Engine and Brakes: European Welfare States and the Medicalization of Social Problems
This is part of our special feature, Public Health in Europe.
The increasing reliance on medicine for dealing with social problems during the twentieth century has been a central issue in social science scholarship since at least the late 1960s (Pitts 1968; Conrad 1975; Foucault; Zola 1972). Many empirical studies have demonstrated how more and more social problems—from childbirth to death, from restless children to melancholic adults—have been interpreted in medical terms and brought under medical jurisdiction. Thereby medicine has in many cases replaced religious and legal interpretations of these states and behaviors (Conrad and Schneider 1992). However, scholars have also explored contexts, when medicalized definitions are challenged, for example, by the natural birth or the holistic health movement (Lowenberg and Davis 1994) or even demedicalization processes occur, i.e., for homosexuality or hormone replacement therapy during menopause (Conrad 2007).
Since medicalization and demedicalization describe changes in the social construction of conditions and behaviors, a major focus of medicalization research has been to examine who is driving these changes (Conrad 2005). While early accounts focused on the power of the medical profession, later work has examined the role of market actors such as the pharmaceutical and biomedical industries (Clarke et al. 2009; Abraham 2010), as well as the influence of capitalism and neoliberalism overall (Reveley 2016; Wolf-Meyer 2011). For instance, the direct-to-consumer advertising of drugs constitutes a mechanism through which medical authority has been partially dismantled (Conrad 2007). While this focus on market forces has been of great value to unravel the economic foundations of medicalization processes, this account has been criticized of being too focused on the unique relationship of the medical profession, the market and the state in the United States (Olafsdottir 2011), thus falling short of explaining the variation of medicalization processes in other Western nations, particularly in Europe (Olafsdottir 2011; Olafsdottir 2007). European scholars have therefore pointed towards the welfare state as a central agent that caninitiate, accelerate, restrict or reverse the medicalization of social conditions (Olafsdottir 2011; van den Bogaert, Ayala, and Bracke 2017; Holmqvist 2012).
Why does the welfare state matter for medicalization?
The institutional configuration of the welfare state and the healthcare system in particular regulates who has access to which healthcare goods and services under which conditions (Reibling 2010). Access regulations are fundamental for limiting medicalization, for example, if certain drugs or services are not covered by the public health care system. Health policy also impacts on medicalization via the regulations of professions, insurers, or the licensing of health goods. The existing type of healthcare system, i.e., private insurance, social insurance, or national health service systems provides different potential for initiating and limiting medicalization (van den Bogaert, Ayala, and Bracke 2017), because power structures and decision-making varies based on the institutional set-up of healthcare systems.
However, it is not only the healthcare system that matters for medicalization. Health and illness are categories that matter for access to (additional) benefits or exemptions from obligations in various welfare programs, such as incapacity benefits, unemployment and social assistance benefits, childcare, school education, child and youth welfare services, geriatric, and hospice care. Thus, medical diagnoses and screenings constitute a central role in many welfare state programs. Therefore, cross-national varieties of welfare states, but also welfare cultures, e.g. who is considered deserving or not (van Oorschot et al. 2017), affect the degree and dynamics of medicalization. I will illustrate this argument with several examples from current research.
1) Restricting medicalization – public healthcare and pharmaceuticalization
International studies have shown that in the US the prescription of a variety of drugs is much higher than in European countries (Fretheim and Oxman 2005; Parkin, Hagberg, and Jick 2011; Steinhausen 2015), but even within Europe there are notable differences (Fretheim and Oxman 2005; Steinhausen 2015). Among those who receive medication, prescription frequency is also more than twice as high in the United States than in the United Kingdom (Parkin, Hagberg, and Jick 2011). This variation in prescription behavior and expert opinions suggest that state regulations of pharmaceuticals clearly can restrict the medicalization of conditions (Fretheim & Oxman 2005). For instance, in countries where only drugs are reimbursed by the public system that are included in the positive list (e.g., in Norway, Sweden, and New Zealand) or can be excluded based on clinical and cost effectiveness (e.g. through the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom) (Landwehr and Böhm 2011), there are much stronger limits to the pharmaceuticalization of new conditions as in countries where all approved drugs can potentially be reimbursed (e.g., in the US).
2) Restricting or reversing the trend: the role of public regulation in the medicalization and demedicalization of childbirth practices
Pregnancy and childbirth are prominent examples of life events that have become strongly medicalized, but for which also tendencies towards demedicalization can be observed. The existing welfare state regime and healthcare system shape how maternity care is organized and to what extent it is medicalized (Kennedy, Kodate, and Reibling 2015). For instance, there is a wide international variation in the autonomy that professional regulations grant to midwives (Kennedy, Kodate, and Reibling 2015). In the Netherlands, for instance, midwives have the authority to perform childbirth in uncomplicated cases without doctoral supervisions. This regulation has already been established in 1865 and has hardly been contested, because it resonates with the Dutch institutional and cultural context of accepting limited choice in healthcare (Kaminska 2015), e.g. out-patient care is based a strict gatekeeping of general practitioners (Reibling 2010). As a result, the Netherlands has retained a high level of out-of-hospital and thus less medicalized births with 11.7 percent delivered in a policlinic and 17.1 percent at home in 2010 (Kaminska 2015). New Zealand is an example of a country which has even reversed the trend towards medicalization and transformed their system from a hospital-oriented delivery system to a community-based system (Firestone et al. 2015). This was possible through changes in professional regulations but also due to legislation “which protects health professionals from civil action and personal law suits” (Firestone et al. 2015, 28). That this is crucial can be seen in comparison to other countries such as Germany where women’s access to out-of-hospital births has become increasingly limited because midwives cannot afford the rising premiums for private liability insurance and therefore many midwives have stopped offering home births despite existing demand (Reibling and Mischke 2015).
3) Initiating/accelerating medicalization: welfare reforms and the medicalization of unemployment and poverty
That unemployment and poverty are associated with worse health is a well-known fact. However, recent studies have shown that unemployed persons receive on average more antidepressants and visit doctors more often when compared to employed persons with a similar health status, indicating that this group is being medicalized (Buffel, Beckfield, and Bracke 2017; Buffel, Dereuddre, and Bracke 2015). Scholars have posed the question to what extent institutional variation and recent reforms in the field of unemployment insurance and social assistance can explain why in certain countries or regions more people classify themselves as permanently/sick or disabled (O’Brien 2015), receive disability benefits (Wong 2016) or more healthcare if they are unemployed compared to employed persons (Buffel, Beckfield, and Bracke 2017), than in other nations. Evidence is accumulating that the increasing conditions that were put on the receipt of unemployment and social assistance benefits in many countries through the introduction of welfare-to-work programs, may have increased the receipt of disability benefits (Wong 2016; Holmqvist 2009). Even in countries where access to disability benefits is regulated strictly, such as in Germany, illness is an importation assessment criterion, e.g. to be (temporally) released from welfare-to-work obligations (Linden, Reibling, and Krayter 2018). This line of research has shown how the welfare state through relying on medical assessment for accessing social security benefits or becoming exempt from work obligation may contribute to medicalization processes. As a result, policymakers outside of the health policy arena, as well as employees in public administration, i.e., in local employment agencies, can be agents of medicalization processes. These actors have different interests as the classical “engines of medicalization” (the medical profession, social movements and other market stakeholders) (Conrad 2005). As a result, medicalization may often be the (unintended) result of actions to shift costs and responsibility between welfare programs (e.g. from social assistance to disability insurance).
4) From medicalization to psychologization and healthism: “unintended” consequences of changing welfare state paradigms
Scholars have posited that we should also look at trends that resemble medicalization, but are not encompassed by the concept as currently understood in medical sociology. On the one hand, Niklas Rose (1998, 59) has argued that rather than medicine the discipline of “psychology came to infuse and even to dominate other ways of forming, organizing, disseminating truths about persons.” Thus, social conditions can be and—according to Rose—are increasingly psychologized. On the other hand, Crawford (1980) suggested that health consciousness and health promotion have spread in everyday life often detached from medical expertise and particularly medical authority. Social movements who are promoting the increased health consciousness even specifically distance themselves from the medical system and its focus on disease. Following Crawford’s thoughts, researchers have explored the healthicization of social life (Lupton 2013). Psychologization and healthism resemble medicalization in many ways as they describe changes in the social construction of conditions and behaviors. However, these are not change towards medical language or jurisdiction, but towards psychological concepts or a broader concept health promotion. The welfare state is again a crucial context to consider when thinking about variation in the degree to which social problems are psychologized or healthicized. An important development in this context is the recent changes of welfare state paradigms from a security to a social investment state. (Morel, Palier, and Palme 2012). With this paradigmatic change, welfare states have started to abandon the idea that social risks are unavoidable. Moreover, the social investment perspective argues that even if strokes of fate render individuals unemployed or ill, this does not mean that they should rely on welfare benefits for a prolonged period of time if there is the potential to include them in the labor market. The central idea of this social investment or preventive perspective is to ensure that individuals have the capability to participate in social life. Physical and mental health are clearly a central component of this capability. Therefore, states are supporting health promotion as well as psychological trainings, e.g. to deal with stress, in various settings (schools, workplaces, etc.) (e.g., Reveley 2016). While these initiatives may help to empower people, they also constitute measures of social control and self-monitoring (Rose 1998), an argument reinforcing the early critical perspectives on medicalization (Zola 1972). These critical considerations are important, because many social policies in this vein also specifically target vulnerable groups such as unemployed adults and underprivileged children and their parents. Their personal habits, actions and personality traits are under scrutiny and target of government intervention in many countries (Pulkingham and Fuller 2012; Heckman and Kautz 2013). More comparative research is needed to show how variation in these developments are related to institutional regulations and cultures of different welfare states (Olafsdottir 2011).
In sum, social science scholarship has started to investigate the fundamental intersection between medicalization and the welfare state. While a number of groundbreaking empirical studies have demonstrated the importance of institutional structures and cultural repertoires to explain when, how, and to what extent social problems are medicalized, there remains a dearth in comparative medicalization studies. However, existing research has already provided us with three important theoretical lessons:
1. The state can be both engine and brakes for medicalization: How the welfare state influences medicalization processes depends upon its institutional arrangement. Research should explore the influence of big system differences, e.g., between different healthcare system types, as well as the role of specific regulations (e.g. professional rules, drug regulation, access regulations to specific welfare programs). Institutions impact on medicalization not only through formal rules, but also through welfare state cultures as changes in the social construction of conditions occur within the given set of cultural schemas, norms, and values (Olafsdottir 2011).
2. The welfare state should not be considered as a unitary actor: The welfare state consists of a wide range of actors with often competing interests and actions with respect to medicalization. Their position towards medicalization is based within their institutional role, but may vary across different issues (van den Bogaert, Ayala, and Bracke 2017). Moreover, we should not limit our analysis to actors in health policy and practice. As the examples have shown, medicalization can be driven by institutional regulation and dynamics of other fields of the welfare state (Holmqvist 2009). As a result, actors with little attachment to the healthcare system, e.g. employment agency employees or teachers, need to be considered as participants in medicalization processes both in individual interactions and on the policy level.
3. The influence of the state can change: The concept of medicalization inherently refers to changes and thus one of the most prudent ways to investigate state influence should be too look at welfare state dynamics. Like existing analyses have identified, how changes in (bio-)technology and market structures have been important for medicalization (Clarke et al. 2009), reforms in regulations and in ideas about the welfare state should be at the focus of work interested in the role of the state. It is in these times of change when we have the best opportunity to see how various actors actively engage in activities to promote or demote medicalization. Moreover, the article has outlined why the recent changes in European welfare states towards activation and social investment particularly bear the potential to affect medicalization and related trends (psychologization, healthism).
Nadine Reibling is a medical sociologist at the University of Siegen in Germany and leads there a junior research group on the medicalization and psychologization of unemployment, poverty and child development. In her research, she is interested in the link between the welfare state, healthcare, and health and illness. Her research has been published in various international, peer-reviewed journals including the European Journal of Public Health, Current Sociology, and the Journal of European Social Policy.
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Published on June 11, 2019.