 So, you're being joined tonight by my online class and as such then the camera is going to be aimed at me. I'm saying this for the camera and we're going to talk tonight about a case study called the American Medical System. All right, so why do I want to give you a case study right now? There are several reasons that I want to give you a case study. One is that this is a good way to go back over a lot of the concepts that we've learned in the class. So, this is a good summary of everything that's going to be on your final, okay? So, this is a review in a way, okay? We're going to be going back over concepts that we've talked about all semester long. The other reason that I want to do this is that one of the requirements for your projects that you're going to be presenting in a couple of weeks is to do a sociological analysis. So, this is going to be giving you examples of sociological analyses. Now, when you do your projects, you're not expected to analyze from all these points of view that I'm going to be analyzing from. You would only pick one, so I'm giving you multiple examples, right? So, when you start looking at your project and trying to figure it out sociologically, you would only do one thing that I'm doing tonight instead of all 15 things. If that makes sense. And then finally, the reason you want to pay attention to this, I just made a pun and didn't mean to, is that it is going to be on the final. Some of the stuff that we're going over will be part of the test. So, you want to pay attention to it because it will be on the test. So, any questions about that? All right, so what are we actually analyzing? Well, what is American medicine? American medicine is essentially the system that we live under. It's a for-profit system. And we're going to look at it from the three perspectives, right? The three paradigms of sociology. So, we're going to look at, well, how, if you're coming from a functionalist point of view, what kinds of things would you think about when you're looking at the medical system? If you're coming from a conflict perspective, what kind of things would you look at when looking at the medical system? If you're coming from a constructionist point of view. And then I'm going to talk a little bit about some issues that don't fit neatly into any of these paradigms, but still draw upon sociological concepts in order to understand it, okay? So, what are the values in the American medical care system? Well, we have a dominant paradigm in the medical system that is called allopathic. You probably haven't heard that word before. Allopathic is a single cause for a disease, okay? It's the belief that diseases stem from some sort of dysfunction in the body. And if you identify the cause of the disease and treat the cause, then the disease will go away. This is sometimes called the magic bullet approach to medicine, right? And so, allopathic would be put up against alternatives like holistic. Holistic paradigms don't look for a single cause, but rather they take it from a systemic point of view, from a whole body point of view. So, a holistic doctor tries to look for total imbalances and not a single cause. An allopathic doctor is going to try to figure out what is the one thing that is causing the problem. We didn't get to an allopathic dominance because science dictated it. We got to an allopathic dominance because in the 1880s, regular physicians, allopathic physicians, campaigned for it. We got to this dominance because the American Medical Association actively tried to get rid of other practitioners. The first group that they went after were midwives. Midwives at the time didn't lose kids and childbirth. Doctors did because midwives did things like boil water. You know, they didn't know the germ theory per se, but they did things that they knew worked empirically, right? They had done these things for centuries, and they knew that if you sanitized the area, cleaned the area, it went better. And because they knew that, and because that's all that they did, they were better at delivering babies than the physicians were. Well, the best market to get into if you're trying to market medicine is the mommy market, right? Because moms are the ones who will bring the kids to you. Moms are the ones who will make the dads go, right? Moms are the ones who make the entire family become a consumer of health care. So this is why they went direct-direct head-to-head competition. And once they figured out that if you, you know, just did an autopsy, you need to wash your hands before you deliver a baby, then, you know, which is part of the problem is that they were doing things like, you know, coming directly from dead people to babies without washing their hands or doing things like that. And lo and behold, they brought diseases with them, okay? So they started figuring out maybe we should wash our hands, maybe we should have more hygiene, started making hospitals. Hospitals were a place they're getting to be this way again. But hospitals were a place nobody wanted to go to because people died from other things by going to the hospital. So if you went to the hospital because you needed, you know, a surgery of some sort, you might die in the hospital of pneumonia or a staff infection or some other kind of thing. So hospitals had a really bad reputation. Most medicine, I'm even old enough to have doctors' home visits. When I had the measles and the mumps when I was a kid, the doctor came to me and visited the house, right? Because I lived in a rural area, so there was no clinic to go to. The clinic was way far away. So the doctor would come by and stop by your house and check on you, right? So hospitals made this, you know, industrialized, centralized place where it was much more efficient. You could see a lot more patients. They started working on making sure that there were standards that have to be met both in licensure and also in hospitals. And they became very powerful and self-regulating. We have medical boards in the United States. They are all run by other physicians. The oversight for doctors are other doctors. And doctors are notorious for not wanting to tell on each other, right? They're afraid that they're, because every doctor makes mistakes, okay? I mean, you know, you want to believe that they don't make mistakes, but every doctor makes mistakes. So the fear is that if they tell on some other doctor's mistakes, then when they make a mistake, they're going to be targeted as well. So there's kind of a, you know, old boys club that just don't own up to some of the stuff that goes on. There's a lot of conflict of interest in modern medicine now. Okay, now think about this. If your doctor is an investor in your pharmaceutical company, how do you know that he's prescribing drugs for you because you need them? Or because he wants another Porsche or wants to go on his European vacation this summer? I mean, you can get really cynical about this really fast, okay? And so this is, you know, there is every once in a while, but every two or three years, if you go back and look in the Journal of American Medical Association, JAMA, it's called, you'll see an article about the conflict of interest of doctors owning stock in hospitals, stock in HMOs, stock in pharmaceuticals and any kind of medical stuff. And they'll give lip service to how this is not that good. Any other profession, this would be just a huge no-no, right? But they, I mean, it just falls on deaf ears. They know it's a problem. And yet, you know, they also know that when most of what they're invested in gives a return of between 15 and 20% every year, you know, it went down a little bit in the last five years, it's down to like 12, 13%. You know, this is while your savings account is making less than 1%, right? And while the average for-profit company is paying somewhere in the range of 6 to 8% and patting themselves on the back for having that kind of return of investment, these things are making money like crazy, and this is what the doctors make their money in. So there are a lot of conflict of interest that are involved in allopathic medicine because of this self-regulation and this dominance. We have what is called a multi-tiered system. It is changed a little bit with Obamacare, but not a whole lot, okay? It's still pretty much a multi-tiered system, and it's pretty much is not quite universal, okay? There are going to be a lot of people who will not get insurance and will pay the penalty under Obamacare. Because the penalty is way less than actually buying the insurance, and people are going to figure that out by next year, so you're going to see a little bit of a shift. And then also, we still have better insurance for the poorest among us and the oldest among us than we do for the rest of us. So there is, you know, if you work and your employer provides insurance for you, that's one tier, if you don't work and you are able to buy insurance for yourself, that's another tier, if you're part of the Medicaid system or the Medicare system, that's another tier, and then you have a tier that do not have insurance at all who cannot, who have to pay out of pocket for everything or go into medical debt. Just to give you an idea of how much pharmaceutical companies really do make, seven, this is between 2003 and 2012, the net profits $711.4 billion, almost a trillion, three-quarters of a trillion dollars, that's profits, guys, not income, profit. And the reason that we have Obamacare and the reason that the Affordable Care Act was passed is in 2011, and this was higher even in 2009 when the act was being, started being debated. There are 46.8 million uninsured Americans. Under Obamacare, the estimate is that it'll probably be down to about 25 million. That'll be uninsured. 17.9% in 2011 of our gross domestic product went to health care costs. We have a very inefficient system. It's inefficient because doctors' offices, hospitals have to, in order to get payment, work with a whole bunch of different providers, none of which is standardized. They all cover different things. They all have different forms. They all have different requirements. And so these organizations have to hire people who basically do nothing all day long but insurance claims. And these cannot be clerks. These people are RNs. One of the reasons we have a nursing shortage is that we need the expertise of nurses in order to bill for insurance. So the overhead is huge. In addition to that, a lot of this 17.9% goes to advertising and promotions. When I interviewed nurses for my dissertation, there were people who were coming in to doctors' offices in nowhere in North Carolina with buffet meals every day. I interviewed one nurse who said she never had to feed her family. She always took leftovers from the lunch of whichever rep was coming through. And that rep would provide, I'm not talking like they came in with, you know, subway sandwiches or something. They came in with big pots of, you know, like today's theme is Asian food. So they would have a big buffet of Asian food. They would have rice dishes and all of this stuff and you would go in. You couldn't eat it all. They had way more. So they would take it home and feed their kids with this food that would come in. And this doesn't even count the ways in which they would take doctors on information trips to the Bahamas, right? So you get a half-day seminar about how Viagra works and then you get to go out and practice it with the locals and then you get to go play golf, right? So you know, it was like you could hang out at the beach after that because you saw your one two-hour seminar. Okay, well, all of this kind of stuff is going away under Obamacare because they have a new rule now and that rule is that all of their advertising, all of their overhead, all of their profits can't make up more than 80% of their premiums. So that means that if they don't spend 80% of the premiums they collected on actually paying claims, they have to give it back. The first rebate was two summers ago. So that means that that profit, which I told you is sometimes as much as a 15 to 20% margin all by itself is going to go down and then it also means that the overhead has got to go down because they have to give that money back. But it means think about how much money they were making because in addition to all of this expensive promotional stuff that they were doing, together with the HMOs and the hospital and the AMA, they were putting over a million dollars a day into lobbying efforts to shape and change the way this Affordable Care Act came out, okay? So either oppose it or to shape it where it's something that would work for them. The debate on healthcare lasted over 400 days. That's 400 million dollars to lobby 530 some odd people. That's a lot per person. This is crazy. I mean they had the money to do that and they still posted double digit profits and they still were going around taking people to the Bahamas and providing food every day. In other countries they don't let them do that, which is why they keep doing it to us because we're the only people who allow them to keep making money off of us. So you see there in 2012 for pharmaceutical companies the profit margin was 18.4%. That was the return on investment in 2012. So when I tell you that this is big business and it is a for-profit industry, I'm not kidding, it's a huge for-profit industry. The Affordable Care Act requires that everybody is covered. The reason that it requires that is so that you have, you know, the thing we did in this country with Medicare and Medicaid is we did something that really insurance is not supposed to do. The whole reason you have insurance is that you have a lot of people in the pool who don't need it this year, who don't need it right now. You need low-risk people and high-risk people together in the pool so that when any one person needs it there's enough to cover the people who need it this year. You know, the opponents to this call it socialized and in a sense it is socialized to a certain extent because it's divvied out on the basis of need, but if they're going to call it socialized then we've got to call car insurance and life insurance and all sorts of other insurances socialized as well because this is the basic principle of insurance and we violated that when we took the two most vulnerable pools of people and put them together in an insurance coverage and that would be old people who get sick and disabled much faster than younger people and poor people who get sick and disabled much faster than older people. Medicaid is poor people and disabled people and Medicare is older people and disabled people with no healthy people mixed in. Many in those pools are high-risk. You're probably somebody in here is probably early enough in their driving career that they're considered, you know, they've had an accident and their age and all this stuff and they're considered high-risk and you can only buy high-risk insurance. High-risk insurance is very expensive. It's very expensive because you're not allowed in the pool with all the other people anymore, right? So that's what we did. We took them out of the pool and put them in their own little segregated areas and then we wondered why the cost went up so high. It was poor actuary business, right? It was not a good way to do things. So by requiring everybody to jump into the pool, right, by saying that everybody has to buy some form of insurance, we are doing good principles in insurance. We're saying we're going to create this and say it's why you have to buy auto insurance. Obamacare is auto insurance for your health. It's essentially what it is. And this is why the Supreme Court challenge didn't work because if the Supreme Court had said that the government doesn't have a right to tell you that you have to buy this, every insurance company that sells health insurance, I mean that sells car insurance would be in trouble because we have required forever for you to buy car insurance. And the reason we do that is that it works. It keeps the cost of anybody paying for insurance low and it makes sure that people aren't losing everything if they have a car accident, right? It makes sure that people are covered in one way or another when they have a car accident. It's a way of spreading that risk around. There are state exchanges and the federal government, it's up to the state whether they do their own exchanges or use the federal website. The federal website is a thing that was all controversial last year because it didn't have a great start. By the way, Medicare, Medicaid didn't have great starts either and they eventually worked out the kinks out and everything. So a lot of analysts at first were like, oh my God, they're not running. And then they went back and looked at the history and they said, hey, you know, this is pretty much the way it always goes. It just looked weirder because we had the internet involved in it this time. But you know, it's settled down a little bit and they actually more than met their goal of enrollment for this year. And they abolished pre-existing conditions. So nobody can refuse to ensure you because you have been ill before. There's just no such thing anymore in America as a pre-existing condition as of 2014. They did away with it for anybody under the age of 18 in 2012. And then this year is the first year that the entire country, there's no pre-existing condition. And I mentioned the 80% already. They have to spend 80% of the money on actual paying for medical expenses for people. I'm not here to say this is a good thing. I'm actually not really happy with the way in which Obamacare worked out. That we're not alone in the approach that we're doing, though we've made it way more complex than we need to. But I don't think it's going to solve the financial costs because we still have all those complexities that are creating that overhead, right? We still have multiple insurance providers with multiple forms that you have to fill out and multiple things that you have to prove and information that you have to give and all of these things that add to the cost of the coverage, right? And no amount of caps are going to make up for that. The problem is that what we're paying for the emergency room care, the problem is what we're paying for the overhead of the emergency room care. If we don't do something about the overhead, we're not going to solve this problem. All right, so let's get into the different perspectives. I've kind of described for you what the case is, okay? So now we're going to look at this case that I've described to you, allopathic medicine, for-profit medicine, self-dominant, self-regulated medicine. We're going to look at this from a functionalist perspective and then we're going to look at it from a conflict perspective and then we're going to look at it from a constructionist perspective. So if we're looking at functionalists, if you remember, functionalism is how do things work, right? And you're going to care about the mechanisms of the system. And so one of the things that comes up when we talk about any kind of functionalist is what roles do people play? Now, Talcott Parsons is not a popular sociologist anymore. He had his heyday in the 40s and 50s and by the 60s, people were kind of like social systems was a little too ambitious and a little too ethnocentric and he sort of fell out of favor. But in that book, Social Systems, he has a section about the sick role and he's pretty right on with this. I mean, there were things that he had in the book that were pretty reasonable, okay, and other people have written about this since. But think about this, what happens when you're sick? You do play a role in society and it's a fairly privileged role because if you can document that you're sick, you don't have to go to school, you don't have to go to work, you don't have to do your household chores, other people have to serve you. It's a pretty privileged thing, right? If you can pull it off, it's kind of cushy. I mean, you know, you're sick and everything, so that part's no fun, right? And all you have to do in exchange for all of these privileges is work on getting well, right? The exchange with other people around you is that you're doing what you are supposed to do to get better. So it is contingent upon it being temporary. If you milk it too much and the people around you, your boss, your teacher, your family, decide that you're kind of faking it a little bit or not trying to get well, all those privileges will start drying up, right? So it's a contract between you and the people around you. You work on getting well and you get to stay in bed for a while and we get to serve you. And you don't have to worry about work and you don't have to worry about school, right? So how do we prove to the people in our lives that we're trying to get well? We do it by following doctors' orders, right? So the physician and nowadays we would say the health care provider, because this is a larger role than it was in the 50s when he wrote about this, the physician's role is very tied up with the sick role, right? In fact, the physician is the gatekeeper. The physician is the one who writes the note and says that note is essentially this person is playing the sick role now. And until such and such a day when I deem that he is better, you have to take care of him. That's what the doctor's note is saying, right? He will be excused from this. He will be excused from that and the other thing, right? I remember I got sick at a, we went to Indianapolis with a youth group. I went on church trips in the summertime and everybody got sick with some sort of stomach thing. Like it was a really fun night because you could hear toilets flushing up and down the hotel corridor, right? I was up, I was one of the first that got sick. I was up all night, sorry. I was up all night long. People are eating and I'm already to tell a vomit story. But anyway, I was up all night long in the bathroom, throwing up and all this other stuff. Well, by the time the doctor got there to look at everybody, I was exhausted. And I had pretty much gone through the thing. So this doctor walks in to the room, doesn't ask me what I've done or anything like that. He's looking around the room, my roommates are sick. And he says, well, this one's OK. She doesn't look sick at all. And my youth director picked up on that and he makes me start working because I'm the only kid who's not sick, right? Even though I'm weak from losing everything I had eaten in the last 48 hours and so forth. And I could not convince my youth director, even though my roommates are all like, she's sick. All the doctor had to do is just label me not sick. And any complaint I had was now regarded as gold-breaking. And I was trying to get out of work. And so I had to go around, I cleaned up stuff, all kinds of fun stuff. Because that doctor said that I was not sick. And that's all it takes, right? If you can't convince the doctor to write you the note, then you can't get out of school. You can't get out of work. So the physician is key to this. So when this goes the way that we expect, it's pretty easy, right? You go to the doctor, they give you medicine. You go home for whatever time that they tell you. You turn in your notes, you go to bed, you take your medicine one week, two weeks, however long they tell you, you're up, you're at them, everybody's happy. Here's the problem, not everybody gets well. Not everybody gets well. And we don't have a lot of norms around not getting well. So it's very stressful, especially on families and especially in work relationships, if somebody gets sick and they don't get better. We don't know what to do with that. We don't know what to do with chronic illness. We don't know what to do with terminal illness, right? Hospices help some with terminal illness. But one of the reasons we had a hospice movement was because everybody felt lost. And why do they feel lost? Because there are no norms on what to do with this, right? We depend upon norms to help us figure out what to do on a daily basis. And when something doesn't go according to expectation, we feel lost. And this creates stress. And this creates difficulties in relationships. It creates, which then again creates more stress, right? You get fired from your job. You get families who think you're faking it. You don't look sick, all of that kind of stuff. All of that stems from these lack of norms, these lack of expectations that center around chronic illness and around terminal illness. Terminal illness, like I said, is a little bit better than it used to be because the hospice movement went out of its way to teach people what are the norms of how to treat somebody who's terminally ill, right? They train physicians and nurses and other health care providers in how to do this. They provide these health care providers at home or in hospice settings and help with this. Chronically ill people, not so much. Chronically ill people, especially people who don't have visible disabilities, who are suffering from pain, things like fibromyalgia and chronic fatigue, that kind of thing, have a harder time because they don't have scars. They don't have marks. They don't have the things that say, hey, you're sick, right? And so they're forever fighting this, well, are you faking it or not? And that stems from this expectation that we have. We're going to see more problems with this as the baby boomers grow older. Every day in this country, 10,000 people turn 65 years of age. And that average is going to be true until 2030. We're in new territory. And that territory includes people who have chronic conditions. That territory includes people who are terminally ill, right? This is a latter part of your life. This is when things start falling apart, right? No matter. I mean, the baby boomers believe they're going to live forever and that they're going to be healthy forever and all that other kind of stuff. But we live in Vegas. I don't think the odds are in their favor. I think eventually they're going to succumb. And the cost of that is going to have a huge impact on your generation, right? There's this thing called the old age burden ratio. It's the number of people who are of working age or who are able-bodied people who can work between the ages of 25 and 65 in a ratio to the number of people who are over the age of 65. So in 2010, that ratio was for every 100 workers, there were 22 people over the age of 65. Now, this doesn't account for how many of those people over the age of 65 are still working, right? But it's still a ratio to look at. By 2030, that ratio will be 35. It will go from 100 people supporting 22 people to 100 people supporting 35 people. If we don't do something about health care costs, right? What we were just talking about with the overhead and all that kind of stuff, it's going to be a tremendous burden on the people between the ages of 25 and 65 in 2030. Add to that the average age of people of color versus the average age of white people. We have a generation gap that has a racial component to it. Because white birth rates are lower than people of color birth rates, the average age among people of color is younger. So this is going to be young people of color expected to support old white folks. And that's got potential for problems as well. So if you're looking to the future and not that far away, the next 20 or 30 years, we have some real tension that is going to happen. And this is going to happen on a societal level and it's going to happen on a family level, right? You're not really sick, grandma. Get out of bed, right? We're not going to have a chance to be that tolerant. There's going to be a lot of tension if we don't own up to it and deal with it, OK? So let's move on to another analysis. If we are taking a look at American medicine from a functionalist perspective, we might ask the question, what is the manifest function of medicine and what is the latent function, right? Who remembers manifest function and latent function? What's a manifest function? I told you this was a review and I was going to make you think. Oh, I don't think I mentioned the make you think part. Did I? OK, I'm going to make you think. OK, manifest function is the stated purpose for something. The manifest function of going to colleges, get an education. The manifest function of medicine is what? Yeah, it's for the health and well-being of the citizenry, right? People say explicitly it's to promote health, promote well-being. Sometimes you'll also hear promote profitability, healthy workers who are productive, right? So productivity, I should say, not profitability, but productivity, right? So we will talk about why we need a good health care system because we need healthy citizens to build this country, right? That's the manifest function. A latent function is a hidden function that essentially supports it and sometimes more so, right? Like if you're wondering why isn't something changing when you're addressing the problems with a manifest function? Probably it's not changing because there's a latent function that is supporting it that is way more powerful than the manifest function. And medicine is a case in point. The latent function of medicine in the United States is to make a few people a lot of money. It is a for-profit system. Doctors don't get up on television or in conferences or that kind of thing and talk about how they were inspired to become a doctor because they wanted to make great profits. They get up and talk about medicine being a calling and that they enjoy helping people get better and that it's satisfying to all this kind of stuff, right? But the truth of the matter is the latent function of American medicine is that it's a highly profitable industry. And as a highly profitable industry, it's not going away anytime soon. Because when people are making this kind of money, they resist change. The status quo is just fine. Thank you very much, right? We're fine. We're making money. That latent function is why we're not seeing a Canada-style single-payer health care. Because you know what would be required to do that? The dismantling of the insurance industry. It would essentially be a public takeover of a private industry. That's why it's not going to happen here. So if you read those 30 pages, what they said was all of the people who are employed right now in the insurance industry will now be employed by the government to oversee this. We will standardize everything, and there will be one insurance company, and it is the government. Everybody, this is why they're having Canada, right? Everybody, it's distributed through the provinces. So it's slightly different in each province. Everybody pays Canada. It is not free health care, OK? You pay a premium. It's way cheaper premium than here. Carla and I paid $98 a month together. The household paid $98 a month. Here? Yeah. So and if you don't pay the bill, you can still go get in care because billing is a different question than care. So they don't take your health card away if you don't pay the premium, right? They'll go after you, right? They may put a ding on your account or something like that, but it's not connected, right? So the reason is everybody's in the pool, so it's much cheaper because everybody in the country is in this insurance pool, right? So we're not going to see that because while all the people who are employed would still be employed, none of the profit would be there. All these people who are making a profit, that would, you know, the 18.7% would go down considerably. The HMOs are around 12%. That would go away totally. The insurance industry would go away. You would have a government negotiate with the pharmaceutical companies the way it's done in other countries. So their profit margins would go down considerably because they would buy it in bulk and they would negotiate a rate with them nationwide. So you have two major industries that make a lot of money, that the latent function is that they make a lot of money and neither one of them wants to let go of that money. And considering that doctors are the major stockholders in these, they're not, you know, too anxious to make it go away either. So this is why it's not going away because of the latent function. Does that make sense? All right, next analysis. Conflict theory. So we have this thing in the country that is some people have labeled the pharmaceutical industrial complex. This should sound familiar to you, military industrial complex. It's using the same idea. If you make a drug, somebody's gonna use it. If you make a medical machine, somebody's gonna use it, right? The technological imperative is part of the pharmaceutical industrial complex. Why does this exist? Why do we have drugs that are on the market that people go out of their way to use them, okay? This is an unintended consequence of the patent system. Patents are an old idea. They came up during the 19th century in the United States and there are patent systems in every country, right? A patent gives, is meant to encourage innovation. It's meant to encourage invention. So the inventor or the developer of something and the patent paradigm, what they're thinking is one guy, right? What happens now is it's companies. That hold patents. But when the law came into being, they've got Thomas Edison in their head, right? Some guy who is inventing things. So we want to reward this innovative engineer, smart guy. So how are we gonna reward him? Well, we're gonna give him a monopoly, right? On his invention. He holds the patent. Anybody else wants to produce his invention? They have to go through him, right? I'm using the male pronoun on purpose because for the most part, this has been a men's world up until the latter part of the last of the 20th century, right? So you have these inventors who invent something and life expectancy was only around 65 years of age. So the patents were like 20 years, right? Which is essentially saying, hey, you invent something in your 30s, you've got mostly a lifetime monopoly on this, right? We're not gonna extend it to your descendants, but since you thought this up while you're alive, you have it. So that's where the 20 years comes from, okay? So this is the problem in medicines. You wanna make a patent pretty early because if you create a formula and you don't patent it and somebody, you know, it's not that hard. I mean, you're only working with a few organic chemicals here, right? So it's pretty possible that somebody else is gonna come up with something similar if they're working with the same chemicals and thinking about the same stuff, right? So you can't risk, even if you don't know whether or not it's really gonna help, you can't risk not patenting it until you know it's really gonna work. So you gotta patent it pretty early in the process, right? So as soon as you have an inkling that this might be something that is curative or a treatment or whatever, you run out, you get the patent. Now you gotta do animal tests, then you gotta do human trials, and then you gotta do an FDA review and all of this stuff. So from the time that you get the patent to it's ready to go on the market is 10 to 13 years. So what have you got? You got a monopoly for another seven years, all right? And the monopoly makes you a lot of money in pharmaceutical companies, and that monopoly for that seven years is probably worth a few billion dollars depending upon what the medicine is, right? Here's the thing, the patent office says that you only have to patent for one treatment, one thing. So if you can come up with a second use, you get a whole another 20 years. And that second use doesn't take as long to get on the market because you've already proven that it's safe, you've already proven that your manufacturing is good, now all you gotta prove is that it treats this other thing, right? If you can show that it treats this other thing, that's like a two or three year do it, and if you're smart, you'll start doing that before the end of that seven years so that when you are at the point where you patent for the next 20 years, you've already got all the data in place, you're gonna get it on the market for that new thing, and now you got 20 more years of monopoly, right? Big incentive to do this. So this is what you get. You get new diseases. You wanna know why we have the super crazy PMS now? I forget what it's called, it's something, something syndrome. You guys know what I'm talking about, right? Early part of 21st century, now it's not just normal PMS, you can have the really bad PMS. Do you suffer from such and such? It's cause, yeah, this is patent ran out, right? Birth control. So YAS is a birth control pill, but if this thing exists with this premenstrual syndrome exists and YAS is a treatment for it, hold another 20 years for YAS, right? In the 1970s, a whole bunch of people patent serotonin uptakes. Zoloft, Prozac, Welburton, you know the names, right? All of this is for antidepressants. Serotonin uptake inhibitors have some questionable science behind it. There's been some problems with these medicines, right? You get serotonin syndrome. Some people have bad adverse reactions to them. Other people have tried to commit suicide when they've been on them. The science wasn't originally all that good anyway, but it managed to make it through and so forth. And they were selling them by the mid 1980s. The patents ran out in the early 90s. So what happens when the patent's about running out? Suddenly you have this thing called anxiety disorder. If you look at the checklist for anxiety disorder and the checklist for clinical depression, they're not that different, right? Now I'm not saying that there aren't people who are not getting something out of this medication, but by reworking the checklist a little bit and convincing the FDA that these are two separate things instead of the same thing, right? They got 20 more years. Got them lots and lots of money, yes. Well, I mean, doctors who make profits off of it are happy. Because they gotta get that exposed before they... Yeah, but a lot of times the doctor is relying upon these checklists that actually were created by scientists who work for pharmaceutical companies. So the doctor may or may not know the history of this, you see? So I'm not ready to just indict all doctors on this, because I mean, if you're running around with a lot of knowledge in your head about different diseases, you go back and look up references and these people get these things into these reference books. So yeah, the doctors are a part of that system, but I don't think it's meant to be cynical on their part. But insurance comes into play on this too, right? Because insurance, you have to have a positive diagnosis in order for the insurance to pay for certain things, like medical equipment, like medications and so forth. They have to be prescribed by a physician and they have to meet certain standards. So it's all interconnected, right? It's all interconnected with lots of incentive to have a name for something. People have physical and mental phenomena, right? And whether we call it ill or not is a question of human decision. It doesn't change the physiology that we call it one thing or another thing, right? It's still a physical phenomenon. We're just defining it a certain way. We're gonna talk about social construction and disease in a minute. So this is essentially creating that construction, right? So sometimes this becomes more profit-driven than science-driven where you have a push. I'm not sure if I assigned this or not. Did I assign the osteopeia radio thing for this week? I'm not sure if I did, probably didn't. I don't know. But anyway, osteopeia, do you know what that is? It's pre, this is a favorite thing going on nowadays, pre-diabetes, pre-high blood pressure. This is pre-osteoporosis. Okay, here's how this came into being. There is a pharmaceutical company that developed a machine that would test bone density of your wrist. So I don't know whether you probably are too young, most of you, to have had a bone density test. But when you go in to have a bone density test, you gotta lay down and there's this big machine and it goes over your legs because they're looking at the biggest bones in your body to see whether or not. They're essentially X-raying them to see how thick they are, right? So this is expensive. It requires the patient to do a lot of, it's painful sometimes depending upon what the, because a lot of these people are older and chronically ill who end up having bone density done. So there was an emphasis to try to do a different bone with a more portable machine that could be done in the office and didn't require a doctor having to send you to a hospital to have it done or to a clinic to have it done, all these reasons, right? To wanna have an easier to deal with machine. The only problem was is that once they put the machine out there and everything, it wasn't very good at, like when they tested it against the leg machines, it wasn't catching the osteoporosis, right? It wasn't good at the diagnostic. So now they've made these machines, they've patented, they put all this research in it and everything and they're freaking out. So they have this big meeting, right? The company that makes the machines, I think it was Merck, but I can't remember for sure, but the company that makes the machines have a big meeting in Italy. Now this is the marketing guys, not physicians, not scientists. These are the leadership of the company, the marketing people, all this stuff. What are we gonna do with this machine? Well, you know, it does kinda tell, you know, if you're heading in the direction of osteoporosis. So what if we said that it is a screening tool for early detection? Now nobody's going out and actually testing this. They said, yeah, it's early detection. We don't wanna call it pre-osteoporosis. What are we gonna call it? They came up with a name in a hotel conference room in Italy. Osteopia is a name that a bunch of marketers came up with, right? So they went out and sold these machines as early detection for osteopia and now women get diagnosed with osteopia. There's starting to be more studies done about it now and they're suggesting that, you know, women with osteopia don't get osteoporosis any faster or any more often than the general population. That has very little relationship, right? But women are taking calcium like crazy because they're afraid that they're gonna end up with osteoporosis, right? And so a pharmaceutical company came along and made like super calcium and got somebody like Sally Field to go on television and talk about how great, you know, this is. There's no, nobody went into a lab. Nobody studied any population. They aren't now, but they did it after the fact. After they sold it, they have a whole bunch of people who are all, and it's not something that has symptoms other than the machine gave a positive test. So all of these women are taking this as preventative, right? For fear that they're going to get something. And it's not preventing anything. They're getting osteoporosis at the same rate that people in the population get it. So that's a very good example of what I mean when I say that we have diseases now that are profit-driven diseases that are defined not by science, but by the profit motive. But because they're out there, because they've been built because of the industrial complex that is part of this, they get used. They get prescribed, right? And doctors sometimes get into a bad position because the marketing doesn't go to the doctors. The marketing goes to the patients. So patients show up in the office and demand these tests, demand these medications because they're getting prompted to do it through advertising. So it doesn't even require the doctor to be cooperative. The doctor sometimes is between a rock and a hard place because on the one hand they got the rep giving them all kinds of incentives. And then they've got the patient saying, I saw it on TV, I want you to test me for this, right? The problem is that this is starting to create something called iatrogenic problems. Iatrogenic means a medical mistake. It's a medical condition that didn't come from a disease that didn't come from an accident. It came from a problem with the doctor. It came from a problem with the hospital. It came from a problem with two wrong kind of medications or medications taken in the wrong way, right? We have two very famous cases in the last few years of iatrogenic deaths. Oh, I can't remember her name on the sudden. Anna Nicole Smith and Heath Ledger. Both of their deaths were iatrogenic. They took medications that didn't get along with each other, right? They were taking over-the-counter and prescription medications. They didn't overdose on illegal drugs that they got off of the street. These were medical mistakes that were made with them. There are some, nobody writes died because the doctor blew it, or uh-oh, I'm a death certificate, okay? So this is a kind of hard stat to keep, right? Because you don't really have official reporting on this. So you have to tease it out of the data. So there are some estimates that suggest that between the ages of 25 and 65, iatrogenic is the third leading cause of death. Like I said, you know, it's gonna show up as drug overdose or bad drug combination or pneumonia or some sort of illness that you got in a hospital or something like that. It's not gonna show up in the death certificate as oops. But so, you know, it may be worse than third leading. It may be better than third leading. But this is the best, the most common estimate that it's a third leading cause of death for early death. And this push for medications for profit is part of why iatrogenic death is happening at a faster rate. Another thing when we talk from a conflict perspective is we're gonna take a look at social class. Social class affects health. It affects health at all social class levels. There are some things that are more prevalent among higher socioeconomic levels than lower socioeconomic levels. And there's a lot more things that are prevalent among lower socioeconomic levels than above high socioeconomic levels. Like asthma is a poor kid's disease. The majority of people who have asthma attacks in this country are impoverished children. So highest rate is what I'm saying. Of incident is among children living in poverty. Now, the most obvious reason for this is that poorer neighborhoods are near pollutants. They live in worse housing that will be dusty, that'll have industrial stuff in it, that's older, right? All of these pollutants, irritants and allergens are what stimulate asthma, what trigger asthma. So they're more likely to run into the triggers. But there is a definite, so I'm not giving you a cause and effect, right? Remember, correlation does not equal cause and effect. If you walk away from anything in this course, I hope you walk away with that, okay? Correlation does not equal cause and effect. But it does predict things. And from an epidemiological point of view, it's not a bad thing to know. So if you look at a population and you see a prevalent of a certain disease in that population, you need to start asking why? What's going on? See, one of the ways that we can fight illness in this country is to fight poverty. Not because it's the cause of the illness, but it's the cause of the things that cause the illness. Right? So if you begin to make, if you begin to have more income equality, better access to healthcare, you will see less disparity and healthcare outcomes according to social class. One of the possible reasons that poor people have more health problems, especially if we're looking at metabolic disorders, like why is it that poor people have more incidences of diabetes, high blood pressure, heart disease, those kind of things? There's some interesting research and if you online wanna click to stigma and health, and for the people who see it on YouTube, it'll be in the description. If you see it on just Canvas, it'll be in the slides that you have here. That'll take you to some articles about something called cytokines. Everybody has cytokines in their body. It's a kind of enzyme, enzyme hormone, enzyme, I think. If I'm wrong about the chemistry, I apologize. It'll tell you in the article, whether it's pretty sure it's an enzyme and not a hormone, but it's naturally occurs in everybody's body, okay? But they are finding that stigmatized populations have higher content of cytokines. And more importantly, that if you have too much cytokines running around in your blood, in your body, you are more prone to diabetes, hypothyroidism, hypertension, high cholesterol, all of these metabolic disorders. So this might be the explanation as to why stigmatized populations have higher incidences of these things. So the question now is, is there something about being stigmatized socially that stimulates overproduction of cytokines? The stress of dealing with a stigmatized status. Fascinating stuff. This is very early. I mean, there's probably only, last time I looked, which was a little over a year ago, there was only about 10 studies right now. So I'm not telling you this is a done deal science-wise, but it's an interesting area to look at because we've loaned for a long time that stigma and health are related. That people who suffer under different stigmatizations have worse health outcomes, have higher incidences of disease and so forth, and nobody's really sure why, right? So this is beginning to get at that. There are some other reasons possibly, right? One of them is access, right? And we certainly see that people who are very poor, who have access, have better health outcomes than working poor people, people who have not had access. In fact, there's a nice little natural experiment that occurred in Oregon. They had more people who qualified for Medicaid, but they didn't have enough money to cover everybody. So they held a lottery. All these people applied, it turned out that there was about twice as much people who then they could cover. So instead of first come, first serve, what they said is, okay, everybody goes into the pool and at random we will pick whether or not you get the Medicaid. Okay, nobody would ever want to do this in a like lab situation, but what they essentially just set up was a control group and an experimental group, right? And they did it at random, which is the most beautiful way to do it in science. So they did it because of economic reasons, but some very bright researchers said, whoa, can we study you while you're doing this? You know, let's see what's going on here. So they did, they followed people who ended up in the non-covered group and people who ended up in the covered group. Now these people were people who randomly chosen into one group or the other. They all were at the same socioeconomic level. They all had similar family compositions, right? Because they all qualified for this program. So they followed them for the next two years and guess what? They demonstrated that if you have access to healthcare, you have better health. That seems like a duh thing, but nobody had ever been able to show that from an evidential point of view before, right? They were able to gather evidence and really show, you know, these people are healthier than these people. This is why we need coverage. This is why we need access. Why would access affect it? Because early intervention leads to better health come, health outcome, right? So if you don't have access to healthcare, you don't go to the doctor early. You put it off as long as possible. You put it off as long as possible. The cancer is already, you know, spread. The disease, the infection is already in your lungs, et cetera, et cetera. You have worse health outcomes. So that's why access might explain this as well. Especially when we've looked at like the poorest of the poor who qualify for Medicaid and the working poor who have not traditionally qualified for insurance and the poorest are actually having better health outcomes because they have access. So that also suggests that access is key. Working the system, because we have this for-profit system, we've got people who are trying to work the system, right? In conflict, you worry about power, and there are power differentials in this. Some people can afford it. Some people can't, right? So you gotta figure out how to get your healthcare. One of the ways you do it is emergency rooms. Emergency rooms are full in the United States of screaming little kids who have bronchitis. While to the parent, it may feel like an emergency. That's not really an emergency. Like if you had a doctor, you would just take him to the doctor and it would be cared for. You don't need to have immediate care for it in a big facility. But the reason they go there is that this is the only place in the United States that you can walk in the door and not have to have money in order to get your kid cared for. So it works the system. They go in there knowing that they're not going to pay or be able to pay. But they can't go to urgent care because urgent care costs you what? $150 just to walk in the door. Lots of people can't afford them. That has created a big problem with emergency rooms across the country. Emergency rooms across the country are overrun and they make more mistakes because of that. Of course, getting medications across borders. I just got some pills this week from India that were manufactured in Turkey that I bought through Canada. It's an international world. And I have insurance but I still do it because my insurance doesn't, this stuff costs like $300 a month here. And we got it for three months worth for 70 bucks doing that. That's the difference. So what is that, $900 versus $70? Duh, I think I'll do it. Anybody ever gone to Mexico for prescription drugs? Let me qualify that. I did it one time. I walked across the border at Negales. It's very simple. Unless you're trying to take narcotics out, like you're not gonna get across the border with morphine or hydrocodone or something like that, but I went and got asthma puffers and just declare it. The rules say that you're supposed to have a script and then go see a Mexican doctor and get a script and all that stuff. But if you read on the internet, they don't actually ever ask because the border guards are so scared that somebody's gonna die because they didn't let them take their medicine back, that if you just declare it, they'll say cool. So I just said, yeah, I've got three puffers and they said why? And I said, because I have asthma and they said, okay. And that's all that happened. You don't wanna not declare it. That's when you get into a lot of trouble. If you try to smuggle it across, but they didn't ask for any proof, I didn't have any script at all. The pharmacy, the pharmacy is they'll give it to you no matter what. But when you come across the border, you're supposed to be able to produce prescriptions, but they never asked for them, right? So, and then of course I ordered from Canada online. Medicaid, a lot of people work the system by hiding income, right? Not telling the government all the money that they make and all because they know if they make too much money, suddenly their kids are not insured anymore. And of course we have alternative healthcare. People get on the internet. If you're like me, you get on there. Like I had this weird kind of smell that I was smelling all the time. I couldn't figure out, I couldn't get this wood smell out of my nose. So that is a symptom of a brain tumor. So like for about a half an hour after reading this on the internet, I was scared I had a brain tumor. This is a, then I figured out that I was putting nasal stuff in and it was the smell of the nasal stuff. And I stopped taking it, the smell went away. So, but anyway, you know, this is, I mean, lots and lots of people get on and do that. If you're chronically ill, this is especially true because the physicians are not well equipped for dealing with you with chronic illness. So there are lots of support groups and people who put information on the net and it's not unusual anymore. There's a lot of JAMA articles about patients bringing information in from the internet and asking questions of their doctors. I've already talked about osteopoeia, so this'll be a quick one. The social construction, all illnesses and diseases are socially constructed. Did you hear what I said? All illnesses and diseases. We have physical phenomenon. Some of that physical phenomenon we call illness, some of it we call just getting old, right? Some of it we call people are different. What we decide is an illness or getting old or just variation is up to us. Different cultures define illness different ways. Different cultures have different ideas about treatments. They have different ideas about what is health. They have different ideas about what is disease, right? And I'm not just talking about differences like whether or not you have a shaman who treats you or not. I'm talking about allopathic medical differences, right? The way they train their doctors, the way they think about diseases. These things get developed in a bunch of different ways. The profit motive is part of it, but so is patient demand, right? Alzheimer's disease is a good example of this. Alzheimer's disease when it first was discovered by Alzheimer, right? And that's why it was called, was early dementia. It was accepted then that if you lived to be 70 or older, you were gonna go a little off in the head. But if you were 50 and you started going a little off in the head and suffer from dementia, then you had Alzheimer's. And they started looking at why is it that people had it early. In the 1970s and 80s, without any research at all, the baby boomers who were then taking care of their elderly parents started saying, well, why is it acceptable to get this way? So they started lobbying for Alzheimer's to be a broader category. And they succeeded. These patient groups and patient advocate groups did this. Nobody went into the lab, right? So now the diagnosis of Alzheimer's is unexplained dementia, right? You get dementia from a bunch of different things. My father died of liver disease and he had dementia for the last three or four weeks of his life. Because as the liver begins to deteriorate, so you don't get enough nutrients to your brain. So there are lots of things, brain tumors, low blood sugar will make you have dementia for a little bit, right? Certain medications. So there are all sorts of reasons why you might have symptoms of dementia. If they eliminate all the things that could explain it, they call it Alzheimer's. And it's chronic. They call it Alzheimer's. That's the diagnosis. That's a socially constructed diagnosis. And the truest were idea of social because that was patient advocate groups calling for that. And then we talked about the osteopenia, right? The hangout in Italy in a room and come up with a diagnosis. All right, then I also wanna mention real quick is that a constructionist view of this question, of the single payer plan, would not look at it as a conflict debate or a functionalist debate, right? The way we looked at it earlier, but it would start looking at the question of social problems construction, right? This was an unsuccessful social problems claim that we needed single payer coverage. It got introduced from 2000 to 2009 every year that 30 pages that they started out with was introduced in Congress every year from 2000 to 2009. It was a very simple thing, but it wasn't successful. It wasn't successful because they couldn't get past the if debate. Remember social problems claims require you to demonstrate two things initially. That it's a problem, okay? And that it is a public issue. The debate in the United States has been whether or not it's a private problem, a personal problem, or a public issue. When every other country in the world has addressed universal healthcare, the question has been, how do we do it? In the United States, the question has been, should we do it, right? The opposition to it is making the argument that this is a personal problem. Between you and your employer, whether you get insurance, it's between you and your doctor, how you pay for it, this should not be a public issue. So the constructionist point of view gives us an understanding of this debate. Does that make sense? Right, it gives us a way to think about why isn't this working? It's not working because they can't get past convincing half of the country that it is a public problem. There's a pretty good case for it being a public problem. Diseases don't care whether you have insurance or not when they spread, right? Germs are pretty social. So it makes sense that treating germs ought to be social as well, right? But there are other ways to construct it. And that's where we're at on that. So let's do some reviewing of what we've learned in this presentation. We took different analyses of American medicine from the three different paradigms in sociology, functionalism, conflict theory, constructionism. And some of the things that we reviewed in this were the sick role. It has with it a very privileged status. And as most functionalists would be concerned with, there are a certain set of norms and sanctions that support that role. Basically, it boils down to if you are sick, you are given certain privileges, and you get to keep those privileges as long as you are trying to get well, which brings in the second role in this little scenario. And that is the healthcare provider who serves as the gatekeeper. The one who writes you a note or gives you instructions and everybody knows that you're trying to get well because you are following the healthcare provider's advice. We also looked at latent and manifest functions. A manifest function is something that is explicitly expressed as the purpose for an organization or for an activity. A latent function are things that are supported or that support the organization or the activity, but are not expressed directly. Latent functions are often more powerful than manifest functions because they often involve profit, prestige, things that people are not as willing to give up as easily. We discussed the pharmaceutical industrial complex. And within that, in the same way that the military industrial complex works, we talked about what is called the technological imperative. Basically, it boils down to if we build something, there is pressure to actually use it. And this is fine when what we build is good technology that supports and helps people, but when it is technology that doesn't work or that destroys more than it builds up, it becomes a very dangerous imperative. We also talked about social class. Socioeconomic levels is a predictor of health. We discussed also that correlation is not the same as causation. Social class is a good predictor because it is correlated with different aspects of health, though it may not necessarily be the cause of either health or illness. But it is true that socioeconomic position in society is highly correlated with different health outcomes, with different disease incidences and so forth. And so it becomes an important aspect, especially in epidemiology for understanding why certain diseases exist and why they spread and how to address public health issues. Closely related to that is the idea of stigmatization, which is also a predictor of health. Populations that are stigmatized, if you call stigmatization, is a group of people that are marked socially as being less than or different from the so-called normal population. And groups that are stigmatized oftentimes have more health issues and there is a strong correlation between stigmatization and health. Again, not a correlation is not causation. We talked about the power of the powerless. When we look at questions of how power works, we know that power is cooperative, that powerful people have their power because other people do what they are asked to do and cooperate with that power, often under coercive situations in which their choices are very limited. But as a powerless group, oftentimes people figure out ways to get what they want anyway, usually by doing something called working the system and working the system can involve sort of sins of omission where you don't let those who are in power know certain pieces of information. It can also involve going outside the system and trying to find other methods to get what you want. And certainly we saw that this applied in questions of inequality and health access. We talked about how all diseases and illnesses and even health are socially constructed. This doesn't mean that the physical phenomenon is not real. It's how we interpret the physical phenomenon is a matter of our culture. It's a matter of the time and place that we are doing this. It changes over time within a particular culture and there can be variances among cultures and how illness is defined, what is a disease, what is not a disease, what is considered healthy, what is not considered healthy and so forth. And then finally, also for a constructionist point of view, we talked about social problems claims making, specifically that one of the first requirements in social problems claims making is to demonstrate that something is not just a personal problem, but is actually a public issue. It's not enough to demonstrate that there is a problem but we must also demonstrate that it is social. And we talked about this and the failure to successfully get single payer healthcare in the United States. So if you look below here in the YouTube, you can check out references that I've put there to different things that we talked about in here. If you wanna go to further information, there are some links to specific words and vocabulary that will help you out. And so be sure to check out not just the video but also the doobly-doo. And thank you for watching.