fields of study.
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An African American protestor’s shirt with handwritten messages linking racism to COVID-19
(Source).

REVIEW SHEET: THE FUTURE OF SOCIOLOGY IN HEALTH & ILLNESS
CLICK THE LINK FOR:

LEARNING OBJECTIVES KEY QUESTIONS
AUDIO KEY POINTS
PRACTICE QUIZ KEY PEOPLE
VOCABULARY CROSSWORD PUZZLES KEY TERMS
https://unsplash.com/photos/qFkVFe9_d38

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