From diagnosis to social diagnosisAuthor Phil Brown Mercedes Lys.docx

From diagnosis to social diagnosis
Author Phil Brown Mercedes Lyson, Tania Jenkins
Abstract
In the past two decades, research on the sociology of diagnosis
has attained considerable influence within medical sociology.
Analyzing the process and factors that contribute to making a
diagnosis amidst uncertainty and contestation, as well as the
diagnostic encounter itself, are topics rich for sociological
investigation. This paper provides a reformulation of the
sociology of diagnosis by proposing the concept of ‘social
diagnosis’ which helps us recognize the interplay between
larger social structures and individual or community illness
manifestations. By outlining a conceptual frame, exploring how
social scientists, medical professionals and laypeople contribute
to social diagnosis, and providing a case study of how the North
American Mohawk Akwesasne reservation dealt with rising
obesity prevalence to further illustrate the social diagnosis idea,
we embark on developing a cohesive and updated framework for
a sociology of diagnosis. This approach is useful not just for
sociological research, but has direct implications for the fields
of medicine and public health. Approaching diagnosis from this
integrated perspective potentially provides a broader context for
practitioners and researchers to understand extra-medical
factors, which in turn has consequences for patient care and
health outcomes.
Highlights
► “Social diagnosis” recognizes interplay between social
structures and illness manifestations. ► Case study shows how
Mohawk Akwesasne dealt with rising obesity. ► Provides broad
context for practitioners and researchers to understand extra-
medical factors.
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Keywords
Diagnosis
Risk
Social movements
Environment
Public health
USA
Canada
Reservations
Introduction
Sociological analysis of diagnosis has achieved considerable
influence in the last two decades, providing important insight
into how we understand health, disease, and illness. It has also
expanded how we view the social and cultural influences that
shape our knowledge and practice on health and illness.
This includes studies of diagnosis that have gone beyond the
interaction between physician and patient, to take into account
the larger social, structural, and temporal forces that shape
diagnosis (see, for example, the categorization of homosexuality
as a mental disorder and the role of gay rights activists in the
American Psychiatric Association’s deliberations) (Cooksey &
Brown, 1998).
Recently we have also seen the emergence of diseases whose
etiologies, symptoms, and, therefore, diagnoses, are often
contested or uncertain. This combination of medical and social
uncertainty leads us to propose a reformulation of the
concept social diagnosis as a new way of thinking about the
sociology of diagnosis. This paper explores social diagnosis by
first, outlining a conceptual framework of social diagnosis;
second, discussing the different actors who contribute to social
diagnoses; and third, providing a case study of how to apply our
social diagnosis approach. Lastly, we conclude with
implications for sociology, medicine, and public health.
Introducing social diagnosis
Social diagnosis is ‘social’ for two reasons: First, it connects an
illness or the act of diagnosing that illness to a set of political,

economic, cultural and social conditions or factors. Second,
social diagnosis is conducted by different social actors, and the
actions of one group of stakeholders often spill over to affect
the actions of other actors. As we will see, social diagnosis is
done by sociologists who study diagnosis, as a way for
researchers of social medicine and the social determinants of
health to look at the process, outcomes, and consequences of
diagnosis. It is also done by the lay public vis-à-vis social
movements that expand what goes into the diagnosing process.
In this more comprehensive, public version of uncovering the
social determinants of health, a condition is diagnosed by a
social group—for example, the politicized collective illness
identity that arises over a contested disease like Gulf War
Illness (Zavestoski, Brown, Linder, McCormick, & Mayer,
2002). Lastly, social diagnosis is a way to expand the lens of
the public health and medical establishment in identifying what
mechanisms and factors are consequential for individual and
community health. Social diagnosis therefore provides a broader
context for health practitioners, medical researchers, and social
scientists to understand the extent of extra-medical factors in
health and illness. With that approach, neighborhood and
community environments (which are themselves determined by
larger structural forces) can be included in approaches to
wellness, highlighting the intersection between individuals and
the larger social forces that structure their lives.
A genealogy of social diagnosticians
Social scientists
The roots of this approach are deep. The term “social diagnosis”
was coined in Richmond’s (1917) book, Social Diagnosis,
considered to be the classic textbook laying a professional
foundation for social work, and which focused on examining a
wide array of social conditions causing poverty and disease.
This was a period when sociology and social work shared many
common interests in documenting and alleviating poverty, with
the reformist Chicago School sociologists categorizing and
analyzing urban social problems that they traced to social

structures rather than inborn characteristics.
Even in the early 20th century, sociology focused on the social
determinants of health and illness, as in Faris and Dunham’s
(1939) work on mental illness. Decades later, Navarro
(1976) and Waitzkin (2000), both MD/PhD sociologists, led the
charge of other political economy scholars who sought to
rekindle social medicine, found as early as Rudolf Virchow’s
work in mid-19th century Europe, and more recently in Chile
during Allende’s Popular Unity Government in the early 1970s.
A committed approach to health inequalities, rooted in England,
worked its way into the literature starting in the 1990s. A
leading medical sociologist, Sol Levine, and a prominent social
medicine physician, Alvin Tarlov, nurtured this endeavor in
their Health and Society group, publicizing well-known British
work such as Michael Marmot’s Whitehall Study, bringing key
health inequalities researchers such as Richard Wilkinson to the
US as visiting scholars, and providing a research setting to
nurture new health inequalities researchers (Amick, Levine,
Tarlov, & Walsh, 1995). A young generation of US-based
scholars brought health inequalities work to the fore,
emphasizing race, class, sex, ethnic, and neighborhood
differences (Kawachi et al., 1999, LaVeist, 2002, Williams,
1994). These scholars’ work helped push the National Institutes
of Health to develop a strong program in health inequalities,
though usually termed “health disparities,” a more neutral-
sounding phrase. From being only a National Center on
Minority Health and Health Disparities, in 2010, NIH
transformed the center into a full institute, the National Institute
on Minority Health and Health Disparities, signifying a major
acceptance of this work.
Public health and medical professionals
Medical professionals and public health scholars in the US
share an important tradition of taking into account social factors
in their work. For an example of 1960s social medicine that
exemplifies social diagnosis performed by a physician, we can
remember the work of Dr. Jack Geiger, a founding member of

the Congress of Racial Equality (CORE) in 1943, a leader in
efforts to end racial discrimination in hospital care and medical
schools admission and a 1960s founding member and National
Program Chairman of the Medical Committee for Human Rights
which protected and provided medical care for civil rights
workers. Geiger was famous for diagnosing poverty, racism, and
hunger, and writing prescriptions for food to give to poor
children, which he and colleagues did to garner public attention.
More practically, the community health centers developed in
that era diagnosed disease as stemming from a multitude of
social conditions. For example, staff would act on these
diagnoses by seeking improvements in neighborhood parks and
fighting for lead removal and blood lead testing (Lefkowitz,
2007).
While the public health field in the US continued a strong
commitment to examining social factors in disease, medicine
often trailed after it. Occupational health, environmental health,
nutrition, and community health training still remain
marginalized in medical education and practice. Federal
research, largely conducted through the National Institute of
Health, emphasizes treatment over prevention. For example, the
prestigious, well-funded National Cancer Institute provides few
resources for researching environmental causation, leaving that
to the much smaller National Institute of Environmental Health
Sciences whose budget is 6.5 times smaller (Brown, 2007)
Sociologists have played a role in examining social factors in
disease, working alongside public health scholars and
community activists in pursuing multi-causal approaches to
understanding disease and developing multi-pronged solutions
(Brody et al., 2009).
Public participation/social movements
Diagnosis is simultaneously a site of compromise and
contestation because it is a relational process. When there is a
disconnect between the patient and the medical explanatory
model, the individual may be unsatisfied with treatment goals,
and collectively work to politicize the illness through social

movements. This would be the case especially if people were
not given a diagnosis for something which they expected to, or
when they received a psychiatric diagnosis for something they
believe is physical. The greater the symptom severity or the
disconnect between lay and professional perspectives on
diagnosis, the greater the likelihood of contestation.
In contesting diseases and conditions, people often seek to
reshape or overturn a shared set of entrenched beliefs and
practices about diagnosis, causation, and treatment that is
embedded within a network of institutions, including medicine,
law, science, government, health charities/voluntaries, and the
media. This network is the “dominant epidemiological
paradigm” for a given disease. Activists challenge the dominant
epidemiological paradigm by shifting the modes of scientific
inquiry, and by refocusing regulatory and policy attention
(Brown, 2007). Scientists may be asked to weigh in on
questions that are virtually impossible to answer scientifically,
either because data do not exist or because studies required to
answer the question at hand are not feasible. Scientists may
frame political, moral, or ethical questions in scientific terms
thus limiting lay participation. This scientization protects the
illusion of medical omnipotence and delegitimizes questions
that cannot be framed in scientific terms (Morello-Frosch et al.,
2006). Health social movements may respond to these situations
by marshaling resources to conduct their own research and
produce scientific knowledge in a process known as “popular
epidemiology” (Brown, 2007). In doing so, they democratize the
production of scientific knowledge and then use that
transformed science as the basis for demands for improved
research on disease etiology, treatment, prevention, and stricter
regulation.
These concerns may extend into the legal realm when diagnoses
are a classification of what the individual’s health status could
be in the future. Exposed people may seek redress through
medical monitoring torts in advance of injury, in an attempt to
offset the costs associated with periodic testing in order to

ascertain whether a given exposure has led to changes in health
status (Maskin, Cailteux, & McLaren, 2001). Even US law now
recognizes that disease is no longer a unique collection of
symptoms equaling a given condition, but rather a constellation
of current symptoms, previous exposures, and
future potential manifestations, all of which make the art of
diagnosis even more precarious.
The democratization of medicine and science we have
mentioned above is made possible by bringing the discussion of
diagnosis out into the open, rather than keeping it restricted to
professionals. Krimsky (2002) notes that the endocrine disrupter
hypothesis (that argues for the central role of endocrine-
disrupting chemicals in many diseases) was discussed quite
extensively in the public light, far beyond the shelter of
academic journals and government funding agencies. His notion
of a “public hypothesis” helps us see that increasingly,
challenges to scientific orthodoxy are shaped by public
discussion in the media, social movement organizations, virtual
communities, and other accessible formats (e.g. homosexuality,
post-traumatic stress disorder). When people view their
diagnosis as stemming from a particular toxic exposure, they
are rarely satisfied with the simple act of diagnosis. Rather,
they seek evidence of causation in order to seek redress in
various forms: medical coverage, medical monitoring,
relocation, compensation, assignment of blame, and (less
commonly) the incalculable but valuable apology from
responsible parties. As discussed earlier, in the absence of a
specific diagnosis, people with a shared environmental exposure
sometimes file suits for medical monitoring, to ensure that they
have lifetime checkups to diagnose a disease process as early as
possible.
Yet despite a rich history of social diagnosis exercised by
various actors, including sociologists, public health officials
and the public, the above-mentioned strands have not yet been
well-connected, nor woven into a social diagnosis framework.
Below, we discuss several elements of a social diagnosis model.

1)
A social diagnosis approach is more comprehensive than a
political economy/health inequalities outlook that accounts for
how larger social structures affect diagnostic processes. In
social diagnosis, we also must “socially diagnose” those
structures themselves. In this light, we would argue that the
injured foot of a ballet dancer is not merely an injury caused by
a pointe shoe. It includes the larger setting of the balletic art
form – its teachers, theaters, dance companies, dance critics –
as socially iatrogenic. It includes gender roles that force-fit
women into many uncomfortable clothes and shoes, and
anorexogenic notions of beauty that limit the art form. Our
diagnosis would be of an unhealthy foot in an unhealthy art
form in an unhealthy culture. Treatment and prevention goes
beyond the individual, seeking to restructure power, capacity,
and community in the surrounding society.
2)
Traditionally, diagnosis dealt with diseases and symptoms in the
past and present, with future orientation toward only treatment
and prognosis. Indeed, even attempts at incorporating social
factors into diagnosis (either by healthcare professionals or
sociologists) do not adequately account for a third dimension of
time; that is, the future. Today, potentiality is an important
concept, where a biomarker may or may not indicate future
diseases. This potentiality introduces new contestations and
foci; preventive medicine now goes beyond generic health
advice, to consider borderline categories: pre-diabetes, pre-high
cholesterol, pre-hypertension. Further, patients are increasingly
prescribed pharmaceuticals to regulate these borderline
conditions (Welch, Schwartz, & Woloshin, 2011). Therefore, a
social diagnosis approach must contend not only with past and
present conditions, but explicitly consider the potentiality of
future conditions, specifically because they may have social
causes and consequences.
3)
The process of diagnosis is carried out by multiple social

actors, including medical professionals, researchers,
government agencies, private corporations, social movements,
and legal institutions. For example, we can understand the role
of public health agencies in new forms of surveillance geared to
population exposure measurement and to the diagnosis of pre-
disease. Combined with increased academic and advocacy
research in this area, biomonitoring and household exposure has
opened vast new realms of seeing potential disease causes at
microscopic levels. Therefore, in a social diagnosis framework,
not only are social factors considered in the diagnosis, but a
variety of social actors are contributing to the creation of that
diagnosis. In doing so, they diagnose not only individuals but
societies—a practice which is growing ever more important in
light of increasing biomedical uncertainty.
To further elaborate on and exemplify this idea of social
diagnosis, we will use the case of obesity and diabetes in
Akwesasne, a Mohawk reservation straddling New York and
Canada. This situation demonstrates how diagnosis has moved
from the individual to society, and is being performed by more
than just doctors.
The multiple layers of diagnosis in obesity and diabetes: A case
study of social diagnosis in action
Obesity and diabetes have become a major concern of both
environmental justice and health groups in the 2000s. There is
broad understanding that, in addition to individual and lifestyle
factors, obesity is caused by numerous social phenomena:
increased consumption of processed foods (especially high
fructose corn syrup), food deserts, poor school lunch programs,
a decline in school physical education, and unsafe recreation
spaces. Social diagnosis looks here at an unhealthy body within
an unhealthy community, itself situated in an unhealthy food
system.
Hoover’s (2010) medical anthropological study of local food
production and community illness narratives in the Akwesasne
Mohawk community found diabetes to be a central concern.
Rising prevalence indicated a rate higher than both the state and

national averages, and lay awareness of this led to a complex
set of diagnoses. Residents in this highly contaminated area
(primarily due to PCBs and fluoride from local industry)
believed that there were two potential pathways through which
contamination increased diabetes risk. The direct pathway was
based on recent science linking exposure to endocrine-
disrupting chemicals, to obesity (Baillie-Hamilton,
2002, Newbold et al., 2007). The indirect pathway was based on
fear of contamination, including fish advisories and concerns
over soil contamination, leading people to abandon traditional
local foods for less healthy processed foods, and hence also
getting less exercise since they were not gardening and fishing.
This second pathway, rooted in a risk society perception, also
led to changes in the traditions and cultures of the community,
leading to a broader social illness.
We do not imply here that the discovery of contamination led to
obesity. Rather, the discovery of the toxicants set off a cascade
of events that meshed with other reservation developments,
which then involved dietary and agricultural changes. Such
changes have occurred in other communities, sometimes
because of contamination discovery and sometimes for different
reasons such as urban decline. This then leads to the departure
of groceries with fresh produce or to the immigration of people
from more self-sufficient food regimes to urban locales flooded
with fast-food restaurants and completely lacking any resources
to continue traditional practices.
Using Chaufan, 2004, Chaufan, 2008 work, Hoover argues that
the medicalized approach to diabetes individualizes and
depoliticizes the problem. Alternatively, a political ecology
framework emphasizes social, economic, and political
institutions of human environments where diabetes is emerging.
Hoover adapts Scheper-Hughes and Lock’s (1987) model of
three bodies – the individual body, the social body and the body
politic. As Hoover points out, in addition to losing the nutrition
from fishing and gardening, people also lost the physical and
cultural activity involved in that food production. This led to

fewer burned calories, affecting the individual body, but also to
broader losses affecting the social body – the failure to connect
with ancestral ways and to pass traditions onto youth. Eating is
an important social experience, and the sharing of food is an
integral part of Mohawk culture, full of morals around
cooperation and proper behavior. This larger unity of the body
politic is especially important at present, when the community
is less united due to overlapping tribal, US, and Canadian
governing bodies. Akwesasne environmental health activists
used their mobilization around contamination as a way to
achieve general social unification and harmony. When people
seek to take control of individual and social levels of
obesogenic and diabetogenic conditions, this crisis that
originates in massive contamination has the capacity to provide
new unity.
In effect, we see that what might appear as a straightforward
diagnosis of a metabolic disease is in fact much more complex.
Hoover’s analysis of the social diagnosis of this condition
builds on the community-based participatory research by the
laypeople and traditional healers of Akwesasne, in alliance with
university scholars and environmental health scientists, and
implicates individual, social and cultural, and body-politic
disease contributors. Such analysis informs us that by the time
it reaches the body politic, biological disease goes to the core of
the social fabric, and warrants an overall restructuring of power,
capacity, and community. Further, we see that struggles over
diagnosis are simultaneously struggles over causation. In this
light, we can understand the multi-temporality of diagnosis: it is
not only about the present, where people seek knowledge about
the symptoms they experience. It is also about the past, whereby
people seek the causes of problems that led to a current
diagnosis. As well, it is about the future, where the medical and
social sequelae of the diagnosis reside along with the treatment
and prognosis.
Conclusion
Studying diagnosis provides a window into many components of

health and illness, and presents an organizing configuration and
master frame. Our expansion into understanding and elaborating
on social diagnosis makes this broader framework more
applicable to an even greater number of research arenas. The act
of diagnosing an illness is important on multiple levels. It is
about an individual’s relationship to the illness or act of
diagnosis, the collectivity of people who suffer from an illness,
and the larger social structures that influence the illness and its
diagnosis. In other words, it is about locating an individual and
a group in relation to key social structures.
In this paper, we have sought to understand the unique context
in which social diagnoses are formed—a sociology of social
diagnosis. To reiterate, social diagnosis is social in that it
considers both larger social structures, as well as the various
social actors which contribute to the diagnosis. In other words,
a broad range of social factors goes into the making of a
diagnosis, which is carried out by a myriad of social actors. The
diagnosing of individuals can allow for the broader diagnosis of
a group of illness sufferers, and an even broader diagnosing of
communities, as the Akwesasne example clearly illustrates.
From here, we have drawn five key lessons which will not
provide a one-size-fits-all framework, but will help
pragmatically identify the role social diagnosis can play across
many different situations and among different constellations of
actors:
1)
Social diagnosis moves beyond individual-level explanations for
health outcomes;
2)
Social diagnosis recognizes commonalities in the group
experience;
3)
Social diagnosis moves beyond a diagnosis that is limited to
treating or identifying symptoms and toward identifying more
macro-structural roots. From here, it prescribes identifying and
treating the fundamental causes of the problem, as opposed to

just the proximal symptoms;
4)
Social diagnosis relies on scientific evidence, but recognizes
that useful science might not always come from mainstream
sources, particularly when it involves laypeople;
5)
Lastly, social diagnosis is attentive to changes across both the
short and long term. It moves beyond a cross-sectional approach
to diagnosis and instead preferences a multi-temporal approach
to diagnosis, one that changes over time.
Social diagnosis offers three benefits: it is a concept that can be
used by diverse actors -- medical sociology and other medical
social sciences, public health, and medicine; it is not only about
diagnosing individuals, but also about diagnosing institutions
and organizations; and it is simultaneously a description of our
analytic approach and a prescription for how to intervene.
Social diagnosis can be an interesting tool for sociologists in
various specialties within the discipline, as well as researchers
outside the discipline. For example, environmental sociologists
examining a disease such as asthma can take students on toxic
tours in order to show the neighborhood factors and pollution
sources related to asthma. Social diagnosis can also be applied
to medical history and science, technology, and society analyses
of disease concepts and medical practices. The social diagnosis
approach offers valuable lessons for physicians and other health
professionals. In particular, the cursory instruction in
occupational and environmental medicine in medical school can
be countered through showing professionals how to ask
appropriate questions about environmental and occupational
exposure. ‘Narrative medicine,’ formulated by Rita Charon
(2006), teaches medical students and physicians to attend to the
totality of life experience through eliciting and listening to
patient stories, in order to more thoroughly diagnose them.
Pediatrician Rosalind Wright diagnoses asthma as being
exacerbated by violence at home and in inner-city
neighborhoods (Wright & Steinbach, 2001). This leads her to

seek intervention strategies aimed at reducing violence
exposure, reducing stress, and counseling victims, in addition to
more traditional asthma treatment. At a preventive level, she
urges policy directions that address the social, economic, and
political factors that contribute to crime and violence.
Social diagnosis as a concept may not seem new to sociology,
but it has yet to be developed into an enunciated framework and
program for research and/or action. For example, sociologist
Eric Klinenberg’s account of the 1995 Chicago heat wave
introduces the notion of social autopsy by effectively
conducting a post-mortem of the natural disaster and the various
social factors that affected its victims (2002). In doing so,
Klinenberg provides a social diagnosis of the heat wave, citing
social isolation as one of the main causes and prescribing
changes in the social structure to prevent relapse. This could
serve as a very potent framework for sociologists and
practitioners alike to carefully and systematically consider those
social factors that play a crucial role in health. Also, while
medical sociology recognizes many extra-medical factors, the
environmental factors so important today have not been widely
considered. Hence, there are still lessons to be learned about the
multi-factorial causes of morbidity and mortality. Sociologists
also continue to face uncertainty in knowing which social
factors they ought to focus their attention on. Further, clinical
examples such as those above may seem logical to medical
sociologists, but they are not generally accepted in the world of
medicine. If medical sociologists work with clinicians and
public health practitioners, they may be able to jointly develop
effective ways to use social diagnosis for both treatment and
prevention.
Acknowledgments
We are grateful to David Ciplet, Alissa Cordner, Leah
Greenblum, Bindu Pannikar, and Allison Waters for comments.
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Question 1:
Explore the various data communication technologies you’ve

learned about this week. What are some things that stood out for
you? What factors would you advise a company to consider
when deciding on the way it connects to the Internet? How
would you advice the CIO of a small, medium, or large
company? Choose one and discuss the pros and cons of a couple
of your selections.
Question 2:
Cryptography Keys
Cryptography provides confidentiality, integrity authentication,
and nonrepudiation for sensitive information while it is stored
(at rest), traveling across a network (in transit), and existing in
memory (in use). Cryptography keys play in the world of data
security and are an extremely important security technology
embedded in many of the security controls used to protect
information from unauthorized visibility and use.
Let’s say you work for one of the following types of industry:
· Manufacturing
· Government
· Research
· Service
· Consulting
After you choose one of the above, consider the three types of
algorithms commonly used today. Which do you find to be the
most secure? Which is the most complex? Which did you
struggle to understand? What do you think you need to know as
a manager in order to choose the right security systems for your
company? Be sure to fully develop your responses and support
your opinion with reasons from your study this week.
Question 3:
"Booting Linux" Please respond to the following:
· The Grand Unified Bootloader or GRUB provides the user the
choice to boot on multiple operating systems. In this discussion,
discuss the following:

. Describe how GRUB V2 has improved the boot process for
Linux.
. Then, explain the purpose of systemd and how it was
implemented into the boot process.
. Lastly, using the Internet and your favorite search engine,
search for a “systemd” controversy or an article about systemd.
Then, summarize the article and explain why some Linux users
are not satisfied with systemd. Provide the link to your article
or any useful resources that explain the boot process.

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