节: 卫生卫生卫生卫生 | 11.3. 卫生

章节大纲

Objectives
::目标目标目标和目标目标目标目标目标

Describe the nature of health care in the United States.
::说明美国保健的性质。

Describe and explain some of the special health-care concerns of various segments of American society.
::描述并解释美国社会各阶层的一些特殊保健问题。

Universal Generalizations
::普遍化

For Americans the top ten priorities are health care concerns.
::对美国人来说,十大优先事项是保健问题。

In the United States, Americans spend a higher percentage of its gross domestic product (GDP) on health care than any other nation in the world.
::在美国,美国人在保健方面的开支占其国内生产总值(国内总产值)的百分比高于世界上任何其他国家。

Managed care has brought down medical costs.
::管理下的护理降低了医疗费用。

The inability to get insurance contributes to more serious medical problems among the poor.
::无法获得保险加剧了穷人中更为严重的医疗问题。

Guiding Questions
::问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问问

What are the main issues about health care in the United States?
::美国保健方面的主要问题是什么?

What has caused the rapid rise in health care costs in the United States?
::是什么导致美国保健费用迅速上升?

Why are the costs of prescription drugs rising so rapidly?
::为什么处方药的成本如此迅速上升?

What effects has Medicare and Medicaid had on the U.S. society and economy?
::医疗保健和医疗补助对美国社会和经济有何影响?

Explain the ways in which poor people suffer disproportionately from healthcare problems.
::解释穷人在保健问题上遭受不成比例痛苦的方式。

HEALTH AND THEORETICAL PERSPECTIVES

refers to the extent of a person’s physical, mental, and social well-being. This definition, taken from the World Health Organization’s treatment of health, emphasizes that health is a complex concept that involves not just the soundness of a person’s body but also the state of a person’s mind and the quality of the social environment in which she or he lives. The quality of the social environment in turn can affect a person’s physical and mental health, underscoring the importance of social factors for these twin aspects of our overall well-being.
::健康是一个复杂的概念,它不仅涉及一个人身体的健全性,而且涉及一个人的心智状况以及他或她所生活的社会环境的质量。社会环境的质量反过来又会影响一个人的身心健康,强调社会因素对于我们整体福祉的这两个方面的重要性。

is the social institution that seeks both to prevent, diagnose, and treat illness and to promote health as just defined. Dissatisfaction with the medical establishment has been growing. Part of this dissatisfaction stems from soaring health-care costs and what many perceive as insensitive stinginess by the health insurance industry, as the 2009 battle over health-care reform illustrated. Some of the dissatisfaction also reflects a growing view that the social and even spiritual realms of human existence play a key role in health and illness. This view has fueled renewed interest in alternative medicine. We return later to these many issues for the social institution of medicine.
::社会机构既寻求预防、诊断和治疗疾病,也寻求按照上述定义促进健康; 对医疗机构的不满日益加剧,部分不满来自保健费用飞涨,以及许多人认为健康保险业的麻木不仁,正如2009年保健改革斗争所表明的那样;有些不满还反映出人们日益认为,人类存在的社会甚至精神领域在健康和疾病方面发挥着关键作用;这种看法激发了人们对替代药物的兴趣;我们后来又回到了社会医学体制的许多问题。

The Sociological Approach to Health and Medicine
::健康和医学的社会学方法

The fact that our social backgrounds affect our health may be difficult for many of us to accept. We all know someone, and often someone we love, who has died from a serious illness or currently suffers from one. There is always a “medical” cause of this person’s illness, and physicians do their best to try to cure it and prevent it from recurring. Sometimes they succeed; sometimes they fail. Whether someone suffers a serious illness is often simply a matter of bad luck or bad genes: we can do everything right and still become ill. In saying that our social backgrounds affect our health, sociologists do not deny any of these possibilities. They simply remind us that our social backgrounds also play an important role (Cockerham, 2009). Cockerham, W. C. (2009). Medical sociology (11th ed.). Upper Saddle River, NJ: Prentice Hall.
::我们的社会背景影响着我们的健康,这一事实对我们许多人来说可能很难接受。我们都认识某个人,而且往往是我们所爱的人,他死于严重疾病或目前患有这种疾病。这个人的疾病总是有“医疗”原因的,医生也尽力设法治愈,防止其复发。他们有时成功;有时失败。一个人是否患重病,往往是不幸或坏基因的问题:我们可以做一切事情,现在仍然生病。说我们的社会背景影响着我们的健康,社会学家们并不否认任何这些可能性。他们只是提醒我们,我们的社会背景也发挥着重要作用(Cockerham,2009年;Cokkerham,2009年;医疗社会学(第11版) 。上萨德尔河,NJ:Prentice Hall。

A sociological approach also emphasizes that a society’s culture shapes its understanding of health and illness and practice of medicine. In particular, culture shapes a society’s perceptions of what it means to be healthy or ill, the reasons to which it attributes illness, and the ways in which it tries to keep its members healthy and to cure those who are sick (Hahn & Inborn, 2009). Hahn, R. A., & Inborn, M. (Eds.). (2009). Anthropology and public health: Bridging differences in culture and society (2nd ed.). New York, NY: Oxford University Press. Knowing about a society’s culture, then, helps us to understand how it perceives health and healing. By the same token, knowing about a society’s health and medicine helps us to understand important aspects of its culture.
::一种社会学方法还强调,一个社会文化决定着它对健康和疾病以及医学实践的理解。特别是,文化决定着一个社会对健康或疾病的意义、疾病的原因、疾病的原因、以及它试图保持其成员健康和治疗病人的方式的认识(Hahn & Inborn,2009年,Hahn,R.A. & Inborn,M. (Eds.) (2009年)。人类学和公共卫生:弥合文化和社会差异(第2版 ) 。纽约:牛津大学出版社。了解一个社会的文化,从而帮助我们了解它如何看待健康和治愈疾病。同样,了解一个社会的健康和医学有助于我们理解其文化的重要方面。

A sociological approach emphasizes that our social class, race and ethnicity, and gender, among other aspects of our social backgrounds, influence our levels of health and illness.
::社会学方法强调,我们的社会阶级、种族和族裔以及性别,以及我们社会背景的其他方面,影响我们的健康和疾病水平。

An interesting example of culture in this regard is seen in Japan’s aversion to organ transplants, which are much less common in that nation than in other wealthy nations. Japanese families dislike disfiguring the bodies of the dead, even for autopsies, which are also much less common in Japan than other nations. This cultural view often prompts them to refuse permission for organ transplants when a family member dies, and it leads many Japanese to refuse to designate themselves as potential organ donors (Sehata & Kimura, 2009; Shinzo, 2004). Sehata, G., & Kimura, T. (2009, February 28). A decade on, organ transplant law falls short. The Daily Yomiuri [Tokyo], p. 3; Shinzo, K. (2004). Organ transplants and brain-dead donors: A Japanese doctor’s perspective. Mortality, 9 (1), 13–26.
::日本在这方面的一个令人感兴趣的文化例子可见于日本对器官移植的厌恶,器官移植在该国比其他富裕国家要少得多。日本家庭不喜欢对死者的尸体进行修饰,甚至对尸体的解剖也是如此,日本的解剖也比其他国家要少得多。这种文化观点往往促使他们拒绝在家庭成员死亡时允许器官移植,导致许多日本人拒绝指定自己为潜在的器官捐赠者(Sehata & Kimura,2009年;Shinzo,2004年;Sehata,G.和Kimura,T.,(2009年,2月28日 ) 。器官移植法十年时间短了。《Yomiuri日报》[东京],第3页;Shinzo,K.(2004年)。器官移植和脑死亡捐赠者:日本医生的观点。死亡率,9(1),13-26。

A society’s culture matters in these various ways, but so does its social structure, in particular its level of economic development and extent of government involvement in health-care delivery. Poor societies have much worse health than richer societies. At the same time, richer societies have certain health risks and health problems, such as pollution and liver disease (brought on by high alcohol use), that poor societies avoid. The degree of government involvement in health-care delivery also matters: the United States lags behind many Western European nations in several health indicators, in part because the latter nations provide much more national health care than does the United States. Although illness is often a matter of bad luck or bad genes, the society we live in can nonetheless affect our chances of becoming and staying ill.
::一个社会的文化从这些不同方面都很重要,但其社会结构,特别是其经济发展水平和政府参与提供保健服务的程度也同样重要。贫穷社会的健康比富裕社会差得多。与此同时,较富裕社会有某些健康风险和健康问题,如污染和肝病(因高酒精使用而深受其害 ) , 贫穷社会避免了这些风险和问题。政府参与提供保健服务的程度也很重要:在几个健康指标方面,美国落后于许多西欧国家,部分原因是后者提供的国家保健服务远远多于美国。虽然疾病往往是坏运气或坏基因的问题,但我们所生活的社会仍然可以影响我们患病和患病的机会。

Sociological Perspectives on Health and Medicine
::健康和医学的社会学观点

The major sociological perspectives on health and medicine all recognize these points but offer different ways of understanding health and medicine that fall into the functional, conflict, and symbolic interactionist approaches. Together they provide us with a more comprehensive understanding of health, medicine, and society than any one approach can do by itself (Cockerham, 2009). Cockerham, W. C. (2009). Medical sociology (11th ed.). Upper Saddle River, NJ: Prentice Hall. summarizes what they say.
::有关健康和医学的主要社会学观点都承认了这些观点,但提供了不同的理解健康和医学的方法,这些方法都属于功能、冲突和象征性的互动主义方法。它们共同为我们提供了比任何一种方法本身都更全面的健康、医学和社会理解(Cockerham,2009年,Cockerham,W.C.(2009年),医疗社会学(第11版),上萨德尔河,NJ:Prentice Hall.总结了它们所说的话。

Theory Snapshot

Theoretical perspective	Major assumptions
Functionalism	Good health and effective medical care are essential for the smooth functioning of society. Patients must perform the “sick role” in order to be perceived as legitimately ill and to be exempt from their normal obligations. The physician-patient relationship is hierarchical: the physician provides instructions, and the patient needs to follow them.
Conflict theory	Social inequality characterizes the quality of health and the quality of health care. People from disadvantaged social backgrounds are more likely to become ill and to receive inadequate health care. Partly to increase their incomes, physicians have tried to control the practice of medicine and to define social problems as medical problems.
Symbolic interactionism	Health and illness are social constructions : Physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society. Physicians “manage the situation” to display their authority and medical knowledge.

U.S. Health Care and the Industrial World
::美国保健和工业世界

Medicine in the United States is big business. Expenditures for health care, health research, and other health items and services have risen sharply in recent years, having increased tenfold since 1980, and now costs the nation more than $2.6 trillion annually (see ). This translates to the largest figure per capita in the industrial world. Despite this expenditure, the United States lags behind many other industrial nations in several important health indicators, as we have already seen. Why is this so?
::美国的医学是大生意,近年来用于保健、保健研究和其他保健项目及服务的支出急剧上升,自1980年以来增长了十倍,现在每年耗资超过26万亿美元(见 ) 。这相当于工业世界人均最高数字。尽管如此,美国在一些重要的健康指标方面落后于许多其他工业国家,我们已经看到。为什么如此呢?

U.S. Health-Care Expenditure, 1980–2010 (in Billions of Dollars)
::1980-2010年美国保健支出(单位:10亿美元)

Source: Data from U.S. Census Bureau. (2010). Statistical abstract of the United States: 2010 . Washington, DC: U.S. Government Printing Office. Retrieved from .
::资料来源:美国人口普查局数据(2010年),《美国统计摘要:2010年》,华盛顿特区:美国政府印刷局。

The U.S. Health-Care Model
::美国保健模式

Other Western nations have national systems of health care and health insurance. In stark contrast to these nations, the United States relies on a , in which patients are expected to pay for medical costs themselves, aided by private health insurance , usually through one’s employer. Table shows the percentages of Americans who have health insurance from different sources or who are not insured at all. (All figures are from the period before the major health-care reform package was passed by the federal government in early 2010.) Adding together the top two figures in the table, 57% of Americans have private insurance, either through their employers or from their own resources. Almost 28% have some form of public insurance (Medicaid, Medicare, other public), and 15.4% are uninsured. This final percentage amounts to about 46 million Americans, including 8 million children, who lack health insurance. Their lack of health insurance has deadly consequences because they are less likely to receive preventive health care and care for various conditions and illnesses. It is estimated that 45,000 people die each year because they do not have health insurance (Wilper et al., 2009). Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health, 99 (12), 1–7.
::其他西方国家都有国家医疗保健和医疗保险体系。与这些国家形成鲜明对比的是,美国依赖一种由私人医疗保险(通常通过雇主)帮助、由私人医疗保险(通常通过雇主)帮助的病人自己支付医疗费用的系统。表显示了从不同来源获得医疗保险或完全没有保险的美国人的百分比。 (所有数字都来自联邦政府在2010年初通过重大医疗保健改革一揽子计划之前的时期 ) , 加上表中的前两个数字,57%的美国人通过雇主或自有资源获得私人保险。近28 % 有某种形式的公共保险(医疗保险、医疗保险、其他公共医疗保险),还有15.4%没有保险。最后这一百分比达到大约4 600万美国人,包括800万儿童,他们没有医疗保险。他们缺乏医疗保险会造成致命的后果,因为他们不太可能获得预防性医疗保健以及各种条件和疾病的护理。据估计,每年有45 000人死于公共保险,因为他们没有医疗保险(Wilper et al.,2009年)。 Wilper, A. P., Woickler, D. D. D., Hisal, Hisal, H. S. D. D., H. Ser., D.

Health Insurance Coverage in the United States, 2008
::2008年美国医疗保险覆盖率

Employer	52.3%
Individual	4.7%
Medicaid	14.1%
Medicare	12.4%
Other public	1.2%
Uninsured	15.4%

Source: Data from Kaiser Family Foundation. (2010). Kaiser state health facts. Retrieved from .
::资料来源:Kaiser家庭基金会的数据(2010年),Kaiser州健康事实,检索自。

Although almost 28% of Americans do have public insurance, this percentage and the coverage provided by this insurance do not begin to match the coverage enjoyed by the rest of the industrial world. Although Medicare pays some medical costs for the elderly, we saw in that its coverage is hardly adequate, as many people must pay hundreds or even thousands of dollars in premiums, deductibles, coinsurance, and copayments. The other government program, Medicaid, pays some health-care costs for the poor, but many low-income families are not poor enough to receive Medicaid. Eligibility standards for Medicaid vary from one state to another, and a family poor enough in one state to receive Medicaid might not be considered poor enough in another state. The State Children’s Health Insurance Program (SCHIP), begun in 1997 for children from low-income families, has helped somewhat, but it, too, fails to cover many low-income children. Largely for these reasons, about two-thirds of uninsured Americans come from low-income families.
::尽管近28%的美国人确实拥有公共保险,但这一百分比和这一保险提供的保险范围与工业世界其他部分享有的保险范围并不相称。尽管医疗保险支付一些老年人的医疗费用,但我们从中看到,其覆盖面几乎不够,因为许多人必须支付数百甚至数千美元的保险费、可扣除的、共同保险和共同支付。另一个政府方案 — — MedicAid — — 为穷人支付一些医疗费用,但许多低收入家庭还不足以获得医疗补助。医疗补助的资格标准因州而异,一个州足以领取医疗补助的家庭可能被认为不够贫穷。 1997年开始为低收入家庭儿童实施的国家儿童健康保险计划(SCHIP)也帮了一定的忙,但它也未能覆盖许多低收入儿童。在很大程度上,由于这些原因,大约三分之二没有保险的美国人来自低收入家庭。

Not surprisingly, the 15.4% uninsured rate varies by race and ethnicity (see ). Among people under 65 and thus not eligible for Medicare, the uninsured rate rises to almost 21% of the African American population and 32% of the Latino population. Moreover, 45.3% of adults under 65 who live in official poverty lack health insurance, compared to only about 6% of high-income adults (those with incomes higher than 4 times the poverty level). Almost one-fifth of poor children have no health insurance, compared to only 3.5% of children in higher-income families (Kaiser Family Foundation, 2010). Kaiser Family Foundation. (2010). Kaiser state health facts. Retrieved from As discussed earlier, the lack of health insurance among the poor and people of color is a significant reason for their poorer health.
::不足为奇的是,15.4%的无保险率因种族和族裔而异(见)。在65岁以下因而没有资格享受医疗保险的人中,无保险率上升到非洲裔美国人的近21%和拉美人人口的32%。此外,65岁以下正式贫困的成年人中,45.3%没有医疗保险,而高收入成年人中只有6%左右(收入高于贫困水平4倍以上 ) , 几乎五分之一的贫困儿童没有医疗保险,而高收入家庭的儿童中只有3.5%没有医疗保险(Kaiser家庭基金会,2010年)。 Kaiser家庭基金会(2010年),Kaiser家庭基金会(2010年),Kaiser州卫生事实。如前所述,穷人和有色人缺乏医疗保险是他们健康状况较差的重要原因。

Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage With No Insurance)
::种族、种族、族裔和缺乏健康保险,2008年(无保险百分比)

Source: Data from Statehealthfacts.org. (2010). Uninsured rates for the nonelderly by race/ethnicity, states (2007–2008), U.S. (2008). Retrieved from .
::资料来源:来自国家健康信息中心(2010年)的数据,按种族/族裔分列的未保险非老年死亡率,各州(2007-2008年),美国(2008年)。

Issues in U.S. Health Care
::美国保健问题

The lack of insurance of so many Americans is an important health-care issue, but other issues about health care also seem to make the news almost every day. We examine a few of these here.
::如此多美国人缺乏保险是一个重要的保健问题,但其他保健问题似乎也几乎每天都有这样的新闻。我们在这里研究其中的几个。

Managed Care and HMOs
::管理下的护理和HMO

To many critics, a disturbing development in the U.S. health-care system has been the establishment of , or HMOs, which typically enroll their subscribers through their workplaces. HMOs are prepaid health plans with designated providers, meaning that patients must visit a physician employed by the HMO or included on the HMO’s approved list of physicians. If their physician is not approved by the HMO, they either have to see an approved physician or see their own without insurance coverage. Popular with employers because they are less expensive than traditional private insurance, HMOs have grown rapidly in the last three decades and now enroll more than 70 million Americans (see ).
::对许多批评家来说,美国保健系统的一个令人不安的发展是建立或HMO,通常通过他们的工作场所注册其订户。 HMO是指定供应商的预付医疗计划,这意味着病人必须看HMO雇用的医生或列入HMO核准的医生名单。如果他们的医生没有得到HMO的核准,他们要么必须看核准的医生,要么必须看自己的医生,没有保险。与雇主相比,HMO比传统的私人保险要便宜,因此,HMO在过去30年中迅速增长,现在有7000多万美国人登记(见 ) 。

Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of Enrollees)
::1980-2007年保健维持组织增长情况(百万人)

Although HMOs have become popular, their managed care is also very controversial for at least two reasons (Kronick, 2009). Kronick, R. (2009). Medicare and HMOs—the search for accountability . New England Journal of Medicine , pp. 2048–2050.
::虽然健康管理组织已经很受欢迎,但其管理下的护理也非常有争议,原因至少有两个(Krnick,2009年);Krnick,R.(2009年);Medicare和健康管理组织——寻求问责制。新英格兰医学杂志,第2048-2050页。

Retrieved from The first is the HMOs’ restrictions just noted on the choice of physicians and other health-care providers. Families who have long seen a family physician but whose employer now enrolls them in an HMO sometimes find they have to see another physician or risk going without coverage. In some HMOs, patients have no guarantee that they can see the same physician at every visit. Instead, they see whichever physician is assigned to them at each visit. Critics of HMOs argue that this practice prevents physicians and patients from getting to know each other, reduces patients’ trust in their physician, and may for these reasons impair patient health.
::从头到尾都是HMO限制医生和其他保健提供者的选择。长期看家庭医生但雇主现在将他们送入HMO的家庭有时不得不看另一个医生或冒着没有保险的风险。在一些HMO中,病人无法保证每次看医生都能看同一个医生。相反,他们在每次看医生时都看到他们被指派给他们的医生。健康MO的批评者认为,这种做法妨碍医生和病人相互了解,降低病人对医生的信任,并可能因此损害病人的健康。

The second reason for the managed-care controversy is perhaps more important. HMOs often restrict the types of medical exams and procedures patients may undergo, a problem called denial of care , and limit their choice of prescription drugs to those approved by the HMO, even if their physicians think that another, typically more expensive drug would be more effective. HMOs claim that these restrictions are necessary to keep medical costs down and do not harm patients.
::管理下的治疗争议的第二个原因也许更为重要。健康管理组织经常限制病人可能接受的医疗检查和手术类型,这是一个被称作拒绝护理的问题,他们选择处方药仅限于由健康管理组织批准的处方药,即使他们的医生认为另一种通常更昂贵的药物会更有效。健康管理组织声称这些限制对于降低医疗费用而不是伤害病人是必要的。

Several examples of the impact of managed care’s denials of coverage and/or care exist. In one case, a woman with a bone spur on her hip had successful arthroscopic surgery instead of open hip surgery, the more common and far more expensive procedure for this condition. When her insurance company denied coverage for her arthroscopic surgery, the patient had to pay doctor and hospital fees of more than $21,000. After a lengthy appeal process, the insurance company finally agreed to pay for her procedure (Konrad, 2010). Konrad, W. (2010, February 5). Fighting denied claims requires perseverance. The New York Times , p. B6. In a more serious case a decade ago, a 22-year-old woman died after going to a physician several times in the preceding week with chest pain and shortness of breath. She was diagnosed with a respiratory infection and “panic attacks” but in fact had pneumonia and a blood clot in her left lung. Her physician wanted her to have lab tests that would have diagnosed these problems, but her HMO’s restrictions prevented her from getting the tests. A columnist who wrote about this case said that “an unconscionable obsession with the bottom line has resulted in widespread abuses in the managed-care industry. Simply stated, there is big money to be made by denying care” (Herbert, 1999, p. A25). Herbert, B. (1999, July 15). Money vs. reform. The New York Times , p. A25.
::管理下护理拒绝覆盖和(或)护理的影响有几个例子。在一个例子中,一位臀部骨骨刺骨部的妇女成功接受了动脉手术,而不是开放的臀部外科手术,这更常见、更昂贵的手术程序。当她的保险公司拒绝其动脉外科手术的保险时,病人不得不支付超过21 000美元的医生和医院费用。经过漫长的上诉过程后,保险公司终于同意支付她的手术费(Konrad, 2010年)。Konrad, W. (2010年, 2月 ) 5 。战斗拒绝要求坚持。《纽约时报》,p. B. 6 10年前的一件更严重的案子中,一名22岁的妇女在上星期去看医生几次后死于胸部疼痛和呼吸短。她被诊断患有呼吸道感染和“精神攻击 ” 但实际上肺部有肺炎和血凝块。她的医生希望她进行实验室测试,诊断出这些问题,但HMO的限制阻止她接受测试。一位专栏作家在10年前写到这个案子,“Brbert 25 ” , “Brestal insmainal ormainal” (在1999年7月大的Alishal-ch) 导致了“Brest-ch-ch) rodustrisder) 。

Inequality and Health
::不平等与健康

Health by Race and Ethnicity
::按种族和族裔分列的按种族和族裔分列的健康状况

When looking at the social epidemiology of the United States, it is hard to miss the disparities among races. The discrepancy between black and white Americans shows the gap clearly; IN 2008, the average life expectancy for white males was approximately five years longer than for black males: 75.9 compared to 70.9. An even stronger disparity was found in 2007: the infant mortality rate for blacks was nearly twice that of whites at 13.2 compared to 5.6 per 1,000 live births (U.S. Census Bureau 2011). According to a report from the Henry J. Kaiser Foundation (2007), African Americans also have higher incidence of several other diseases and causes of mortality, from cancer to heart disease to diabetes. In a similar vein, it is important to note that ethnic minorities, including Mexican Americans and Native Americans, also have higher rates of these diseases and causes of mortality than whites.
::在看美国的社会流行病学时,很难忘记种族之间的差异。黑人和白人美国人之间的差异明显显示了这一差距;2008年,白人男性的平均预期寿命比黑人男性大约长5年:75.9比70.9。 2007年,发现差距更大:黑人的婴儿死亡率几乎是白人的两倍,为13.2比每1 000名活产儿的5.6(美国人口普查局,2011年)。根据Henry J. Kaiser基金会(2007年)的一份报告,非裔美国人从癌症到心脏病到糖尿病等其他几种疾病和死因的发病率也更高。同样,必须指出,少数民族,包括墨西哥裔美国人和土著美国人,这些疾病的发病率和死因也高于白人。

Lisa Berkman (2009) notes that this gap started to narrow during the Civil Rights movement in the 1960s, but it began widening again in the early 1980s. What accounts for these perpetual disparities in health among different ethnic groups? Much of the answer lies in the level of health care that these groups receive. The National Healthcare Disparities Report (2010) shows that even after adjusting for insurance differences, racial and ethnic minority groups receive poorer quality of care and less access to care than dominant groups. The Report identified these racial inequalities in care:
::Lisa Berkman(2009年)指出,在1960年代的民权运动期间,这一差距开始缩小,但在1980年代初又开始扩大。为什么不同族裔群体之间在健康方面长期存在差异?答案主要在于这些群体得到的保健水平。《国家保健差异报告》(2010年)显示,即使在调整了保险差异之后,种族和族裔少数群体得到的护理质量不如主要群体,获得护理的机会也比主要群体少。

Black Americans, American Indians, and Alaskan Natives received inferior care than Caucasian Americans for about 40 percent of measures
::黑人美国人、美国印第安人和阿拉斯加土著人在大约40%的措施中,得到了比高加索裔美国人低的照顾。

Asian ethnicities received inferior care for about 20 percent of measures
::约20%的措施为亚裔族裔提供了低级护理

Among whites, Hispanic whites received 60 percent inferior care of measures compared to non-Hispanic whites (Agency for Health Research and Quality 2010). When considering access to care, the figures were comparable.
::在白人中,西班牙裔白人比非西班牙裔白人(2010年健康研究和质量机构)得到的治疗措施低60%,在考虑获得治疗机会时,数字是可比的。

Health by Socio-Economic Status (SES)
::按社会经济状况分列的健康状况(SES)

Discussions of health by race and ethnicity often overlap with discussions of health by socioeconomic status, since the two concepts are intertwined in the United States. As the Agency for Health Research and Quality (2010) notes, “racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor,” so many of the data pertaining to subordinate groups is also likely to be pertinent to low socioeconomic groups. Marilyn Winkleby and her research associates (1992) state that “one of the strongest and most consistent predictors of a person's morbidity and mortality experience is that person's socioeconomic status (SES). This finding persists across all diseases with few exceptions, continues throughout the entire lifespan, and extends across numerous risk factors for disease.”

Many people who are poor or near-poor lack medical insurance and in other ways have inadequate health care. These problems make it more likely they will become ill and, once ill, less likely they will become well.
::许多穷人或近贫困的人没有医疗保险,在其他方面保健不足,这些问题使他们更容易生病,一旦生病,就更不可能康复。

A related reason for the poor health of poor people is unhealthy lifestyles, as just implied. Although it might sound like a stereotype, poor people are more likely to smoke, to eat high-fat food, to avoid exercise, to be overweight, and, more generally, not to do what they need to do (or to do what they should not be doing) to be healthy (Pampel, Krueger, & Denney, 2010; Cubbins & Buchanan, 2009). Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010, June). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36 , 349–370. doi:10.1146/annurev.soc.012809.102529; Cubbins, L. A., & Buchanan, T. (2009). Racial/ethnic disparities in health: The role of lifestyle, education, income, and wealth. Sociological Focus, 42 (2), 172–191. Scholars continue to debate whether unhealthy lifestyles are more important in explaining poor people’s poor health than factors such as lack of access to health care, stress, and other negative aspects of the social and physical environments in which poor people live. Regardless of the proper mix of reasons, the fact remains that the poor have worse health.

It is important to remember that economics are only part of the SES picture; research suggests that education also plays an important role. Phelan and Link (2003) note that many behavior-influenced diseases like lung cancer (from smoking), coronary artery disease (from poor eating and exercise habits), and AIDS initially were widespread across SES groups. However, once information linking habits to disease was disseminated, these diseases decreased in high SES groups and increased in low SES groups. This illustrates the important role of education initiatives regarding a given disease, as well as possible inequalities in how those initiatives effectively reach different SES groups.

Health by Gender
::按性别分类的保健情况

Women are affected adversely both by unequal access to and institutionalized sexism in the health care industry. According a recent report from the Kaiser Family Foundation, women experienced a decline in their ability to see needed specialists between 2001 and 2008. In 2008, one quarter of females questioned the quality of her health care (Ranji and Salganico 2011). In this report, we also see the explanatory value of intersection theory. Feminist sociologist Patricia Hill Collins developed this theory, which suggests we cannot separate the effects of race, class, gender, sexual orientation, and other attributes. Further examination of the lack of confidence in the health care system by women, as identified in the Kaiser study, found, for example, women categorized as low income were more likely (32 percent compared to 23 percent) to express concerns about health care quality, illustrating the multiple layers of disadvantage caused by race and sex.

Women more than men tend to have more health problems that are not life threatening. Two reasons for this gender difference are gender inequality in the larger society and the stress accompanying women’s traditional caregiving role in the family.
::与男性相比,女性的健康问题往往更多,对生命没有威胁,造成这种性别差异的有两个原因,一是整个社会的性别不平等,二是妇女在家庭中的传统照料角色所带来的压力。

We can see an example of institutionalized sexism in the way that women are more likely than men to be diagnosed with certain kinds of mental disorders. Psychologist Dana Becker notes that 75 percent of all diagnoses of Borderline Personality Disorder (BPD) are for women according to the Diagnostic Statistical Manual of Mental Disorders . This diagnosis is characterized by instability of identity, of mood, and of behavior, and Becker argues that it has been used as a catch-all diagnosis for too many women. She further decries the pejorative connotation of the diagnosis, saying that it predisposes many people, both within and outside of the profession of psychotherapy, against women who have been so diagnosed (Becker).

Many critics also point to the medicalization of women’s issues as an example of institutionalized sexism. Medicalization refers to the process by which previously normal aspects of life are redefined as deviant and needing medical attention to remedy. Historically and contemporaneously, many aspects of women’s lives have been medicalized, including menstruation, pre-menstrual syndrome, pregnancy, childbirth, and menopause. The medicalization of pregnancy and childbirth has been particularly contentious in recent decades, with many women opting against the medical process and choosing a more natural childbirth. Fox and Worts (1999) find that all women experience pain and anxiety during the birth process, but that social support relieves both as effectively as medical support. In other words, medical interventions are no more effective than social ones at helping with the difficulties of pain and childbirth. Fox and Worts further found that women with supportive partners ended up with less medical intervention and fewer cases of postpartum depression. Of course, access to quality birth care outside of the standard medical models may not be readily available to women of all social classes.

Complementary and Alternative Medicine (CAM)
::补充和替代药物(CAM)

As the medical establishment grew in the 19th and 20th centuries, it helped formulate many standards for medical care and training, including licensing restrictions that prevent anyone without a degree from a recognized medical school from practicing medicine. As noted earlier, some of its effort stemmed from well-intentioned beliefs in the soundness of a scientific approach to medical care, but some of it also stemmed from physicians’ desire to “corner the market” on health care, and thus raise their profits, by keeping other health practitioners such as midwives out of the market .
::随着医学机构在19世纪和20世纪的成长,医疗机构帮助制定了许多医疗和培训标准,包括许可证发放限制,禁止任何从公认的医学院没有学位的人从事医学活动。如前所述,医疗机构的某些努力源于对科学医疗方法的正确性怀有善意的信念,但其中的一些努力也源于医生希望 " 开拓市场 " 医疗保健,从而通过将助产士等其他保健从业者(如助产士)排除在市场之外来增加利润。

There is increased recognition today that physical health depends at least partly on psychological well-being. As the old saying goes, your mind can play tricks on you, and a growing amount of evidence suggests the importance of a sound mind for a sound body. Many studies have found that stress reduction can improve many kinds of physical conditions and that high levels of stress can contribute to health problems (B. W. Smith et al., 2010). Smith, B. W., Papp, Z. Z., Tooley, E. M., Montague, E. Q., Robinson, A. E., & Cosper, C. J. (2010). Traumatic events, perceived stress and health in women with fibromyalgia and healthy controls. Stress & Health: Journal of the International Society for the Investigation of Stress, 26 (1), 83–93.

::如今人们日益认识到,身体健康至少部分地取决于心理健康。俗话说,你的思想可以欺骗你,越来越多的证据表明身体健康的重要性。许多研究发现,减轻压力可以改善许多类型的身体状况,高压力会助长健康问题(B.W.Smith等人,2010年)。 Smith, B.W., Papp, Z.Z., Tooley, E.M., Montague, E.Q., Robinson, A.E., & Cosper, C.J.(2010年)。创伤事件,对患有纤维瘤症和健康控制的妇女感到的压力和健康。压力与健康:《压力与健康:国际压力调查学会杂志》,26(1),83-93。

Acupuncture is one of the many forms of alternative medicine. It is used by about 40% of Americans annually.
::针灸是多种替代药物的一种形式,每年约有40%的美国人使用针灸。

Evidence of a mind-body connection has fueled the growing interest in complementary and alternative medicine (CAM) that takes into account a person’s emotional health and can often involve alternative treatments such as acupuncture and hypnosis. In the last two decades, several major medical centers at the nation’s top universities established alternative medicine clinics. Despite the growing popularity of alternative medicine, much of the medical establishment remains skeptical of its effectiveness. Even so, about 40% of Americans use an alternative medicine product or service each year, and they spend about $34 billion per year on the various kinds of products and services that constitute alternative medicine (Wilson, 2009) Wilson, P. (2009). Americans spend $33.9 billion a year on alternative medicine. Consumer Reports Health Blog .
::精神-身体连接的证据刺激了人们对考虑到一个人的情感健康的辅助和替代药物(CAM)的日益浓厚的兴趣。补充和替代药物(CAM)常常涉及替代治疗,如针灸和催眠。在过去20年中,全国顶尖大学的几家主要医疗中心建立了替代医疗诊所。尽管替代药物越来越受欢迎,但大部分医疗机构仍然对其有效性产生怀疑。即便如此,大约40%的美国人每年使用替代药品或服务,他们每年花费大约340亿美元用于构成替代药物的各类产品和服务(Wilson,2009年;Wilson,2009年;P.2009年。美国人每年花339亿美元用于替代药物。 Consumer Reports Health Blog ) 。

Retrieved from (see ).
::取自(见.)。

Use of Selected Forms of Complementary and Alternative Medicine (CAM), 2007 (Percentage of U.S. Adults Using Each Form During Past Year)
::2007年《使用某些形式的补充和替代药物(CAM)》(美国成年人在过去一年中使用每种表格的百分比)

章节大纲

HEALTH AND THEORETICAL PERSPECTIVES

The Sociological Approach to Health and Medicine ::健康和医学的社会学方法

Sociological Perspectives on Health and Medicine ::健康和医学的社会学观点

Theory Snapshot

U.S. Health Care and the Industrial World ::美国保健和工业世界

The U.S. Health-Care Model ::美国保健模式

Issues in U.S. Health Care ::美国保健问题

Inequality and Health ::不平等与健康

Health by Socio-Economic Status (SES) ::按社会经济状况分列的健康状况(SES)

Other Problems in the Quality of Care ::护理质量方面的其他问题

Complementary and Alternative Medicine (CAM) ::补充和替代药物(CAM)