Health Care Hitoshi Shigeoka

Health Care Hitoshi Shigeoka

This dissertation has been motivated by the question of how countries should
optimally structure health care. Especially, there are two important economic and
policy questions asked that extend beyond the area of health economics. The
Örst is how the expansion of health insurance coverage a§ects the utilization and
health of its beneÖciaries (extensive margin); the second is how generous should
health insurance be (intensive margin) to balance the provision of care and Önancial
protection against risk while containing medical expenditures. The three chapters
in this dissertation aim to make empirical contributions to these ongoing research
questions.
First Chapter, ìThe E§ect of Patient Cost-Sharing on Utilization, Health and
Risk Protection: Evidence from Japanî addresses the second question. It inves￾tigates how cost-sharing, requiring patients to pay a share of the cost of care,
a§ects the demand for care, health itself, and risk protection among the elderly,
the largest consumers of health service. Previous studies of cost-sharing have had
di¢ culty separating the e§ect of cost-sharing on patients from the ináuence of medical providers and insurers. This paper overcomes that limitation by examining a sharp reduction in cost-sharing at age 70 in Japan in a regression discontinuity
design. I Önd that price elasticities of demand for both inpatient admissions and
outpatient visits among the elderly are comparable to prior estimates for the non￾elderly. I also Önd that the welfare gain from risk protection is relatively small
compared to the deadweight loss of program Önancing, suggesting that the social
cost of lower cost-sharing may outweigh social beneÖt. Taken together, this study
shows that an increase in cost-sharing may be achieved without decreasing total
welfare.
Third Chapter, ìE§ects of Universal Health Insurance on Health Care Utiliza￾tion, Supply-Side Responses and Mortality Rates: Evidence from Japanî (with
Ayako Kondo) address the Örst question. Even though most developed countries
have implemented some form of universal public health insurance, most studies on
the impact of the health insurance coverage have been limited to speciÖc subpop￾ulations, such as infants and children, the elderly or the poor. We investigate the
e§ects of a massive expansion in health insurance coverage on utilization and health
by examining the introduction of universal health insurance in Japan in 1961. We
Önd that health care utilization increases more than would be expected from pre￾vious estimates of the elasticities of individual-level changes in health insurance
status such as RAND Health Insurance Experiment in the US.
The two chapters addressed above focus on consumersí incentives. Second
chapter, ìSupply-Induced Demand in Newborn Treatment: Evidence from Japanî
(with Kiyohide Fushimi) examines the incentives faced by medical providers. Since medical providers exert a strong ináuence over the quantity and types of medical
care demanded, measuring the size of supply-induced demand (SID) has been a
long-standing controversy in health economics. However, past studies may under￾estimate the size of SID since it is empirically di¢ cult to isolate SID from other
confounding hospital behaviors, such as changes in the selection of patients. We
overcome these empirical challenges by focusing on a speciÖc population: at-risk
newborns, and we measure the degree of SID by exploiting changes in reimburse￾ment caused by the introduction of the partial prospective payment system (PPS)
in Japan, which makes some procedures relatively more proÖtable than other pro￾cedures. We Önd that hospitals respond to PPS adoption by increasing utilization
and increasing their manipulation of infantís reported birth weight, which deter￾mines infants reimbursement and maximum length of stay. We also Önd that this
induced demand substantially increases hospital reimbursements without improv￾ing infant health, implying that the additional money spent has no commensurate
health gains.
Data and IdentiÖcation
I use one of the most comprehensive sources of health-related datasets ever
assembled on Japan. Here I summarize the most important datasets in the study;
further details can be found in the Appendix A.3. My main outcomes are health
care utilization on the cost-side, and health outcomes, and out-of-pocket expendi￾tures on the beneÖt-side.
1.3.1. Data
The dataset for health care utilization is the Patient Survey, a nationally represen￾tative repeated cross-section that collects administrative data from both hospitals
and clinics.20 Since the survey is conducted every three years, I have individual
patient level data for nine rounds of surveys between 1984 and 2008. One of the
biggest advantages of this survey relative to usual hospital discharge data is that
the Patient Survey includes information for outpatient visits as well. In contrast,
most existing datasets capture either outpatient visits or inpatient admissions. In
20See Bhattacharya et al. (1996) for an example of a study that uses the Patient Survey.

fact, the Agency for Healthcare Research and Quality (AHRQ) has recognized the
need to develop a methodology for studying preventive care in an outpatient set￾ting by using inpatient data to identify admissions that should not occur in the
presence of su¢ cient preventive care (AHRQ, 2011).21 In my case, I can look at
changes in the number of patients for beneÖcial and preventive care in the outpa￾tient setting.22 The disadvantage of this data is that, as in the case for most of the
discharge data, it only includes limited individual demographics such as gender,
and place of living (no education or income).
The Patient Survey consists of two types of data: outpatient data and discharge
data. I use the former to examine outpatient visits and the latter for inpatient
admissions. The outpatient data is collected during one day in the middle of October of the survey year and provides information on all patients who had outpatient
visits to the surveyed hospitals and clinics during the survey day.23 This data in￾cludes patientsíexact date of birth and the survey date, which is equivalent to the
exact date of the visits. The discharge data contain the records of all patients who
were discharged from surveyed hospitals and clinics in September of the survey
year. The discharge data report the exact dates of birth, admission, surgery, and
discharge, which enable me to compute age at admission.24 Hospital and clinic
information are obtained from the Survey of Medical Institutions and merged with
Patient Survey.
As health outcomes, I examine both mortality and morbidity. I examine mor￾tality since it is one of the few objective, well-measured health outcomes and is also
often easily available, and comparable across di§erent countries. I use the universe
of death records between 1987-1991, which report the exact dates of birth, death,
place of death, and cause of death using International ClassiÖcation of Diseases
(ICD) Ninth. The main advantage of the death records is that they cover all deaths
that occur in Japan, unlike hospital discharge records, which only report deaths
that occur in the hospital.25 I complement the mortality results by examining
23Since outpatient visits are collected on only one day, the survey is susceptible to external
factors such as weather. Therefore it is important to include the survey year Öxed e§ects in the
speciÖcation to account for this common shock within years. This short survey period is another
reason why I do not exploit the year-to-year variation in cost-sharing in this paper.
24I describe these dates in chorological order for simplicity, but each unit of data is per discharge.
25A rare exception is hospital discharge records in California used in Card et al. (2008, 2009) that
tracks mortality within one year of discharge. To my knowledge, data that tracks post-discharge
mortality does not exist in Japan.
These two issues are less relevant for outpatient visits, since I will show later
that there does not appear to be a catch-up e§ect, and reaching the stop-loss is very
unlikely since outpatient visits are not costly. The more relevant case is inpatient
admissions. I will show later that overall age trend does not seem to display
any catch-up e§ects, but close inspection of inpatient admissions with elective
surgery shows some drop-o§ just below age 70, and a sudden surge just over age
70. Though not far from perfect, to partially account for the catch-up e§ect, I run
a ìdonut-holeî RD by excluding a few observations around the threshold. This
approach was initially proposed by Barreca et al. (2011) to account for pronounced
heaping in the observations around the threshold in RD framework.42 The caveat
of this methodology is that there is no clear economic or statistical consensus
on the optimal size of the donut and excluding observations near the threshold
undermines the virtue of the RD design, that is, comparing outcomes just below
and above the threshold. Nonetheless, this donut-hole RD may show whether my
RD estimates are sensitive to the catch-up e§ects.
Accounting for non-linearity associated with stop-loss is much harder, since
to fully understand the size of the di§erence between true and nominal price, I
may need data on episodes of illness rather than monthly aggregated data (Keeler).
and Rolph, 1988).43 I argue that the e§ect of the stop-loss on over-utilization is
probably much smaller in my case rather than RAND HIE because the stop-loss is
set by monthly in Japan rather than annually like the RAND HIE and most health
insurances in the U.S. To the extent that illnesses are unpredictable, this shorter
interval may make it harder for people to time and overuse the medical services.
Keeler et al. (1977) and Ellis (1986) formally show that the more time left in the
accounting period, the more the e§ective price falls. Furthermore, even under an
annual stop-loss, Keeler and Rolph (1988) empirically shows that people in the
RAND HIE respond myopically to stop-loss, i.e., people do not appear to change
the timing of medical purchases to reduce costs. Nonetheless, to partially account
for this e§ect, I simply apply formula of (1 ￾ xt)Pt for those whose out-of-pocket
medical expenditures are more than median in each survey year t since this problem
is most relevant for consumers who are close to reaching the stop-loss. Since the
probability of reaching the stop-loss is not high even for the inpatient admissions
(14 percent for those admitted, and 2 percent for non-conditional population), the
nominal price (38.0 thousand Yen) for those just below age 70 is not so di§erent
from the ìtrueî price (35.3 thousand Yen). Therefore, the bias coming from the
non-linearity associated with stop-loss may be negligible in this case.

Obesity and Health Tips

Obesity and Health Tips

Acknowledgements
During writing this dissertation, I beneÖted from a number of people. First of
all, I would like to thank my main advisor, Douglas Almond, for his guidance at
every stage of the my research. Without his continuous encouragement through
my entire dissertation, I could not complete the dissertation. Wojciech Kopczuk
and Tal Gross gave me invaluable advices and supports during job market.
I am also grateful to helpful comments and suggestions from Prashant Bharad￾waj, Kasey Buckles, Janet Currie, Joseph Doyle, Mark Duggan, Amy Finkelstein,
Kiyohide Fushimi, Michael Grossman, Hideki Hashimoto, Masako Ii, Amanda
Kowalski, Ilyana Kuziemko, Frank Lichtenberg, Jason Lindo, Bentley MacLeod,
Shinya Matsuda, Robin McKnight, Matt Neidell, Cristian Pop-Eleches, Heather
Royer, Bernard SalaniÈ, Miguel Urquiola, Eric Verhoogen, Till von Wachter, Reed
Walker, and the seminar participants at Bank of Japan, Columbia University,
McGill University, National University of Singapore, Osaka University, Simon
Frazer University, University of Michigan, Uppsala University, and NBER Japan
project meeting.
Special thanks go to Hideo Yasunaga and Hiromasa Horiguchi for their invaluable help in obtaining the data and for helpful discussions.


Yet others suggest that it is not relevant or desirable to envisage any illness, obesity included, as a social
construct (Berger, Luckman, 1975, pp.65-108). This is because it tends to relegate, preventive medicine to be
an external factor within health and denies the role in which an individual plays, in being responsible for
their own health concerns (Germov, 2005, pp.15-17) (Jusssim, 1991, pp.54-73). Which according to the early
17th century Philosopher, Descartes, this was neither desirable nor relevant, if medicine / health and society
was to progress within the 17th century. Infact with Descartes, individualist philosophical claims off; I think
there for I am; discourse, becoming embodied, within an enlightenment period of history. The individual In conclusion as I mentioned at the outset of this essay, that from a social constructivist, philosophical
perspective, the illness of obesity is a socially constructed health concept and that within a western
liberalistic, philosophical tradition and context, obesity tends to be envisioned as a symptom of a modern
lifestyle process. I have endeavoured to elaborate, how obesity has become a chronic health problem, within
a modern western society and endeavoured to explain, why a modern liberalistic, philosophical tradition,
finds it hard to diagnose, what causes the health condition- obesity. Indeed I would tend to agree with the
Social Scientist Lupton, when he suggests that: “Within a western liberalistic, philosophical paradigm,
health is seen as risk concept, (obesity in this case), and it thus can become a covenant, hegemonic tool for
big business and politicians, so as to maintain a power structure within society. This is achieved because, big
business and politicians are in the unique position, as to be able to identity and define, what a health risk is
(symptoms), (obesity in this case) and if there is to be any solutions (diagnoses), to such health risks.
Consequently because politicians and big business are able to determine what a health risk is, they are then
able, to also, legitimize and control a specific ideology and social practice within society, when it is
necessary.” p.432 (Lupton, 1993, p. 432
became cental to decision making, this is because self responsibility and the idea of the body, as a biological
machine took root, while an individuals mind became a separate entity (Turner, 2003, pp.15-16).
Consequently the Cartesian / rational idea, of the body, as machine suited the adventures of an enlightened,
empirical science process (Parker, 1995, pp. 24-29) (Duhamel, 1933, pp. 162-166). Indeed envisioning any CHAPTER 1
The E§ect of Patient Cost-sharing on Utilization, Health
and Risk Protection: Evidence from Japan
1.1. Introduction
Governments increasingly face an acute Öscal challenge of rising medical expen￾ditures especially due to aging population and expansion of coverage. Spending
growth for Medicare, the public health insurance program for the elderly in the
United States, has continued unchecked in spite of a variety of government at￾tempts to control costs.1 As more than one third of current health spending is on
the elderly, future cost control e§orts can be expected to focus on seniors.2
One main strategy for the government to contain cost is cost-sharing, requiring
patients to pay a share of the cost of care. However, cost-sharing has clear tradeo§s.
While cost-sharing may reduce direct costs by decreasing moral hazard of health
1Examples of supply-side attempts by the government to control cost are the introduction of
prospective payment for hospitals and reductions in provider reimbursement rates (Cutler, 1998).
2The elderly are the most intensive consumers of health care. Patient over age 65 consume 36
percent of health care in the US despite representing only 13 percent of the population (Centers
for Medicaid and Medicare Services 2005). Furthermore, Medicare costs are expected to comprise
over a quarter of the primary federal budget by 2035, or between Öve and six percent of GDP
(CBO, 2011). Likewise, in Japan, the elderly consume Öve times as many health services as
non-elderly (Okamura et al, 2005). Also Japan has the most rapidly aging population in the
world (Anderson and Hussey, 2000)
). Employment-based health insurance covers the employees of Örms that sat￾isfy certain requirements and employeesídependents.9 NHI is a residential-based
system that provides coverage to everyone else, including the employees of small
Örms, self-employed workers, the unemployed, and the retired.
For this study, there are two important features of Japanese medical system
that arguably permits isolation of the patient demand for health care services
from responsive behavior by insurers and medical providers: universal coverage
and the uniform national fee schedule. First, under universal coverage, patients
in Japan have unrestricted choices of medical providers unlike in the U.S where
managed-care often restricts the set of the providers at which beneÖciaries can
receive treatment. For example, it is common for individuals to visit hospitals for
outpatient care rather than clinics (similar to physiciansío¢ ce visits in the U.S.)
in Japan. Patients have direct access to specialist care without going through
a gatekeeper or referral system. There is also no limit on the number of visits
a patient can have. Patients may go either hospitals or clinics for outpatient
visits and go to hospitals for admissions, unlike in the U.S., where those who lack
insurance use hospitals as primary care.
9Employment-based health insurance is further divided into two forms; employees of large Örms
and government employees are covered by union-based health insurance, whereas employees
of small Örms are covered by government-administered health insurance. Enrollment in the
government-administered health insurance program is legally required for all employers with Öve
or more employees unless the employer has its own union-based health insurance program
Second and perhaps more importantly, all medical providers are reimbursed
by the national fee schedule, which is uniformly applied to all patients regardless
of patientsí insurance type and age. Since patientsí insurance type and age do
not a§ect reimbursements, physicians have few incentives to ináuence patientsí
demand.10 For example, from physiciansí perspective, there are few reasons to
delay surgeries until age 70 because reimbursements do not di§er by age of patients.
The uniform fee schedule also implies that there is little room for cost-shifting, a
well-known behavior of medical providers in the U.S. where they charge private
insurers higher prices to compensate for losses from beneÖciaries of public health
insurance (Cutler, 1998).11
As a result, while people in Japan enjoy the relatively easy access to health
care services, Japan has the highest per-capita number of physician visits among
all OECD countries; physician consultations (number per capita per year) is 13.2
in Japan, which is more than three times larger than 3.9 in the U.S. (OECD, 2011).
While some blame universal coverage for high frequency of unnecessary physician
visits, others claim that these medical services contribute to the longevity of the
Japanese (Hashimoto et al., 2011).
10The national schedule is usually revised biennially by the Ministry of Health, Labor and Welfare
through negotiation with the Central Social Insurance Medical Council, which includes repre￾sentatives of the public, payers, and providers. See Ikegami (1991) and Ikegami and Campbell
(1995) on details.
11Japan introduced prospective payment for hospitals since 2003 for only acute diseases, but the
reimbursement does not di§er by the insurance type or age of the patients. See Shigeoka and
Fushimi (2011).

Obesity and Health

Obesity and Health

Why is it, that health is such a major concern for humans? Is it because health for humans, and all other
living things for that matter, is such an essential primordial process in staying alive? The answer of course is
yes. The next question of sociological importance is to what extent, is any illness, socially constructed?
Hence this is the question I am to endeavour to answer in this essay. Infact I will argue that from a social
constructivist philosophical perspective, that the illness of obesity is a socially constructed health concept
and that within a western, liberalistic paradigm and context, obesity tends to be envisioned as a symptom of a
modern lifestyle process. I will endeavour to elaborate as to how obesity has become a chronic health
problem within a modern western society and endeavour to explain, as why a modern, western liberalistic
society, finds it hard to diagnose what causes the health condition- obesity. First, what in general terms, is
obesity? According to the early 17th century Doctor, Tobias Venner and his enlightened, liberalistic
philosophical paradigm; obesity is: “An individual disease process, of a fat an gross habit of body, which is
far worse than a lean individual body, as it is more prone to become sick.” pp.19-20. (Gilman, 1998, pp.19-
20) (Blackburn, 2005, pp. 209-210). However from a social constructivist, philosophical paradigm
perspective, obesity is seen as a socially constructed illness, which is something quite different entirely
(Blackburn, 2005, pp.158, 342). Indeed according to the Political Scientist Oliver, a social constructivist,
philosophical paradigm, tends to envisage heath concerns, such as obesity within a social context, so as to
fully understand and identify the health issue concerned (Oliver, 2006, pp. 611-626) (Haralamobos, Holborn,
1991, pp. 2-5, 19, 758-761, 768, 799-804). Infact within the context of this essay, according to the Professors Hafferty and Castellani, they suggest that in general terms, health in any society, is always, intrinsically
bound up in contested dialogues. So it thus becomes very hard to envisioned, what is good health and bad
health concepts (Hafferty, Castellani, 2006, pp. 331-338) (Poynter, 1973, pp.22-43). Indeed such a statement
tends to confirm the many tensions within the medical fraternity itself. For instance, the concept of a chronic
illness is completely different, to what an acute illness is. Infact a chronic illness is defined as: “As a health
problem, which is long-lasting or recurring over a lifetime, some examples are, arthritis, cancer, diabetes,
Alzheimer’s disease, depression, and heart disease.” p.1 (AARP-Educating Community, 2003, p.1). Which is
completely different to what an acute health problem is: “ Which is a disease that lasts for just a short time,
but can begin rapidly and have intense symptoms, such as, colds, influenza and strep throat, etc. ” p. 8
(Geddes,Grossent,1997, p.8).
Infact it has been suggested that within a modern, liberalistic philosophical perspective, it is not really
possible to envisage obesity, as a socially constructed illness (Klienman, 1998, pp.3-8). This is because,
according to a liberalistic philosophical view, a society is made up of individuals, who are embedded within
voluntary contractual relationships within an authoritative paradigm concept, such as say, within
government and business processes, etc (Bullock, Trombley, 1999, pp. 479-480) (Russell, 2008, pp. 544-
550). Consequently there seems to be no such thing, as a perceived social community, thus health can not be
seen as a social construct. Infact, according to the Psychiatrist Ogden, she suggests that an individuals
identity is constructed through a process of individual knowledge concepts and to thus assume other wise, in
that an individuals identity, is somehow embedded within an individuals concept of health and psychology, is
to be very mistaken (Ogden, 2002, pp.98-107). Indeed Ogden implies, that an individuals self image is an
internal, (ego-orientated), process that has little to do with any external (social) influences (Ogden, 2002,
pp.19-30). For instance according to Ogden, this is obvious in that within the twentieth century, there have
been three distinct internal selves, which have shaped an individuals identity, these are the passive self,
interactive self and intra-active reflexive self (Ogden, 2002, p. 101). Infact the Sociologist Foucault, implies
that this is essentially why a liberalistic philosophical perspective, should and can not, possible envisage any
illness, such as obesity as an example, as a chronic health problem, but rather, it must be seen as an acute
health problem (Foucault, 1998, pp.125-151). For example; “An acute illness is a lot more serious for an individual, requiring attention from trained medical personnel and possible hospitalization procedures as a
result (physicians, nurses, physical therapists). Where in contrast, a chronic illness is often controlled and
even overcome by an individual, acting on their own initiative and without any help from others “pp.1-2
(Roy, Russell, 2006, pp.1-2). Consequently obesity has become a illnesses in today’s modern world, which is
also seen within an epidemic, biological disease problem context, thus obesity tends to become classified as
acute illness and requiring some form of medical treatment to rectify the problem (Williams, Germov, 2005,
pp.138, 340-341, 344). Indeed Gilman mentions that many government departments, now, treat obesity as an
epidemic illness and thus biological cures are necessary to treat this dire disease (Gilman, 1998, pp.3,
79,146-147, 14-44,164-175). For instance, China has a concern that their children, are at risk of becoming
obese and dying before their parents. Infact it is mentioned that up to 20% of Chinese children, living in
china’s cities within the 1990s were obese (Gilman, 1998, pp.146-151).
Though I suggest, from a social constructivist, philosophical perspective that any concept of obesity and all
its imaging have, is constructed through a social health, paradigm concept (Oliver, 2006, p.626). For
example, as implied by the Sociologist Blumer, who reigns from symbolic internationalism perspective, or a
social constructivist philosophical view in essence, health in any society, is envisioned as a symbolic
internationalism process, with health, cultural and social concepts experienced and embodied, in different
ways within different “health expert” knowledge areas (Blumer,1969, pp.1-21) (Julian,2005, pp.150-151).
Moreover in regards to Ogden suggestion that the self, (our identity), is an internal matter not to be
incorporated within a social construct. I would have counter her view and agree with the Sociologist
Gofman, when he implies that the self is intimately entwined within a social constructionist process and that
this is quite obvious, in the case of how stigmas and labels are attributed to an assumed health illness, or
anything else for that matter (Gofman, 1975, pp.13-83, 141-166, 231-249).For instance obesity has been
stigmatized / labelled in our present historical period, as a non desirable concept, even deviant to some
extent (Millen, Walker, 2003, pp.89-91) (Gilman, 1998, pp.78-101). Thus the assumed illness obesity is
constructed through a social process, incorporating our self identity, (ego), in many respects. Infact, such a
process confirms the suspicion of the Sociologist Klienman, for according to him, obesity has now become a
chronic health problem, rather than an acute health problem (Klienman, 1998, pp. 5-30) (Conrad, Barker,
2010, pp. 72-73) (AARP-Educating Community, 2003, pp.1-28). Consequentially because a chronic health
problem is defined as a long lasting in its duration, both within an individual and by proxy within a
community, then obesity in essence, can only but be envisioned within a social construct (Cockerham, 2005,
pp. 51-67). This is because health is seen to be analogical akin, as to how a society functions and thus it is
statistically, much easy to implement preventative medicine to alleviate obesity concerns, rather than from a
liberalistic, acute health perspective, which tends to initiate, only, symptomatic short term cures to obesity
issues (Conrad, Barker, 2010, pp. 67-79). Indeed according to the Socialists Cleland, Teijlingen and Cotton,
this is exactly the reason why it is virtually impossible, for a pharmacists / medical practitioner, who has a
liberalistic philosophical perspective, to accurately diagnose when, where and why, a chronic health illness
may originate from (Cleland, Teijlingen, Cotton,2011, pp.3-9). Specifically because pharmacists / medical
practitioners who have liberalistic philosophical perspectives, can not, thoroughly diagnose what may cause
obesity, without investigating and researching, as to how and why a chronic illness context may evolve. For
instance the Sociologist White suggests, that today’s obsession with medicalzation; (Our present western
societies, reliance upon doctors, drugs and the concept of normalization), as cure for an illness, obesity
included, tends deny that any external factors, such as a communities cultural and social practices, can play a
part in an illness evolving, which in reality is quite the opposite (White, 2002, pp.34-35, 41-44, 49).
Yet others suggest that it is not relevant or desirable to envisage any illness, obesity included, as a social
construct (Berger, Luckman, 1975, pp.65-108). This is because it tends to relegate, preventive medicine to be
an external factor within health and denies the role in which an individual plays, in being responsible for
their own health concerns (Germov, 2005, pp.15-17) (Jusssim, 1991, pp.54-73). Which according to the early
17th century Philosopher, Descartes, this was neither desirable nor relevant, if medicine / health and society
was to progress within the 17th century. Infact with Descartes, individualist philosophical claims off; I think
there for I am; discourse, becoming embodied, within an enlightenment period of history. The individual
became cental to decision making, this is because self responsibility and the idea of the body, as a biological
machine took root, while an individuals mind became a separate entity (Turner, 2003, pp.15-16).
Consequently the Cartesian / rational idea, of the body, as machine suited the adventures of an enlightened,
empirical science process (Parker, 1995, pp. 24-29) (Duhamel, 1933, pp. 162-166). Indeed envisioning any illness as a social construct within this period was not relevant as the main cultural paradigm of the time. As
it has been implied that this period in history, was more of a religion based, cultural artefact. This is obvious
in that; if you became ill within this period, it was the will of God and it had little to do with any social
constructive processes within the society, at the time (Poynter, 1973, pp.43-62) (Parker, 1995, pp.22-23).
Moreover from a liberalistic philosophical perspective, it is really quite easy to define and diagnose what
obesity is and thus then find a solution to the illness (Hafferty, Castellani, 2006, pp. 331-338). Indeed it can
be implied that due to “science” becoming involved within medical / research procedures, it has been much
easer to diagnose any illness (obesity included). Specifically because a scientific evidenced based, empirical
research processes tends to eliminate, many other complex pathogens, (biological and / or otherwise),within
an illness / diseases process (Swami, 2007, ”pp. 1-37).For instance a 2010 Chinese study, has shown that
obesity within Chinese culture seems to defy the social constructivist notion that a modern culture, with all
its media communications seeming to advocate obese eating habits, can socially construct obesity scenarios
within a culture. For instance, the study implied that males who were slender in BMI / build (Body Mass
Index) had more heart attacks than those of men, who had high BMI and were obese in build (Yang,
Maigeng, Smith, Yang, Peto, Wang, Boreham, Hu Chen, 2010, pp.1027–1036).
However I would argue, along with many others, from a social constructivist, philosophical
perspective, that because obesity is envisioned as a socially constructed health concept, it is thus
much easy to diagnose what causes the health condition obesity (Lupton, 1993, pp.429-431) (Jary,
1995, pp. 605-606). Infact according to the Sociologist Shove, because pattens of diets, such as
high junk food diets, can become socially acceptable concepts, embedded through, infrastructural
and institutional processes, it thus creates an environment where obesogenic, or normative
conceptual frameworks evolve. Which unfortunately, is not a good outcome for humanity, as it
tends to highlight the fact that we are ignorant of how and why normative social constructs can / do
evolve (Shove, 2011, pp.9-10). Indeed this is no more obvious in how the 18th century American
puritan pioneers, were ignorant of the fact that Native Americans, did not have any immunity to 18th
century health problems, such as tuberculosis, influenza, small pox, etc. Consequentially the 18tcentury.