I. Evolution of the Concept of Medicalization

Many regard the term medicalization with suspicion. In fact, the meaning of this term has changed over time.^{Reference Nye1} For some, the term resurrects 16th century notions of the “unworthy poor,” who without medical pathology to explain their need, merit no public support or intervention. In this sense, medicalizing the human condition has merit and assists the poor in particular. With the Industrial Revolution at the turn of the 19th century, anti-medicalization schools of thought emerged, challenging the public's uncritical worship of the medical system's ability to eradicate pain or sickness. In this time of mechanistic miracles, modern medical society expropriated sickness and death, becoming in the process a “medical nemesis” to health itself.^{Reference Illich2} German philosopher,^{Reference Hansen, Bourgois and Drucker3} Ivan Illich, wrote in Medical Nemesis: The Exploration of Health that the “medical establishment has become a major threat to health.”⁴ Illich advanced the overarching view of the healthcare system as a “medical Leviathan” in which medical professionals transform a normal human condition into disease. The result he termed “clinical iatrogenesis” — the process of medicalization that causes individuals to lose or cede control of the body to physicians and hospitals.

French philosopher Michel Foucault continued the medicalization critique in The Birth of a Clinic: An Archeology of Medical Perception.^{Reference Misselbrook5} Foucault's critique extended to analyzing power dynamics within social systems that contemporary sociologist Paul Starr would later call, “the medical-industrial complex.”^{Reference Starr6} Foucault described the “medical gaze” as the medical professional's way of selecting the biomedical aspects of patient narratives, and fitting them into a biomedical paradigm, while discarding non-biomedical information, unsuitable for doctor-oriented, rather than patient-oriented controls. In this view, medicalization operated to create an abusive power structure of control by physicians over patients.

Critics of the medicalization of the human condition have continued to dominate the discourse during the 21st Century. Some scholars continue to object to control over individual choice that medicalization implies. In Medicine as an Institution of Social Control, for example, Irving Kenneth Zola disparages the medical community's absolute control over technology and consequent intrusions upon personal freedom.^{Reference Zola7} Zola argues medicine has become “a major institution of social control” that has “led us down the path of the reluctant reliance on the expert.” Similarly, Margaret Lock cites waves of medicalization that threaten “individual choice in connection with decisions relating to health and illness.”^{Reference Lock, Albrecht, Fitzpatrick and Scrimshaw8} In contrast, feminist scholars over the last two decades have been able to parse out further nuances, distinguishing “good”^{Reference Parens9} from “bad”^{Reference Purdy10} medicalization as it affects social control over natural occurrences such as childbirth or instead empowers welfare-enhancing reforms. And one outspoken critic of neo-liberal policy abhors the medicalization framework because he believes it ignores the structural nature of problems in favor of constructing inadequate, individualized solutions to systemic problems.^{Reference Maturo11}

By this view, admonitions to cease smoking, exercise more, and drink less crowd out attention to structural inequities that characterize the social determinants of poor health, and make adherence to individual-level recommendations to improve health behaviors nearly impossible. Perhaps the concepts most severe critic has been psychiatrist, Thomas Szasz, who famously said that he saw neither science nor medicine in the medicalization concept; instead, medicalization is regarded as a semantic social strategy that benefits some patients while harming others.^{Reference Szasz12}

Politicians are equally divided on the efficacy of medicalizing social problems. This divide manifests in public policy debates that surround contrasting views toward healthcare reform generally, and Medicaid policy specifically.¹³ For example, the Democratic party announced in the “Health and Safety” section of its 2016 party platform that “Democrats believe your zip code or census tract should not be a predictor of your health, which is why we will make health equity a central part of our commitment to revitalizing communities left behind.”^{Reference Kenen14} In this view, health reform should address the disparate impact that social factors associated with one's geographic neighborhood have on different populations. The Republican platform took a different approach: that “[t]o guarantee first-rate care for the needy, we propose to block grant Medicaid and other payments and to assist all patients, including those with pre-existing conditions, to obtain coverage in a robust consumer market.”^{Reference Kenen15} The platform described Medicaid “[a]s the dominant force in the health market with regard to long-term care, births, and persons with mental illness, [making block grants] the next frontier of welfare reform.” The central characteristic of this position suggests that market forces best organize the priorities for health spending. The salient contrast in these visions for health reform is that while both Democrats and Republicans are focused on improving health for the neediest populations — children, low income families, people with disabilities — they have very different perspectives on whether social factors such as neighborhood conditions are a medical concern, or whether instead medical issues are those related to market distributed payments that cover biomedical conditions. That is to say that the two positions differ on the concept of medicalization. On one hand, Democrats medicalize social risk factors as part of a health reform platform, while on the other hand, Republicans medicalize markets to distribute health and health care.

Public health scholars, by contrast, regard “medicalization” as a scientific approach to promote and protect population health. Thomas Frieden's effort to apply traditional public health tools to the HIV epidemic is an example.^{Reference Frieden16} Frieden's approach focuses on the epidemiologic trends revealed by surveillance, which he proposes to use to direct public health interventions, such as partner notification and increased access to antiretroviral treatment to control the disease. In essence, this brand of medicalization is a departure from the social debate that had focused on conflicting political influences; it turns the lens on the underlying disease in order to reduce the human and economic costs of HIV/AIDS, and focuses on the public health goals to prevent the deaths of thousands.

We regard Frieden's public health approach to medicalization as an improvement over prior views. A scientific approach, focused on health outcomes, rather than a conceptual debate mired in relative status and position of stakeholders, is more likely to generate improvements in population health. Still, we propose here another interpretation of medicalization. Instead of medicalizing people (e.g. pregnant women) or conditions (pregnancy) or even the social position or views of stakeholders which can stymie effective treatment (e.g. HIV prevention or teenage pregnancy), we think the preferred conceptual framework is medicalization of the risk factors that contribute to diseases. More precisely, we propose a framework that medicalizes the condition of poverty, and the cluster of risk factors incident to poverty. We use housing as an instructive exemplar to explain.

II. Why the Medicalization of Risk Factors

Medicalization is most appropriately a descriptive and operative framework to understand the comprehensive range of contributors that cause the need for medical care and intervention in the first place. Commonly, these “causes of the causes” of disease are called social determinants of health.^{Reference Tarlov17} By their very nature, incorporation of the social determinants of health into clinical settings results in the medicalization of these socially-created risk factors for poor health — that is, we use the clinical encounter as an opportune setting in which to identify and coordinate the address poverty-driven needs. There are many advantages to this approach. First, medicalization of risk factors represents a more accurate acknowledgement of the broad range of factors that contribute to healthy outcomes. Today, social and clinical scientists estimate that only 20% of health outcomes are determined by healthcare.^{Reference Park18} In contrast, social determinants have far greater influence on health disparities than medical care alone. Differences in social and environmental factors account for an estimated 40% of health outcomes. Another 30% of health outcomes are related to health behaviors which occur within a social context, like alcohol consumption and smoking, and are therefore also susceptible to environmental influences. Of course, the causality versus selection debate has not been resolved and we may find that many poor health outcomes are only associated with, not the direct result of, substandard conditions.^{Reference Ruel19} However, as well-designed studies finding an association between poor living and poor health continue to amass, the less credibly social scientists and policy-makers can ignore the causal inference. Therefore, we are willing to assume arguendo here that social determinants play a much larger role in predicting health outcomes than genetics or healthcare services.

A second advantage of medicalizing risk factors is the added incentive for increasingly integrated rather than fragmented and siloed health delivery. By appreciating the profound influence on biomedical outcomes that social risk factors have, medicalization can motivate clinical providers to seek alliances with social service providers to achieve better health outcomes. Third, medicalization of social risks creates a business case for blending and braiding various funding sources together in order to finance comprehensive health interventions that go beyond narrow “medically necessary” services defined by traditional payment structures. We will demonstrate the importance of medicalizing one social determinant — access to safe, decent, affordable housing — in order to demonstrate these advantages that may better help to achieve equitable health opportunities and outcomes. Housing, in particular, has been shown in a number of epidemiological studies, to be an important determinant of population health.^{Reference Sandel and Desmond20} The next section applies the “medicalization of risk factors” approach to substandard housing, unaffordable housing, and the neighborhood conditions that accompany both.

III. Medicalization of Access to Decent Housing as a Social Risk Factor

The paradigmatic example of how poverty, housing, and health are related for an asthmatic child helps to situate the medicalization debate in context. Asthma disproportionately affects children living in poverty.²¹ Imagine a child who may, in fact, have regular access to high quality healthcare to obtain preventive services and to clinically treat asthma.^{Reference Wilson22} Nevertheless, the child will most likely remain at risk and her asthma has a greater probability of continuing uncontrolled if she lives in poverty. This is because her home environment is more likely to be moldy,^{Reference Jacobs, Duncan and Brooks-Gunn23} pest-infested,^{Reference Meltzer and Schwartz24} poorly heated, inadequately ventilated,^{Reference Desmond and Bell25} and contaminated by lead.²⁶ This child is at increased risk of finding that lead has contaminated the paint, plumbing, and water available to her, all of which have been associated with long-term, adverse impacts on mental health, neurological disorders, psychological, and behavioral dysfunction.^{Reference Bashir27} The third National Health and Nutrition Examination Survey (NHANES) estimated that 40% of childhood asthma is related to children's home environment.^{Reference Krieger and Higgins28} The dangers to this child's health due to poverty most likely extend beyond the risk that her asthma persists or worsens. She is very likely to live within a community that suffers concentrated poverty, and therefore will face further health risks in addition.^{Reference Braveman29} Buildings where low-income families reside are often unsafe for all residents.^{Reference Hood30} Every year, people are injured in homes that have structural and design defects, such as unstable stairwells associated with falls, electrical defects associated with burns and fires, or faulty furnaces that emit carbon monoxide — all defects that pose their own risks to health but that would be harmful to this child's asthma as well.³¹

Compounding matters, poverty brings with it exposure to neighborhood-level factors that could exacerbate asthma and other health problems.^{Reference DePriest and Butz32} Poverty increases the odds that this asthmatic child lives in a neighborhood disproportionately burdened by social stressors such as violence.^{Reference Evans33} She is more likely to be exposed to risk factors for pollution such as proximity to landfills, power plants, or interstate highways — all of which have been shown to adversely impact health.^{Reference Renalds34} Poorer families live in neighborhoods with fewer markets that sell fresh, healthy food options, but with many more fast and convenience food outlets than wealthier neighborhoods.^{Reference D'Angelo35} Poorer families live in neighborhoods with fewer safe options for outdoor exercise yet more deteriorated infrastructure.^{Reference Sallis36} And poorer families live in neighborhoods with more exposure to unhealthy tobacco and alcohol marketing but less exposure to parks, open and green recreational spaces.^{Reference LaVeist and Wallace37}

The health impacts of all these neighborhood deficits are especially pronounced if our asthmatic child lives in a racially as well as economically segregated community. Childhood asthma is closely associated with whether families occupy housing in segregated or integrated neighborhoods.^{Reference Alexander and Currie38} Sociologists David Williams and Chiquita Collins argue this may be because segregation affects entire minority communities' disparate exposure to jobs, education, crime, food, transportation, built environment (or manufactured structures in which our activity occurs), and pollution.^{Reference Williams and Collins39} Similarly, other researchers have found an association between segregated neighborhood conditions and poor mental health due to the stress of coping with perceived discrimination and messages of inequality. Public health researchers Carol Aneshensel and Clea Sucoff, for example, have shown that both subjective neighborhood conditions (e.g. attractiveness, desirability) and objective ones (e.g. crime, blight) have an impact on adolescents' mental health and health behavior.^{Reference Ludwig40} The enduring presence of segregated neighborhoods may be part of the reason that the lifetime asthma prevalence for white children remains much lower than for black children.^{Reference Akinbami41}

Poverty also has medical consequences related to housing affordability. Housing affordability is measured as a ratio: the share of a family's total income that goes to purchase housing. A generally accepted convention says housing is affordable if a household spends less than 30% of its income on rent or mortgage payments.⁴² By contrast, when a household spends more than 30% of income on housing, they are said to be “cost burdened.” In the United States, nearly 19 million households spend more than 50% of income on housing;⁴³ the overwhelming majority of these “severely cost burdened” households are low-income families and nearly 25% of them spend over 70% of their income on rent.^{Reference Desmond and Bell44} Poor medical outcomes can be traced to the problem of unaffordable housing for poor families. Families living in poverty are more likely to make unhealthy spending trade-offs, purchasing cheaper or inferior food and forgoing healthcare in order to afford costly housing. These same households may save on housing expenses by combining households, contributing to the rise in “doubled-up” households — that is, households that have not only a head of household and his or her spouse or partner, but one or more additional adults, who might be an adult child, a parent, or an unrelated second family — and possibly to the crowded living conditions that contribute to the spread of chronic disease.^{Reference Johnson45} The alternative for many families may be homelessness, which is certainly associated with chronic and acute health consequences. Indeed, one analyst has described the shortage of affordable housing as a “public health crisis.”⁴⁶ The medicalization question, of course, is whether there is reason to justify translating the empirical associations between poverty, housing, and poor health reviewed here into a policy approach that reflects the associations between social risk factors and medical outcomes. In short, should we medicalize housing as a risk factor?

The framework we have suggested here implies medicalizing housing as a risk factor may help improve clinical outcomes for patients living in poverty for three reasons. First, medicalization offers an integrated and holistic conceptual approach to addressing medical problems that cannot be solved by clinical intervention alone. Second, medicalization of risk factors like substandard housing aligns otherwise disparate threads of information and resources to support evidence-based solutions to the complex health problems that vulnerable populations face. Third, medicalization of a social risk factor can help to identify partners to collaborate with healthcare providers, who need more tools at their disposal to accomplish the medical goals for patients. This is not a suggestion to further medicalize poverty. And this certainly is not a proposal to freight doctors with the responsibility to identify, screen for, and address all the social risk factors that affect their patients' health outcomes. But it is an acknowledgment that poverty — and housing — are medicalized now and that medicalization offers an opportunity to partner with healthcare providers to address very real human needs today.

Perhaps the greatest contribution of the medicalization framework will be to enhance traditional, individualized patient care, with a view that includes the larger context of community and population health. The medicalization framework is an invitation to join previously siloed experts together for the purpose of constructing systemic interventions that tackle the “causes of the causes” of disease among the poor.^{Reference Marmot47} These might include provider-informed housing redevelopment projects that allow hospitals to recover patients in stable settings, allow clinicians to treat patients who have the capacity to adhere to medical advice to “eat better and exercise,” and encourage providers to refer patients to behavioral health partners who, due to payment reforms that sustainably finance collaboration, can cooperate in treating traumatic injury due to racism and community violence.