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2. SOCIOLOGICAL PERSPECTIVES ON SOCIETY AND HEALTH AIM: To describe the functionalist or social consensus based sociological perspective. To describe the conflict or Marxist sociological perspective. To describe the social interactionist or subjectively based sociological perspective. To give examples of how health is approached from these perspectives. To explain the need for flexibility grounded upon a holistic approach to gathering evidence which is clearly related to the particular situation under consideration. FUNCTIONALIST SOCIOLOGY EMPHASISES SOCIAL CONSENSUS Functionalist sociologists focus upon the apparent consensus, which appears to exist among the members of any society. This apparent consensus supposedly also explains the nature of the social institutions which assist the reproduction of society. Emile Durkheim (1858-1917) was one of the most influential founders of the functionalist sociological perspective. This may be summarised by a comparison with biology. If biologists want to know how the human body works, they begin by examining its parts, such as the brain, lungs, liver, etc. in order to see how they contribute to the smooth functioning of the whole body, and to the continuation of life. To do this, they would have to examine the role of the body parts in relation to each other and also in relation to overall body functioning. Functionalism adopts a perspective towards society which is similar to that which the biologist adopts towards the body. To understand any part of society, such as the family, government or religion, the part must be analysed in terms of its functions in relation to other social parts or structures, and in relation to society as a whole. Functionalists are sometimes called structural functionalists because they begin with the observation that society is structured. This means that relationships between organizations and members of society are organised according to apparently accepted rules. Social relationships are patterned and recurrent. Values provide general guidelines for behaviour and are translated into more specific directives in terms of expected social roles (behaviour patterns) and norms. From a social consensus perspective, the parts of the society are generally believed to be integrated to ensure overall social functioning and reproduction occurs smoothly. Such integration is supposedly based on a value consensus which is shared by the great majority of members of society. According to the functionalist, to explain the existence of social institutions we should look not merely for purposive intention of individuals, but also at how the social system as a whole requires its needs to be satisfied. The functionalist starting point is that people are strongly socialised into conformity to group norms and into acceptance of a wider social consensus. Social phenomena can be explained in terms of the functions they perform, and may be labelled functional or dysfunctional. Change is introduced from outside the system, in the same way that injury of the body may be explained by an accident or the entry of a virus. An extreme functionalist account provides a picture of society that is static, without internal mechanisms for change, and without conflicts between opposed social groups. Critics think the functionalist approach overemphasises the consensual and determining nature of the socialisation process, leading to a false and oversimplified view of society, action and personality. MARXIST SOCIOLOGY EMPHASISES SOCIAL CONFLICT Karl Marx (1818-83) is the father of a conflict-based approach to analysis of society. His most famous work ‘Capital’ analysed the historical development and structure of capitalist society in Europe. Marx began with the observation that in order to survive, humans must produce food and material objects. (Engels added later that they must also produce and nurture babies, but I will discuss the sexual division of labour elsewhere.) For Marx, the nature of humanity, and the nature of society, is seen to derive primarily from the vital production of food and related necessities to support social life. In undertaking production, people enter into primary relationships with others. From the social relationships involved in production, a way of life develops which can be seen as the expression of these primary productive relationships. How individuals think and behave is also seen primarily as an expression of their location in regard to production, its processes and outcomes. Because wants are great and resources to satisfy them are comparatively slender, Marx saw societies as divided into primary groups which relate to each other through the processes of production in an often antagonistic manner, rather than with consensual and cooperatively implemented goals. He described capitalist society primarily in terms of a two class model in which capitalists own or have the money to purchase the means of production, such as land, factories, raw materials and the labour power of workers. The workers are seen as subject to the domination and control of this employing class, because they own no land or wealth, and therefore have no alternative means of subsistence other than selling their labour. For Marx, there is a fundamental conflict of interest between these production related groups (classes), and one usually gains at the expense of the other. The major interest of the capitalist is in producing goods more cheaply than competitors, so that the markets for goods may be expanded. This drive for profit leads to the oppression of workers and to their replacement with machinery wherever possible. Workers, on the other hand, want to maximise their incomes and reduce the hours and intensity of their labour wherever possible. Marx saw this class conflict as the motor of history and technological development. He tended to explain all social groups in terms related to the historical expression of the developing central economic relationships of capitalist production. Criticisms of Marx often relate to his strong views about the primacy of the economic dimension in determining human actions and social events. Marx predicted that the expanding process of capitalist development would also lead to the development of an international market. However, he seems to have been wrong in thinking that as a result of the capitalist search for profit and the consequent replacement of workers with machines, there would also be a growing army of unemployed and consequently ‘immiserated’ people who would eventually undertake violent revolution against those who own or control wealth. In general, capitalism has been so productive as a system that it has constantly expanded its markets, products, services, and employment opportunities. As consumers, workers have often benefited and enjoyed new comforts and pleasures. However, global terrorism by economically and politically threatened groups has become a growing preoccupation. In general, as capitalism expanded so has the role of government. As a result of the wealth generated by this profit driven, highly competitive and productive system, the state first developed primarily to support capitalist requirements, including the need for education for increasingly complex forms of employment. As the right to vote was extended as a result of popular pressure, government performed an increasingly wide range of regulating, socialising and supporting roles. Marx addressed the 19th century rise and organising role of trade unions positively. However, he saw the government of his day as inevitably acting primarily to organise and pursue the interests of the owners and controllers of production. The extension of the right to vote, education, the free press, television and effective birth control has made Western government much more responsive to broader democratic demand than Marx ever envisaged. Following Marx, Weber discussed the functions of government, including the collection of taxation and the administration of bureaucracy under mature capitalism. His vitally important work is addressed in a later discussion. SOCIOLOGY FROM A SOCIAL INTERACTIONIST PERSPECTIVE The consensus and conflict versions of social organization approach society in terms of its existence as a whole, and are thus sometimes known as macro-theories. Such structurally based sociological perspectives see societies as more or less coherent overarching systems which shape human action. From a functionalist perspective, behaviour is shaped largely by shared norms and values disseminated throughout the social system. From a Marxist viewpoint, behaviour is ultimately determined by productive location and the interactions of conflicting economic interests. Action theorists differ from structuralist sociologists in that their focus is not on the persistence of a larger social system, but on action to change it. Social interactionists are action theorists of a kind who usually focus on the micro-levels of society, and on related small-scale interactions between groups and individuals. They differ from structuralist and functionalist sociologists in that their focus is generally on the apparent perceptions people have, the related choices they make, and on general interactions between groups and individuals, often in micro-climates. Social interactionists see human behaviour as the product of what people feel and decide is going on around them. They are therefore most interested not in events and their apparent causes, but in the meaning or interpretation that individuals place upon events. Alfred Schutz was a founding social interactionist who wrote ‘The Phenomenology of the Social World’ in 1932. He was interested in how definitions of reality are arrived at, used and sustained by social actors. In 1966 W.I. Thomas emphasised that social behaviour is a product of how people interpret the behaviour of others, and how they interpret their own situation in relation to this. Whether or not these interpretations are correct, every social encounter involves a process of interpretation on the basis of available evidence, whether this is self conscious or not. Social interactionists often show how individuals may dispute definitions of reality or rules made by dominant social groups, and how social actors negotiate shared rules and ideas. Meanings are not fixed entities and a multiplicity of meanings may be constructed by a multiplicity of groups and individuals. An emphatic distinction between personal meanings or beliefs and more broadly derived or scientific forms of social meaning or evidence was strongly linked to the emergence of an interest in psychology and the interior life during the 20th century, but this interest was not new in sociology. For example, Marx had earlier discussed ideologies and distinguished them from more scientific approaches to understanding. He saw ideologies as narrow, self-protective and distorted beliefs grounded primarily in local knowledge and emotional responses which arise as a result of occupation of a particular class or related social location. He thought of ideologies as self sustaining and partially blind belief and action systems, which could be contrasted with the adoption of broader and more scientifically based approaches to evidence gathering, in order to establish a more effective and therefore more socially inclusive construction of reality. WHAT HAPPENED IN WORLD HISTORY? Marxism gained many adherents and during the 20th century some socialist revolutions took place. They occurred, for example, in Russia in 1918, in China in 1949, and in Cuba in 1953. The new governments seized private land and property, collectivised farms so the peasants ran them and then tried to plan economic production and distribution for the nation. Marx had thought that socialist leadership would come from urban workers and their trade unions in the industrial heartlands of production. However, it was established in a variety of ways. The major revolutionary target was often the dismantling of pre-capitalist and agrarian (feudal) modes of production, which also supported colonial rulers and traders, prior to introducing the difficult process of industrialisation to a largely peasant population. Large and middle landholders were dispossessed, often with force. The communal production systems which were established sold to the government rather than in any other marketplace. This process was often inefficient and the production planners were also ill informed about likely communal production outcomes. By the end of the 20th century it seemed clear to all nations that, for a variety of reasons, government planning of economic production and distribution was unable to provide a comparatively efficient and effective substitute for the competitive market. A privileged and sometimes corrupt political managerial class could easily arise in lieu of a capitalist ruling class. The problems of poor production, resource degradation and environmental pollution in socialist countries were often worse than under capitalism. At the beginning of the 21st century we confront a world where capitalist and formerly socialist economic systems are now seeking peaceful integration in a global economy. This is fortunate, because we could easily have had a third world war forced upon us instead – this time a nuclear one. Sporadic but powerful forms of war and terrorism by those who are comparatively economically disadvantaged are now the major global anxiety, rather than war between nation states. An equally important concern is that market driven cultures may not be responsive enough to ecologically sustainable development needs, and that as a result of this our beautiful natural world and its related quality of life may become increasingly degraded, bleak and ugly – except, perhaps, for those rich enough to have the means to preserve parts of it for themselves. AN EXAMPLE OF FUNCTIONALIST THEORY APPLIED TO HEALTH Perhaps the most well known functionalist sociologist writing about health and illness was Talcott Parsons. He wrote in the United States after World War II. Parsons argued than in an advanced and industrialised Western society the very high level of structural differentiation poses a potentially dangerous situation for the maintenance of the social system as a whole. Every individual has a specific social role to play and associated tasks must be carried out effectively, in order to assist the smooth functioning of the total system. The stability of the social system is maintained only if all the interdependent social roles are carried out, because each specific role depends on others. Parsons argued that there are only two major ways in which people may deviate from expected social behaviour. They may refuse their normally allotted role either because they are sick, or because they choose not to perform it. In the latter case they are likely to be considered criminal, and are treated accordingly. From the functionalist perspective, sick people must be turned over to the appropriate medical agency in order to be returned to their original healthy state as a result of the application of a diagnostic and therapeutic process. Parsons thus saw sickness, like crime, as a potentially disturbing influence upon the smooth operation and reproduction of the society. In 1951 he developed his sick role concept, which tells us what type of behaviour we should be able to expect from and associate with the sick person. There are four basic aspects of the Parsonian sick role: • The absence of responsibility of the individual for his or her condition • The exemption of the sick individual from normal task and role obligations • The recognition that being sick is undesirable and one should want to get well • The obligation to seek out competent help Associated with being sick is the ‘secondary gain’ of the temporary exemption of normal task and role obligations. However, two new obligations are added – to want to and try to get well, and to seek out and cooperate with competent helpers. The sick role, if properly undertaken, becomes the social control mechanism necessary for the maintenance of the social system. Wolinsky discusses some criticisms of Parson’s sick role theory. Firstly, the sick role appears to apply predominantly in the case of acute physiological illness, rather than in the case of chronic conditions. The latter may not be readily observable early on, and may not be readily correctable by later practitioner treatment. For the chronically ill, it is often impossible to resume normal role performance at pre-illness level. The chronically ill are forced to adapt to a permanent condition, rather than overcome a temporary one. They are forced to emphasise the retention and mobilisation of whatever level of role performance and autonomy they now have, rather than attempt to regain higher ones. Finally, as a result of their chronic illness, they are in danger of finding themselves on a downward slide in terms of their socio-economic status. Another criticism of Parson’s concept of the sick role was that how people react to sickness may depend strongly on their culture, their gender, and their socio-economic situation. Some, for example, may prefer to drop dead in harness rather than admit to being sick, others may tend to be hypochondriacs. Some critics argued that the traditional one on one patient/practitioner relationship on which the Parson’s sick role is based has changed, and that the sick role itself is a typically middle class American concept. In relation to this, Friedson argued that medicine is now engaged in the creation of illness as an ‘official social role’. Whenever I have requested a doctor’s certificate from a student in order to legitimate a missed exam, I am aware that this process also costs the Australian taxpayers money, and I tend to remember Friedson’s view. (I’m not sure, however, what a better alternative might be.) Other critics argued that patient practitioner relationships are highly variable and that the doctor may not always have the kind of esteemed and authoritative role envisaged by Parsons. Parsons agreed with many of his critics, but said they tended to be focusing on the trees rather than the forest. EXAMPLES OF CONFLICT PERSPECTIVES APPLIED TO HEALTH It will be shown elsewhere later that the development of international capitalism seems generally to have improved human health and longevity, although its development has also widened social inequality and trampled many societies which have been in the way of market expansion. Following Marx, some conflict theorists have discussed the close relationship which often exists between premature death on the one hand, and poverty, dangerous work, unemployment and lower socio-economic status on the other. This relationship still exists globally and within countries, including contemporary Australia. In the 19th century, Engels, who often worked with and supported Marx, likened the 19th century Manchester workforce to an army returned from battle, so heavy was the toll on its limbs. Today, the unfettered use of dangerous chemicals in production, and the potential effects to the health of workers and the environment which occur as a result of this, are probably of more urgent concern than the use of poorly guarded machinery, although the latter problem continues as well. The invention of cars has added new dangers. Lupton points out that those contemporary theorists who study political economy, and have therefore been influenced by the Marxian perspective on capitalist development, focus on the identification of the political, economic and historical factors that shape heath, disease and treatment. For example, even in developed economies, the poor generally have worse health than the wealthy because of their comparatively poor environment and related lifestyle. Globally, infant diarrhoea and infectious diseases still take a huge toll as a result of lack of adequate food, clean water, effective sanitation systems and sound housing. Children are particularly likely to die. On the other hand, in economically developed countries, individuals have more real and apparent control over their lives, and this is reflected in their having fewer and healthier children, a comparatively long life span and in the nature of illnesses experienced. In developed nations these relate primarily to lack of exercise, poor diet and use of drugs - mainly tobacco, alcohol. Peoples’ health is also affected by their access to treatment for injury and illness. The Australian government provides a universal taxpayer funded system of hospital and medical treatment know as Medicare. The taxpayer also subsidises a wide range of pharmaceuticals through the Pharmaceutical Benefit Scheme. Duckett’s research has shown that poorer Australians use medical and hospital services more than richer ones. In the U.S. the reverse is the case. In the U.S., the employer or the individual, not the taxpayer, generally purchases health insurance and services. Many sick people consequently go untreated because of their lack of adequate personal insurance cover. More effective health promotion and management of services would be good for both countries. However, an effective preventive focus is hard to obtain, in part because both systems, although very different, provide incentives which are often geared to serving traditional economic and professional interests, rather than the consumer or broader public interest. A major difference between an early Marxist approach to health and a contemporary critical analysis is that government intervention in the economy and the related provision of health welfare and development has grown enormously in Western countries since the time of Marx. This is reflected in contemporary writing. For example, David Henry, the Professor of Clinical Pharmacology and Head of the School of Population Health at Newcastle University recently pointed out that prescription writing is one of the commonest and most important tasks undertaken by doctors. The pharmaceutical manufacturers spend huge sums of money promoting their products to doctors, and the relationship between the industry and the profession has become complex and intertwined. It is hard to find medical specialists who are not on an ‘advisory committee’ and many general practitioners are recipients of drug industry largesse which includes expensive dinners where experts sponsored by drug companies give talks. These experts gain considerable income from their close relationship with industry. Mental health is seen as a growing problem in all developed countries, for many complex reasons. Anxiety, depression, anger or other unwanted behaviours are increasingly likely to be diagnosed as the result of genetic or related physical imbalance and treated with drugs. Thomas Szasz, Professor of Psychiatry at New York University, argues against a growing popular tide, that mental illness should primarily be conceptualised as a moral and political problem related to the interaction of an individual with his or her environment. He sees mental health practitioners as part of the problem if they avoid pursuit of general social understanding and autonomous self-control. He points out that drugs may function as chemical straightjackets and that specific diagnoses and drugs may relieve the providers of the necessity to convince themselves that they may not be acting altogether on behalf of their patient. Szasz says psychiatrists and their powerful allies (drug companies, lawyers, doctors and insurance companies) have succeeded in persuading the scientific community, the courts, the media and the public that the conditions they call ‘mental disorders’ are diseases rather than unwanted behaviours fashioned in response to an environment. He argues that professional diagnosis authenticates people as legitimate occupants of the sick role, for example to secure drugs, compensations payments and disability support. It is the social role of the mental health practitioner to diagnose the ‘other’ as sick and needing drugs. They see what they want to? Could we become a nation where taxpayer-funded drug dependency is accepted as the norm because of such pressures? Are people who are sad, depressed or difficult also being drugged, with the bill sent to the taxpayer? How effectively does the current situation meet any person’s need for a greater sense of personal adequacy, acceptance, companionship, and control over meaningful activity? Henry points out that the preference of multinational companies for profits over customers becomes clearest in developing countries. The HIV/AIDS epidemic in Africa has been the greatest peacetime tragedy for mankind since the plague. For years, drugs have been available that control disease progression and prevent mother to child transmission. However, these drugs have remained out of the reach of millions of potential beneficiaries who cannot afford them. The drug industry argues that their development costs are the reason for high prices. Henry points out that drug companies spend more on developing drugs for the domestic pet industry in North America than on new drugs for malaria. These same companies cry poor in Australia because of the price regulation undertaken by the government in this country. The kind of perspective which Marx expressed for the world is commonplace in mainstream discussions of health today. If you want to be entertained and also learn about how government and the health industry may be conducted in developing countries, and how this may also relate to the career aspirations of public servants and international health researchers, I suggest you read the novel ‘The Constant Gardener’ by John le Carre. This author used to write spy stories about the Cold War, between Capitalist and Communist aligned nations, but lack of one in recent years, has moved him on to newer topics. Speaking as a person who has worked in West Africa, and also in the NSW public service and the Health Sciences College of Sydney University, I found the book chillingly convincing. FOUCAULT’S PERSPECTIVE ON THE PROFESSIONS AND THE BODY Lupton points out that for Foucault and his followers, the body is the ultimate site of political and ideological control, surveillance and regulation. Foucault sees historical development as entailing a widening process of state and professional control, where bodies are increasingly subjected to regulation, monitoring, discipline and surveillance by the institutions of government. These include the hospital, the prison, the school, the asylum, the military and the research centre. Through study and attempted control of the body and its behaviours, state funded professions such as medicine, psychiatry and the law, define the limits of acceptable ‘healthy’ behaviour. These professionals record activities and punish those bodies which do not behave appropriately, from the dominant, professional, perspective. For Foucault, medical power is intrinsically linked to the forms of knowledge produced by medicine. These forms of knowledge and their related ways of speaking (discourses), are then used to increasingly control the behaviour of individuals and populations. Through the apparently benign power of medical practitioners, the ‘medical gaze’ becomes the dominant, defining and controlling discourse of the modern society. While not wishing to disagree with Foucault’s historical account, I think the evidence is that we appear to be living longer and healthier lives, partly as a result of the increasing surveillance and management activities Foucault describes. In the contemporary context, such surveillance is usually, in my view, a narrow, clumsy and managerially or professionally driven version of our early democracy, rather than a more abstract and apparently sinister form of state domination. Ivan Illich presents an argument which has similarities with that of Foucault when he asserts that the medicalisation of life has drained many people of their capacity and responsibility for independent analysis, action and self-care. He states that as a result of the general rise of controlling professions, many people no longer have the confidence, initiative or resources to think about their life’s passage in a more holistic, non-medical, and constructive way. The recent development of computers and the internet, provides many individuals with new ways of seeking knowledge for themselves. However, such people often come from comparatively privileged social groups, not those where health is poorest. While the rise of modern information technology may be empowering for many people, including health care consumers, for others it may be just another factor which is making life increasingly complex, anxious and hard to negotiate. With economic development, the personal life and its health concerns become more complex and so does the range of possible treatments for health and social problems. This complexity is sometimes the unnecessary result of the actions of people whose main game is the elevation of their own professional status and related discourse. Part of the answer to this is for governments and related institutions to take much more broadly coordinated, planned and consultative approaches to the promotion of health, including environment protection and sustainable development, in international, national, and regionally managed contexts. The argument for this broader, better planned and more consultative form of national and community health management is primarily presented in the subject Health Policy and Service Delivery, which also seeks to teach the requirements for critical implementation of the Australian policy direction. GOFFMAN: SOCIAL INTERACTIONIST THEORY APPLIED TO HEALTH One of the most influential social interactionist theorists was Erving Goffman whose work on total institutions is addressed in a later lecture. In his book Stigma, written in 1963, Goffman argued that status symbols are identifiers which establish a special claim to prestige, honour or other desirable treatment for the person who possesses them. However, his main concern was to analyse stigma symbols. These draw attention to a debasing identity discrepancy, with consequent reduction in the valuation of the individual by so-called ‘normals’ in society. Goffman used the term stigma to refer to any attribute that is deeply socially discrediting, and discussed its meaning using a language of potential and actual interpersonal relationships. He addressed three different types of potential social stigma. These are physical deformities, perceived abnormalities or blemishes of character (such as addiction, mental disorder, or imprisonment) and tribally allocated stigmas related to another’s race, nation or religion. Goffman’s view was that an individual has both a personal and a social identity, and that the central feature of the stigmatized individual’s situation in life is the search for acceptance by so-called ‘normals’. He stated that there are three stages in the learning of the stigmatised person. Stage one is learning the ‘normal’ point of view and that he or she is disqualified according to it. Stage two is learning to cope with the way others treat the kind of person he or she is supposed to be. Stage three is learning to cover an abnormality and pretend to be like everyone else in the group. For example, an illiterate person may try to ‘pass’ as literate by pretending to read the newspaper, or a mentally distressed person may make a special effort to behave in ways which others find acceptable. Because of the great rewards in being considered normal, Goffman argued that all people who are in a position to pass as normal usually try to do so. In addition, their stigma may relate to matters which cannot appropriately be divulged. Voluntary disclosure of a hidden stigma may radically transform the person’s situation from that of an individual with information to manage, to that of an individual with an uneasy social situation to manage. Goffman stated that stigmatised individuals might adopt a variety of means for negotiating social situations, including defensive cowering or hostile bravado. ‘Normals’ will often find encounters difficult as well – feeling that the stigmatized individual is either too aggressive or too shamefaced, and in either case too ready to read unintended meanings into their actions. Stigmatised individuals may withdraw from social interaction or may forge a group identity to fight against a stigma and create an alternative ideology to ‘normality’. Goffman says that the lucky person who comes to feel they are above the need to please others, and who accept him or herself, will feel no need to conceal. THE PASSAGE OF ANTI-DISCRIMINATION LEGISLATION Goffman was writing at a time when black power movements and many other organizations forged by disadvantaged groups in the U.S. were fighting to improve their status in society. Their success in this regard is partly reflected in the passage of anti-discrimination and equal opportunity legislation in the U.S. and elsewhere, including Australia. The equal treatment requirements of this legislation are also reflected in the Universal Declaration of Human Rights and other international conventions developed by the United Nations and its organizations after World War II. This is discussed elsewhere. One should point out, however, that lawyers are not cheap and more wealthy and confident members of any group may use that legislation against discrimination most effectively. In the absence of broader legislation to address poverty and related inequality, anti-discrimination legislation may provide window dressing which also serves to exacerbate traditional economic inequalities. It may hide the fact that many harmful social situations are primarily rooted in poverty and remain essentially the same as in earlier times. This assertion requires further empirical examination in order to improve the current situation of all people, particularly those most disadvantaged. Under Australian state Anti-Discrimination Acts it is against the law to discriminate on the basis of : • Sex, pregnancy, marital status • Race, colour, nationality, ethnic or ethno-religious background • Physical or intellectual disability • Homosexuality (actual or presumed) • Age There is matching Commonwealth legislation for state anti-discrimination acts, which takes precedence to the extent of any inconsistency between the State and Commonwealth approaches. The Human Rights and Equal Opportunity Commission is a national independent statutory body established in 1986 by an act of the same name. It has responsibility for inquiry into alleged infringements under three anti-discrimination laws – the Racial Discrimination Act 1975, the Sex Discrimination Act 1984, and the Disability Discrimination Act 1992, as well as inquiring into alleged infringements of human rights under the Human Rights and Equal Opportunity Act 1986. Direct discrimination occurs when someone is treated unfairly or unequally because they belong to a particular group or category of people. Indirect discrimination is where there is a requirement (a rule, policy, practice or procedure) that is the same for everyone, but which has an unequal or disproportionate effect or result on a particular group. It is clearly more difficult and expensive to deal with indirect discrimination. For example, it is discriminatory to have long steps and no ramp leading to a public or private facility. However, it may be expensive to transform this situation. Australian anti-discrimination legislation refers to conditions in employment, education, provision of goods and services, accommodation and registered clubs. In order to avoid discrimination employers are advised to adopt an appropriate policy statement and appoint someone to ensure the policy is followed. Consultation and feedback mechanisms should be established for workers and clients. There should be a management and staff education process. A grievance handling mechanism should be established. All employment, production and service provision practices should be checked to see that they are fair and non-discriminatory. Such a review should cover hiring, training, promotion, work organization, service provision, recreation and retrenchment practices. Under the legislation it is also the responsibility of the organization to try to ensure that sexual harassment does not occur. An Australian disability awareness package makes the following suggestions for action between a person with a disability and another person. It recommends that the person with a disability should: • Tell the other person if any form of assistance is required • Let people know what you wish to do yourself • Don’t let people treat you like an invalid • Do not assume that everyone knows and understands your disability The following actions are recommended to the other person: • Ask the person with a disability if help is required, but do not insist and do not assist without asking • If you are unsure of how to behave, ask the person. Accept the fact that disability exists, don’t try to pretend it isn’t there • Regard and treat the person as healthy • Be aware of the environment and how it may present difficulties CONCLUSION Functionalists adopt a perspective towards society which is similar to that a biologist adopts towards the human body. To understand any part of society, such as the family, government or religion, it must be analysed in terms of its functions in relation to other social parts or structures, and in relation to society as a whole. Functionalists generally take a consensus perspective. The parts of the society are believed to be integrated to ensure overall social functioning and reproduction occurs smoothly. Marx instead saw societies as divided into conflicting social groups which relate to each other primarily through the economic process, where there is a battle of opposing interests. Marx saw conflict between employers and workers (those who have only their labour to sell) as the motor of historical and technological development. Criticisms of Marx often relate to his strong views about the primacy of the economic in determining actions and events. However, Marx has influenced many later and contemporary researchers, who tend to take a theoretical approach based on observing the interactions of social groups which have differing degrees of power to pursue their economic and political interests, which are their driving forces. Social interactionists see human behaviour as the product of what people decide is going on around them. They are therefore most interested not in events and their apparent causes, but in the meaning or interpretation that individuals place upon events. The perspectives people are taking when discussing health matters are not always obvious, but need to be thought about. In order to have relevance for explaining the world, including all aspects of health and health care provision, such approaches should normally be clearly grounded in specific studies of particular regional, historical, political, cultural and economic contexts. This is discussed again later. FURTHER READING Baumes, P. (2001) How Do Decisions on the Listing of Pharmaceuticals Influence Health and Health Services in Australia. Australian Health Policy Institute Commissioned Paper Series 2001/03. Sydney: Australian Health Policy Institute in collaboration with the Medical Foundation at the University of Sydney. Haralambos, M. Van Krieken, R., Smith P and Holborn, M. (1996) Sociology: Themes and Perspectives (Aust. Edition). South Melbourne: Addison Wesley Longman. Germov, J. (ed.) (1998) The Body: Social Process and Cultural Theory. London: Sage Publications. Lupton, D. (1995) Medicine as Culture: Illness, Disease and the Body in Western Societies. London: Sage Publications.
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