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From Diagnosis to Social Diagnosis

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From Diagnosis to Social Diagnosis

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Social Science & Medicine 73 (2011) 939e943

Contents lists available at ScienceDirect

Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed

From diagnosis to social diagnosis
Phil Brown*, Mercedes Lyson, Tania Jenkins
Department of Sociology, Brown University, Box 1916, Providence, RI 02912-1916, United States

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 12 June 2011

In the past two decades, research on the sociology of diagnosis has attained considerable influence
within medical sociology. Analyzing the process and factors that contribute to making a diagnosis amidst
uncertainty and contestation, as well as the diagnostic encounter itself, are topics rich for sociological
investigation. This paper provides a reformulation of the sociology of diagnosis by proposing the concept
of ‘social diagnosis’ which helps us recognize the interplay between larger social structures and individual or community illness manifestations. By outlining a conceptual frame, exploring how social
scientists, medical professionals and laypeople contribute to social diagnosis, and providing a case study
of how the North American Mohawk Akwesasne reservation dealt with rising obesity prevalence to
further illustrate the social diagnosis idea, we embark on developing a cohesive and updated framework
for a sociology of diagnosis. This approach is useful not just for sociological research, but has direct
implications for the fields of medicine and public health. Approaching diagnosis from this integrated
perspective potentially provides a broader context for practitioners and researchers to understand extramedical factors, which in turn has consequences for patient care and health outcomes.
Ó 2011 Elsevier Ltd. All rights reserved.

Keywords:
Diagnosis
Risk
Social movements
Environment
Public health
USA
Canada
Reservations

Introduction
Sociological analysis of diagnosis has achieved considerable
influence in the last two decades, providing important insight into
how we understand health, disease, and illness. It has also
expanded how we view the social and cultural influences that
shape our knowledge and practice on health and illness.
This includes studies of diagnosis that have gone beyond the
interaction between physician and patient, to take into account the
larger social, structural, and temporal forces that shape diagnosis
(see, for example, the categorization of homosexuality as a mental
disorder and the role of gay rights activists in the American
Psychiatric Association’s deliberations) (Cooksey & Brown, 1998).
Recently we have also seen the emergence of diseases whose
etiologies, symptoms, and, therefore, diagnoses, are often contested
or uncertain. This combination of medical and social uncertainty
leads us to propose a reformulation of the concept social diagnosis as
a new way of thinking about the sociology of diagnosis. This paper
explores social diagnosis by first, outlining a conceptual framework
of social diagnosis; second, discussing the different actors who
contribute to social diagnoses; and third, providing a case study of

* Corresponding author.
E-mail address: [email protected] (P. Brown).
0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.05.031

how to apply our social diagnosis approach. Lastly, we conclude
with implications for sociology, medicine, and public health.

Introducing social diagnosis
Social diagnosis is ‘social’ for two reasons: First, it connects an
illness or the act of diagnosing that illness to a set of political,
economic, cultural and social conditions or factors. Second, social
diagnosis is conducted by different social actors, and the actions of
one group of stakeholders often spill over to affect the actions of
other actors. As we will see, social diagnosis is done by sociologists
who study diagnosis, as a way for researchers of social medicine and
the social determinants of health to look at the process, outcomes,
and consequences of diagnosis. It is also done by the lay public visà-vis social movements that expand what goes into the diagnosing
process. In this more comprehensive, public version of uncovering
the social determinants of health, a condition is diagnosed by
a social groupdfor example, the politicized collective illness identity that arises over a contested disease like Gulf War Illness
(Zavestoski, Brown, Linder, McCormick, & Mayer, 2002). Lastly,
social diagnosis is a way to expand the lens of the public health and
medical establishment in identifying what mechanisms and factors
are consequential for individual and community health. Social
diagnosis therefore provides a broader context for health practitioners, medical researchers, and social scientists to understand the

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P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

extent of extra-medical factors in health and illness. With that
approach, neighborhood and community environments (which are
themselves determined by larger structural forces) can be included
in approaches to wellness, highlighting the intersection between
individuals and the larger social forces that structure their lives.
A genealogy of social diagnosticians
Social scientists
The roots of this approach are deep. The term “social diagnosis”
was coined in Richmond’s (1917) book, Social Diagnosis, considered
to be the classic textbook laying a professional foundation for social
work, and which focused on examining a wide array of social
conditions causing poverty and disease. This was a period when
sociology and social work shared many common interests in documenting and alleviating poverty, with the reformist Chicago
School sociologists categorizing and analyzing urban social problems that they traced to social structures rather than inborn
characteristics.
Even in the early 20th century, sociology focused on the social
determinants of health and illness, as in Faris and Dunham’s (1939)
work on mental illness. Decades later, Navarro (1976) and Waitzkin
(2000), both MD/PhD sociologists, led the charge of other political
economy scholars who sought to rekindle social medicine, found as
early as Rudolf Virchow’s work in mid-19th century Europe, and
more recently in Chile during Allende’s Popular Unity Government
in the early 1970s.
A committed approach to health inequalities, rooted in England,
worked its way into the literature starting in the 1990s. A leading
medical sociologist, Sol Levine, and a prominent social medicine
physician, Alvin Tarlov, nurtured this endeavor in their Health and
Society group, publicizing well-known British work such as Michael
Marmot’s Whitehall Study, bringing key health inequalities
researchers such as Richard Wilkinson to the US as visiting scholars,
and providing a research setting to nurture new health inequalities
researchers (Amick, Levine, Tarlov, & Walsh, 1995). A young generation of US-based scholars brought health inequalities work to the
fore, emphasizing race, class, sex, ethnic, and neighborhood differences (Kawachi, Kennedy, & Wilkinson, 1999; LaVeist, 2002;
Williams, 1994). These scholars’ work helped push the National
Institutes of Health to develop a strong program in health inequalities, though usually termed “health disparities,” a more neutralsounding phrase. From being only a National Center on Minority
Health and Health Disparities, in 2010, NIH transformed the center
into a full institute, the National Institute on Minority Health and
Health Disparities, signifying a major acceptance of this work.
Public health and medical professionals
Medical professionals and public health scholars in the US share
an important tradition of taking into account social factors in their
work. For an example of 1960s social medicine that exemplifies
social diagnosis performed by a physician, we can remember the
work of Dr. Jack Geiger, a founding member of the Congress of Racial
Equality (CORE) in 1943, a leader in efforts to end racial discrimination in hospital care and medical schools admission and a 1960s
founding member and National Program Chairman of the Medical
Committee for Human Rights which protected and provided medical
care for civil rights workers. Geiger was famous for diagnosing
poverty, racism, and hunger, and writing prescriptions for food to
give to poor children, which he and colleagues did to garner public
attention. More practically, the community health centers developed in that era diagnosed disease as stemming from a multitude of
social conditions. For example, staff would act on these diagnoses by

seeking improvements in neighborhood parks and fighting for lead
removal and blood lead testing (Lefkowitz, 2007).
While the public health field in the US continued a strong
commitment to examining social factors in disease, medicine often
trailed after it. Occupational health, environmental health, nutrition, and community health training still remain marginalized in
medical education and practice. Federal research, largely conducted
through the National Institute of Health, emphasizes treatment
over prevention. For example, the prestigious, well-funded
National Cancer Institute provides few resources for researching
environmental causation, leaving that to the much smaller National
Institute of Environmental Health Sciences whose budget is 6.5
times smaller (Brown, 2007) Sociologists have played a role in
examining social factors in disease, working alongside public
health scholars and community activists in pursuing multi-causal
approaches to understanding disease and developing multipronged solutions (Brody et al., 2009).
Public participation/social movements
Diagnosis is simultaneously a site of compromise and contestation because it is a relational process. When there is a disconnect
between the patient and the medical explanatory model, the
individual may be unsatisfied with treatment goals, and collectively
work to politicize the illness through social movements. This would
be the case especially if people were not given a diagnosis for
something which they expected to, or when they received
a psychiatric diagnosis for something they believe is physical.
The greater the symptom severity or the disconnect between lay
and professional perspectives on diagnosis, the greater the likelihood of contestation.
In contesting diseases and conditions, people often seek to
reshape or overturn a shared set of entrenched beliefs and practices
about diagnosis, causation, and treatment that is embedded within
a network of institutions, including medicine, law, science,
government, health charities/voluntaries, and the media. This
network is the “dominant epidemiological paradigm” for a given
disease. Activists challenge the dominant epidemiological paradigm by shifting the modes of scientific inquiry, and by refocusing
regulatory and policy attention (Brown, 2007). Scientists may be
asked to weigh in on questions that are virtually impossible to
answer scientifically, either because data do not exist or because
studies required to answer the question at hand are not feasible.
Scientists may frame political, moral, or ethical questions in
scientific terms thus limiting lay participation. This scientization
protects the illusion of medical omnipotence and delegitimizes
questions that cannot be framed in scientific terms (Morello-Frosch
et al., 2006). Health social movements may respond to these situations by marshaling resources to conduct their own research and
produce scientific knowledge in a process known as “popular
epidemiology” (Brown, 2007). In doing so, they democratize the
production of scientific knowledge and then use that transformed
science as the basis for demands for improved research on disease
etiology, treatment, prevention, and stricter regulation.
These concerns may extend into the legal realm when diagnoses
are a classification of what the individual’s health status could be in
the future. Exposed people may seek redress through medical
monitoring torts in advance of injury, in an attempt to offset the
costs associated with periodic testing in order to ascertain whether
a given exposure has led to changes in health status (Maskin,
Cailteux, & McLaren, 2001). Even US law now recognizes that
disease is no longer a unique collection of symptoms equaling
a given condition, but rather a constellation of current symptoms,
previous exposures, and future potential manifestations, all of
which make the art of diagnosis even more precarious.

P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

The democratization of medicine and science we have
mentioned above is made possible by bringing the discussion of
diagnosis out into the open, rather than keeping it restricted to
professionals. Krimsky (2002) notes that the endocrine disrupter
hypothesis (that argues for the central role of endocrine-disrupting
chemicals in many diseases) was discussed quite extensively in the
public light, far beyond the shelter of academic journals and
government funding agencies. His notion of a “public hypothesis”
helps us see that increasingly, challenges to scientific orthodoxy are
shaped by public discussion in the media, social movement organizations, virtual communities, and other accessible formats
(e.g. homosexuality, post-traumatic stress disorder). When people
view their diagnosis as stemming from a particular toxic exposure,
they are rarely satisfied with the simple act of diagnosis. Rather,
they seek evidence of causation in order to seek redress in various
forms: medical coverage, medical monitoring, relocation,
compensation, assignment of blame, and (less commonly) the
incalculable but valuable apology from responsible parties.
As discussed earlier, in the absence of a specific diagnosis, people
with a shared environmental exposure sometimes file suits for
medical monitoring, to ensure that they have lifetime checkups to
diagnose a disease process as early as possible.
Yet despite a rich history of social diagnosis exercised by various
actors, including sociologists, public health officials and the public,
the above-mentioned strands have not yet been well-connected,
nor woven into a social diagnosis framework. Below, we discuss
several elements of a social diagnosis model.
1) A social diagnosis approach is more comprehensive than
a political economy/health inequalities outlook that accounts
for how larger social structures affect diagnostic processes. In
social diagnosis, we also must “socially diagnose” those structures themselves. In this light, we would argue that the injured
foot of a ballet dancer is not merely an injury caused by a pointe
shoe. It includes the larger setting of the balletic art form e its
teachers, theaters, dance companies, dance critics e as socially
iatrogenic. It includes gender roles that force-fit women into
many uncomfortable clothes and shoes, and anorexogenic
notions of beauty that limit the art form. Our diagnosis would
be of an unhealthy foot in an unhealthy art form in an
unhealthy culture. Treatment and prevention goes beyond the
individual, seeking to restructure power, capacity, and
community in the surrounding society.
2) Traditionally, diagnosis dealt with diseases and symptoms in
the past and present, with future orientation toward only
treatment and prognosis. Indeed, even attempts at incorporating social factors into diagnosis (either by healthcare
professionals or sociologists) do not adequately account for
a third dimension of time; that is, the future. Today, potentiality
is an important concept, where a biomarker may or may not
indicate future diseases. This potentiality introduces new
contestations and foci; preventive medicine now goes beyond
generic health advice, to consider borderline categories:
pre-diabetes, pre-high cholesterol, pre-hypertension. Further,
patients are increasingly prescribed pharmaceuticals to regulate these borderline conditions (Welch, Schwartz, & Woloshin,
2011). Therefore, a social diagnosis approach must contend not
only with past and present conditions, but explicitly consider
the potentiality of future conditions, specifically because they
may have social causes and consequences.
3) The process of diagnosis is carried out by multiple social actors,
including medical professionals, researchers, government
agencies, private corporations, social movements, and legal
institutions. For example, we can understand the role of public
health agencies in new forms of surveillance geared to

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population exposure measurement and to the diagnosis of
pre-disease. Combined with increased academic and advocacy
research in this area, biomonitoring and household exposure
has opened vast new realms of seeing potential disease causes
at microscopic levels. Therefore, in a social diagnosis framework, not only are social factors considered in the diagnosis,
but a variety of social actors are contributing to the creation of
that diagnosis. In doing so, they diagnose not only individuals
but societiesda practice which is growing ever more important
in light of increasing biomedical uncertainty.
To further elaborate on and exemplify this idea of social diagnosis, we will use the case of obesity and diabetes in Akwesasne,
a Mohawk reservation straddling New York and Canada. This situation demonstrates how diagnosis has moved from the individual
to society, and is being performed by more than just doctors.
The multiple layers of diagnosis in obesity and diabetes: A
case study of social diagnosis in action
Obesity and diabetes have become a major concern of both
environmental justice and health groups in the 2000s. There is
broad understanding that, in addition to individual and lifestyle
factors, obesity is caused by numerous social phenomena:
increased consumption of processed foods (especially high fructose
corn syrup), food deserts, poor school lunch programs, a decline in
school physical education, and unsafe recreation spaces. Social
diagnosis looks here at an unhealthy body within an unhealthy
community, itself situated in an unhealthy food system.
Hoover’s (2010) medical anthropological study of local food
production and community illness narratives in the Akwesasne
Mohawk community found diabetes to be a central concern. Rising
prevalence indicated a rate higher than both the state and national
averages, and lay awareness of this led to a complex set of diagnoses. Residents in this highly contaminated area (primarily due to
PCBs and fluoride from local industry) believed that there were two
potential pathways through which contamination increased
diabetes risk. The direct pathway was based on recent science
linking exposure to endocrine-disrupting chemicals, to obesity
(Baillie-Hamilton, 2002; Newbold, Padilla-Banks, Snyder, Phillips,
& Jefferson, 2007). The indirect pathway was based on fear of
contamination, including fish advisories and concerns over soil
contamination, leading people to abandon traditional local foods
for less healthy processed foods, and hence also getting less exercise since they were not gardening and fishing. This second
pathway, rooted in a risk society perception, also led to changes in
the traditions and cultures of the community, leading to a broader
social illness.
We do not imply here that the discovery of contamination led to
obesity. Rather, the discovery of the toxicants set off a cascade of
events that meshed with other reservation developments, which
then involved dietary and agricultural changes. Such changes have
occurred in other communities, sometimes because of contamination discovery and sometimes for different reasons such as urban
decline. This then leads to the departure of groceries with fresh
produce or to the immigration of people from more self-sufficient
food regimes to urban locales flooded with fast-food restaurants
and completely lacking any resources to continue traditional
practices.
Using Chaufan’s (2004, 2008) work, Hoover argues that
the medicalized approach to diabetes individualizes and depoliticizes
the problem. Alternatively, a political ecology framework emphasizes
social, economic, and political institutions of human environments
where diabetes is emerging. Hoover adapts Scheper-Hughes and
Lock’s (1987) model of three bodies e the individual body, the

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P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

social body and the body politic. As Hoover points out, in addition to
losing the nutrition from fishing and gardening, people also lost the
physical and cultural activity involved in that food production. This
led to fewer burned calories, affecting the individual body, but also to
broader losses affecting the social body e the failure to connect with
ancestral ways and to pass traditions onto youth. Eating is an
important social experience, and the sharing of food is an integral
part of Mohawk culture, full of morals around cooperation and
proper behavior. This larger unity of the body politic is especially
important at present, when the community is less united due to
overlapping tribal, US, and Canadian governing bodies. Akwesasne
environmental health activists used their mobilization around
contamination as a way to achieve general social unification and
harmony. When people seek to take control of individual and social
levels of obesogenic and diabetogenic conditions, this crisis that
originates in massive contamination has the capacity to provide new
unity.
In effect, we see that what might appear as a straightforward
diagnosis of a metabolic disease is in fact much more complex.
Hoover’s analysis of the social diagnosis of this condition builds on
the community-based participatory research by the laypeople and
traditional healers of Akwesasne, in alliance with university
scholars and environmental health scientists, and implicates individual, social and cultural, and body-politic disease contributors.
Such analysis informs us that by the time it reaches the body politic,
biological disease goes to the core of the social fabric, and warrants
an overall restructuring of power, capacity, and community.
Further, we see that struggles over diagnosis are simultaneously
struggles over causation. In this light, we can understand the multitemporality of diagnosis: it is not only about the present, where
people seek knowledge about the symptoms they experience. It is
also about the past, whereby people seek the causes of problems
that led to a current diagnosis. As well, it is about the future, where
the medical and social sequelae of the diagnosis reside along with
the treatment and prognosis.
Conclusion
Studying diagnosis provides a window into many components
of health and illness, and presents an organizing configuration and
master frame. Our expansion into understanding and elaborating
on social diagnosis makes this broader framework more applicable
to an even greater number of research arenas. The act of diagnosing
an illness is important on multiple levels. It is about an individual’s
relationship to the illness or act of diagnosis, the collectivity of
people who suffer from an illness, and the larger social structures
that influence the illness and its diagnosis. In other words, it is
about locating an individual and a group in relation to key social
structures.
In this paper, we have sought to understand the unique context
in which social diagnoses are formedda sociology of social diagnosis. To reiterate, social diagnosis is social in that it considers both
larger social structures, as well as the various social actors which
contribute to the diagnosis. In other words, a broad range of social
factors goes into the making of a diagnosis, which is carried out by
a myriad of social actors. The diagnosing of individuals can allow for
the broader diagnosis of a group of illness sufferers, and an even
broader diagnosing of communities, as the Akwesasne example
clearly illustrates. From here, we have drawn five key lessons which
will not provide a one-size-fits-all framework, but will help pragmatically identify the role social diagnosis can play across many
different situations and among different constellations of actors:
1) Social diagnosis moves beyond individual-level explanations
for health outcomes;

2) Social diagnosis recognizes commonalities in the group
experience;
3) Social diagnosis moves beyond a diagnosis that is limited to
treating or identifying symptoms and toward identifying more
macro-structural roots. From here, it prescribes identifying and
treating the fundamental causes of the problem, as opposed to
just the proximal symptoms;
4) Social diagnosis relies on scientific evidence, but recognizes
that useful science might not always come from mainstream
sources, particularly when it involves laypeople;
5) Lastly, social diagnosis is attentive to changes across both the
short and long term. It moves beyond a cross-sectional approach
to diagnosis and instead preferences a multi-temporal approach
to diagnosis, one that changes over time.
Social diagnosis offers three benefits: it is a concept that can be
used by diverse actors – medical sociology and other medical social
sciences, public health, and medicine; it is not only about diagnosing individuals, but also about diagnosing institutions and
organizations; and it is simultaneously a description of our analytic
approach and a prescription for how to intervene. Social diagnosis
can be an interesting tool for sociologists in various specialties
within the discipline, as well as researchers outside the discipline.
For example, environmental sociologists examining a disease such
as asthma can take students on toxic tours in order to show the
neighborhood factors and pollution sources related to asthma.
Social diagnosis can also be applied to medical history and science,
technology, and society analyses of disease concepts and medical
practices. The social diagnosis approach offers valuable lessons for
physicians and other health professionals. In particular, the cursory
instruction in occupational and environmental medicine in medical
school can be countered through showing professionals how to ask
appropriate questions about environmental and occupational
exposure. ‘Narrative medicine,’ formulated by Rita Charon (2006),
teaches medical students and physicians to attend to the totality of
life experience through eliciting and listening to patient stories, in
order to more thoroughly diagnose them. Pediatrician Rosalind
Wright diagnoses asthma as being exacerbated by violence at home
and in inner-city neighborhoods (Wright & Steinbach, 2001). This
leads her to seek intervention strategies aimed at reducing violence
exposure, reducing stress, and counseling victims, in addition to
more traditional asthma treatment. At a preventive level, she urges
policy directions that address the social, economic, and political
factors that contribute to crime and violence.
Social diagnosis as a concept may not seem new to sociology,
but it has yet to be developed into an enunciated framework and
program for research and/or action. For example, sociologist Eric
Klinenberg’s account of the 1995 Chicago heat wave introduces the
notion of social autopsy by effectively conducting a post-mortem of
the natural disaster and the various social factors that affected its
victims (2002). In doing so, Klinenberg provides a social diagnosis
of the heat wave, citing social isolation as one of the main causes
and prescribing changes in the social structure to prevent relapse.
This could serve as a very potent framework for sociologists and
practitioners alike to carefully and systematically consider those
social factors that play a crucial role in health. Also, while medical
sociology recognizes many extra-medical factors, the environmental factors so important today have not been widely considered. Hence, there are still lessons to be learned about the
multi-factorial causes of morbidity and mortality. Sociologists
also continue to face uncertainty in knowing which social factors
they ought to focus their attention on. Further, clinical examples
such as those above may seem logical to medical sociologists, but
they are not generally accepted in the world of medicine. If medical
sociologists work with clinicians and public health practitioners,

P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

they may be able to jointly develop effective ways to use social
diagnosis for both treatment and prevention.
Acknowledgments
We are grateful to David Ciplet, Alissa Cordner, Leah Greenblum,
Bindu Pannikar, and Allison Waters for comments.
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