Being normal

One of the most lively conversations during my medical sociology class tends to come when we talk about eating disorders. This comes as part of a series of discussions about the sick role and definitions of health and deviance. My students really get into thinking about social pressures to conform, media influences on body image, and the idea that eating disorders can be much more than expression of a desire to be thin; we talk about eating disorders as a kind of model for deviant behavior that becomes symbolic of will, control, and independence as much as anything.

Today’s Times has an article on race and eating disorders that raises some intersting ideas that intersect with some of that discussion. The general idea of the piece is that African American women in particular 1) have unknown rates of eating disorders, but 2) are believed to be underdiagnosed and 3) are treated at much lower rates than white women. Research discussed in the piece suggests that “young black women were as likely as white women to report binge eating,” and “black women were as likely as white women to report binge eating or vomiting and were more likely to report fasting and the abuse of laxatives or diuretics than their white peers.”

So while there’s some evidence of similar rates of eating disorders, there’s nothing to suggest that treatment is equal: 28% of white women reported receiving treatment or therapy, while only 5% of black women do so. The research discussed has an admittedly small sample size, but it corresponds with plenty of other work, such as Sing Lee’s1 review of cross-national prevalance of eating disorders and cultural barriers to diagnosis and treatment.

The Times article suggests that issues of resources may prevent many black women from seeking treatment, and that culture plays a role in the belief that they may be unaffected by eating disorders: A researcher interviewed in the article comments that, “experts traditionally had thought that “anorexia and bulimia didn’t happen to black, Asian or Hispanic women, that they were somehow immune.” In her own article, Lee demolishes the idea that eating disorders are bound to particular (Western) cultures by re-explaining them as being about much more than simple fear of being overweight (which is usually included as part of the diagnosis).

What the Times article doesn’t quite do is put this situation of underdiagnosis and treatment into context: It fits perfectly with what we know about other medical concerns in underserved populations. There’s a gender factor at work here as well as a racial one, such that the most readily-treated subject of medical care—the model for baselines of normal and abnormal—is still largely based on white men. Just as eating disorders are less likely to be diagnosed in black women, heart disease was undiagnosed in women generally for decades. And what might have been diagnosed as anxiety in male patients was frequently determined to be hysteria in female patients. The Times article, then, is a nice and detailed depiction of just one of the ways in which social characteristics affect treatment and diagnosis at multiple points in the process, from definition to clinical findings to patient perceptions of their own dis-ease.

1 Sing Lee, “Reconsidering the Status of Anorexia Nervosa as a Western Culture-Bound Syndrome.” Pp 21-34 in Social Science & Medicine vol 42, no 1 (1996).

Starting assumptions

Class is well underway, and again I’m teaching medical sociology. A good portion of the first half of the semester is dedicated to making sense of the relationships between social variables—like socioeconomic status, gender, race—and health outcomes. For example, we know from decades of data that SES affects just about every measurable aspect of health: Lifespan, infant mortality, heart disease, and cancer rates. The benefits of money and status are tangible.

Class and life expectancy

Across twenty years, the semi-skilled workers in class IV eventually become healthier than the professional workers of class I in the 1970s, so it’s clear that overall health has increased. However, the increase is far sharper for those in class I than in class V, indicating that the benefits of better medical treatment and improved technology accrue more quickly to those at the top. Status pays off in substantial and persistent ways.

In the U.S., we have similarly suggestive data that show how much more likely those without private insurance are to fall into the lowest category of a ranking of health.

Health status and insurance type

Plenty of people in the lowest health category do have private insurance, but, conversely, very few people who lack reliable, private coverage find themselves in the highest health category.

This is the sort of material I’ve been presenting to my class the past handful of days, using it to motivate the core puzzle: How do we make sense of relationships like these? The argument made by scholars is that SES is intimately tied to factors that put us at risk of exposure to disease, and because there are so many such proximal factors, treating them individually has little effect on the outcome. That is, the poor tend to stay sick even as we improve sanitation, promote vaccinations, and address the other proximal causes of disease. At the level of health care it’s a similar story, namely that social variables structure our access to care and the quality thereof—in dozens of ways.

It’s common for students to not quite get this; they’re young, usually well-insured, and mostly healthy. Persistent disease just isn’t something they’re familiar with, and their own experience tends to make it a little challenging to get a handle on the bigger, macro picture of social causes of disease. This is understandable, I think, and figuring out how to evaluate personal experience in the context of broader data is part of the sociological project. So the more important starting point is some willingness to work within the parameters of the project; without that willingness, the puzzle motivated by the data is unimportant or even suspect, and that’s before we even reach the question of mechanisms—the place where notions of individual responsibility really collide with constraints on the ability to do healthy things, and it becomes far harder to avoid the on-coming political debate.

This pretty quickly turns into a sort of meta-question about what we want to get out of education and educating. I sincerely have no desire to indoctrinate anybody, nor do I want students to believe that they just need to think like I do long enough to pass my course, but I do think there’s something to the idea of critically thinking about the world, and I’m invested in sociology as a way to do this. On one hand, a sort of first principles examination—“what’s the purpose of this field of study, and what do I want to get out of it?” and “what kind of data does it take to convince me?” for instance—is important, and ought to be a part of one’s education. But on the other hand, the class has plenty of substantive material to cover, and that kind of examination can sometimes be distracting.

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