A Sociology of Health

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Edited by: David Wainwright

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    Preface

    DavidWainwright, Bath, April 2007.

    Social science may be confused, but its confusion should be exploited rather than bemoaned. It may be sick, but recognition of this fact can and should be taken as a call for diagnosis and perhaps even as a sign of coming health.

    C. WrightMills, The Sociological Imagination, 1959

    While many medical sociologists are safely ensconced in departments of sociology and rarely teach students from outside their faculty, others are located in medical schools or other settings where they encounter a range of healthcare professionals both as students and research collaborators. First-year medical students, for example, are obliged to take a brief course introducing them to the social sciences as they are applied to medicine. The intention is to broaden the students' horizons beyond the realm of medical science and enable them to develop an awareness of the patient as a social being. Not surprisingly, many react against this imposition and would rather spend their scarce time on what they see as more clinically useful topics, such as neurology or anatomy. All too often what was intended to spark the sociological imagination of the healthcare professional, only serves as a vaccination against future contact with the discipline.

    Teaching sociology to healthcare professionals can be a dispiriting occupation, but it does provide an insight into the uneasy relationship between the discipline and its subject matter. Qualitative researchers sometimes use the technique of ‘informant validation’ in which the results of the researcher's analysis are presented to those who participated in the study to see if they fit with the informants' own interpretations. The technique is of limited value because sociological analysis can reveal ‘truths’ about a group which are not apparent to its members, and to which they may take exception, but which are no less valid for that. But the antagonism between medical sociology and medical practitioners goes much deeper than that between analyst and analysed. It is not just that medical students take issue with some of the claims of sociology, but that they detect in it a hostile opposition to the principles of modern medicine and the implication that to practise medicine is an act of bad faith.

    What the medical students pick up on are the claims that science should be given no primacy over other ‘truth-claims’, that medical knowledge is just a cloak for the exercise of professional power and that the putative achievements of medical practice are insignificant compared to the gains that could be made by addressing the social determinants of health. The spark for this book came not from those medical students who put up a spirited defence against such claims, but from the many others who acquiesced in them; from the growing number expressing the belief that homeopathy has an important role to play, or that the patient's diagnosis was every bit as valid as the doctor's. It occurred to me that this response was more in touch with the spirit of the times and reflected a broader malaise in the dominant medical institutions and elites.

    For more than a generation medical sociology has defined itself in opposition to what James Le Fanu (1999) describes as the golden age of clinical science which emerged in the post-war period and which was characterised by commitment to the Enlightenment project of using science and reason to overcome the problems of humanity.1 However, as Le Fanu has observed, this golden age was drawing to a close by the 1970s: medical science and the profession that practised it were increasingly challenged and questioned, not least by medical sociology. Of course, sociology should always question the established order and challenge orthodox ways of thinking about the world, and challenging the hubristic claims of modern medicine must have seemed radical and progressive at the time. However, in today's context there are new orthodoxies to be debunked, a new discourse of health to be critically explored.

    The aim of this book is to apply a critical approach to the most pressing issues and controversies in the contemporary discourse of health. Central to our perspective is the belief that although the concepts, theories and methods of medical sociology (in its broadest sense) can aid our understanding of these issues and controversies, the discipline itself does not stand outside of its subject matter as an objective observer; but rather the social models which have emerged from medical sociology have themselves had a fundamental impact on the way in which health and illness are made sense of and understood in contemporary western societies. This influence has not always been progressive and much of what follows takes issue with many of the assumptions and claims of medical sociology; as such it is both an exposition and a critique of the discipline.

    It is traditional for ‘textbooks’ to offer an even-handed précis of the canon; of course, perceptive students will always ask how the content of the canon was decided and what lies behind this claimed even-handedness. No such claims are made here. We have selected from medical sociology those concepts and theories which we believe have had most impact upon the new discourse of health, or which are of most value in understanding it. The contributors to the book are a diverse group, not all of whom would describe themselves as medical sociologists. They subscribe to no individual school of thought or uniform theoretical standpoint, but there are common threads running through their analyses. The achievements of medical science are recognised and valued, but there is also recognition that there is a social and psychological dimension to health and illness. Medical pluralism and epistemological relativism are eschewed, but there is recognition that knowledge is always socially situated and may (or may not) be distorted by vested interests. More importantly, there is a humanist orientation which emphasises the capacity for humans to make sense of the world around them and use reason to overcome the problems and difficulties they face. It is this humanist orientation and re-engagement with the Enlightenment project that gives the book its distinctive approach. As the chapters unfold it will become apparent that the new discourse of health is founded on a far gloomier interpretation of human potential.

    The Structure of the Book

    Chapter 1 provides a brief introduction to some of the key themes and contradictions that characterise the new discourse of health, before describing three social models of health and illness that have emerged from medical sociology and related disciplines such as epidemiology and social medicine. The three approaches are appraised in terms of their influence on the new discourse of health and in terms of their theoretical adequacy. The chapter closes with an outline sketch of what an alternative approach to the sociology of health and illness, grounded in critical realism and humanism, might look like. This new perspective is a work in progress rather than a firmly established and clearly defined paradigm. The remaining chapters provide examples of this approach in practice.

    In Chapter 2 Alan Buckingham asks why, after a century in which medical science made phenomenal progress in the fight against disease, we appear to have a heightened sense of anxiety about our health, which has led to ever greater regulation of perceived ‘health risks’ and ‘unhealthy lifestyle choices’. Close analysis of the statistical evidence behind such health scares not only reveals that such claims are often based upon poor research or ‘junk science’, but that many of the statistical techniques employed by researchers exploring the social determinants of health and unhealthy lifestyles, even if applied with great rigour and precision, must inevitably give rise to a degree of anxiety which is disproportionate to the threat posed, for example, the calculation of relative rather than absolute risk ratios. The chapter concludes by considering the extent to which health statistics are both a cause and consequence of a broader culture of fear.

    There is more to health and illness than the presence or absence of physical pathology. The western medical model is frequently criticised for its ‘biological reductionism’; the failure to recognise the role of subjectivity and social relations in the aetiology, experience and outcome of illness and disease. Proponents of ‘holistic medicine’ have argued for greater understanding of the subjective aspects of suffering and a transcendence of mind-body dualism. In Chapter 3 Stephen Bowler explores the mind-body problem, in the context of the humanist Enlightenment project. Where medical sociology has frequently viewed the objectification of the body as a limitation of the bio-medical gaze, Bowler argues that the capacity for science to master the objective reality of the body is central to the success of modern medicine. The current trend towards holistic and complementary medicine does not represent the emergence of more humane practice, so much as a loss of faith in human agency; a trajectory which leads away from science and medical progress.

    Several chapters in this book refer to health scares or health risks, and the emergence of a heightened sense of mental and physical vulnerability. In Chapter 4, Adam Burgess asks what it is about contemporary western societies that provides such fertile ground in which the seeds of health risk can take root and flourish. Grounding his analysis in recent health scares, such as the putative link between the combined vaccination for Measles, Mumps and Rubella (MMR) and the onset of autism in childhood, and the equally spurious claims about health risks associated with the use of mobile phones, Burgess develops a multi-dimensional sociological framework which locates the preconditions for the risk society at the macro level of social development, the intermediate level of contextual factors, and the direct role of ‘risk entrepreneurs’ and other groups and institutions in promoting alarm.

    Chapter 5 examines the influence that the three social models of health and illness have had on the broader discourse of health and illness through the New Public Health and the adoption of Patient Centred Practice in primary care. It is argued that the redefinition of health in terms of mental and social wellbeing has broadened the domain of healthcare policy and practice to include new areas of everyday life, while the identification of psycho-social stressors and lifestyle risk factors has given rise to a new sense of mental and physical vulnerability. At the same time, the role of the doctor as gatekeeper to the sick has been eroded by a shift from evidence of physical pathology as the basis of diagnosis, towards the subjective illness claims of the patient. These changes have contributed to an epidemic of medically unexplained illness behaviour and an expansion of the role of healthcare in the governance of everyday life.

    The purpose of medicine is to ameliorate suffering, but the pursuit of this goal entails entering into a set of social relations that are embroiled in the exercise of power and control. Sociologists have conceptualised this contradiction through the category of medicalisation, and in Chapter 6 Frank Furedi explores how this construct has been reformulated during its 40-year history. Emerging during the radical questioning of professional and institutional power of the late 1960s, medicalisation was initially coined as a challenge to the professional dominance of ‘problems’ such as madness, childbirth, and homosexuality. However, as Furedi's analysis reveals, the phenomenon of medicalisation has undergone a vault-face. Medicalisation no longer refers to the expanding power and influence of the medical profession, but to a broader cultural turn, in which diagnosis and therapy have become entangled in the validation of identity – ironically, the impetus for medicalisation no longer comes from the doctor but from the would-be patient.

    Second-wave feminism made a significant contribution to the theory of medicalisation, and also provided its operational arm, in the form of the women's health movement of the 1970s; rejecting medicalised categories which asserted that women's subordinate role in society had a biological rather than political basis, and asserting the right for women to identify and address their own health needs. In Chapter 7 Ellie Lee and Elizabeth Frayn document the retreat from this emancipatory standpoint, as contemporary feminists demand recognition of new medicalised categories such as Post-natal Depression or Pre-menstrual Syndrome, which imply that women really are slaves to their biology. The extent of this reversal is nowhere more apparent than in the rise of the men's health movement which is grounded in the critique of masculinity and encourages a more pusillanimous approach to the negotiation of health risks. The feminization of health is explored through a detailed case-study of the topical and controversial issue of cancer screening.

    The uneasy relationship between medical science and medical sociology is woven deeply into the fabric of this book. In Chapter 8 Tracey Brown explores this tension, placing the relativist challenge to medical knowledge in the broader context of the conflict between science and ‘wilful superstition’. The rise of the evidence-based medicine movement is charted and the different strands of the backlash against it are discussed, from the feminist standpoint theory to complementary and alternative medicine. It is concluded that although medicine may have won the science wars, the victory is becoming increasingly pyrrhic, as leading scientific institutions and authorities retreat into defensive and conservative strategies.

    In Chapter 9 Mike Bury draws together many themes discussed earlier in the book and applies them to the latest policy initiatives relating to the National Health Service. Central to the analysis is the shifting relationship between the providers of health care and its recipients, variously constructed as: the public, consumers, partners, or expert patients. The medical profession have retained much of their social standing and trust, but in other respects they appear beleaguered; hemmed in by bureaucratic regulation and control, threatened by litigation, and obliged to cede authority to a range of competing interests. Rhetorically at least, the chief beneficiary of this apparent redistribution of power is the patient; empowered by new mechanisms of consumerism and choice, with their preferences and subjective beliefs buoyed to at least equal status with the expertise of the doctor. Yet all may not be as it seems and through a highly nuanced analysis the reality of this top down revolution in the doctor-patient relationship is revealed.

    In the final chapter, Chapter 10, Vanessa Pupavac reveals how the tensions and uncertainties of western medicine are being exported to the developing world. Following the Second World War international health policy was linked to a broader project of economic and social modernisation, which saw the exportation of high-technology medicine to the towns and cities of the third world, coupled with ambitious public health programmes to eradicate smallpox and malaria. However, by the mid 1970s the modernisation agenda was faltering under criticisms that it was unaffordable, inappropriate and unsustainable. Modernisation gave way to the more modest goal of sustained development, and rather than attempting to equip the developing world with high-technology medicine international agencies shifted towards meeting basic health needs among the rural poor through deprofessionalised initiatives which often embraced traditional healing and environmentalist concerns. Earlier chapters describe the way in which the focus of health policy in the affluent West has shifted from the treatment of disease towards a broader pursuit of ‘healthy lifestyles’ and ‘psycho-social wellbeing’; Pupavac's analysis reveals the extent to which this therapeutic model is being adopted by international aid and development agencies as a means of ameliorating the ‘trauma’ of poverty and hardship, but failing to address the core problems of uneven and unequal development.

    Conclusion

    Illness is not easy terrain for humanists; it is where we encounter our limitations. Ultimately physiology extinguishes human consciousness – death is the end of all our projects and aspirations. But it is also the place where we transcend at least some of these limitations in a uniquely human way. Animals do not make sense of their symptoms, they do not derive theories of aetiology, they have no system of diagnostic categories, and they have developed no curative treatments for their afflictions beyond the most basic adaptive responses. Humans do all of these things, not alone, but through social relations, lay and professional networks, and the production of knowledge. The profoundly social character of illness and medicine means that health can never be absolutely reduced to biological science. The sociological imagination has an important role to play in revealing the ways in which social relations influence how we make sense of our ailments and find ways of overcoming them. In the past the relationship between medical sociology and medical science has often been an antagonistic one. Social models of health have often been presented as a superior alternative to bio-medicine, and the Enlightenment claim that social progress results from the application of science to the natural world has been dismissed by some sociologists as a cloak for tyranny. Our purpose in writing this introductory text is to posit a very different relationship between medical sociology and its subject matter. A critical humanist approach to medical sociology is one which recognises the contribution that modern medicine can make to social progress and which uses the concepts and methods of sociological inquiry to reveal and understand the social and cultural obstacles to the realisation of that potential.

    References
    1 Le Fanu, J. (1999) The Rise and Fall of Modern Medicine. London: Little Brown & Co.

    Acknowledgements

    I would like to thank everyone who has contributed to the production of this book. My co-authors have responded promptly and with good grace to requests for drafts and redrafts. The anonymous reviewers provided many helpful suggestions for improving the content and format of the book. The staff at SAGE have been supportive and helpful throughout, particularly Zoë Elliott-Fawcett and Anna Luker.

    Epigraphs

    The editor would like to thank the copyright holders for permission to reproduce the following quotations:

    Foreword epigraph: Wright Mills (1963). Reproduced with permission of Oxford University Press, Inc.

    Chapter 1 epigraph: Porter (1997). Reprinted by permission of HarperCollins Publishers Ltd © Roy Porter, 1997.

    Chapter 2 epigraph: Wildavsky (1997) © 1977 by the American Academy of Arts and Sciences. By permission of MIT Press Journals.

    Chapter 4 epigraph: Douglas and Wildavsky (1983). Reproduced by permission of The University of California Press.

    Chapter 6 epigraph: Zola (1978/1972: 501). Reproduced with permission.

    Figures

    Figure 2.1: Office for National Statistics (2006) Social Trends. London: HMSO. Crown copyright 2006. Online Edition.

    Figure 2.2: Adapted from Griffiths, C. and Brock, A. (2003) ‘Twentieth Century Mortality Trends in England and Wales’, Health Statistics Quarterly, 18: 5–17. Crown copyright 2003. Online edition.

    Every effort has been made to trace all the copyright holders, but if any have been inadvertently overlooked the publishers will be pleased to make the necessary arrangements at the first opportunity.

    List of Contributors

    Stephen Bowler is currently researching a book on suffering and subjectivity. Stephen has also contributed several essays on health at http://www.spiked-online.com.

    Tracey Brown is Director of Sense About Science, a charitable trust promoting good science and evidence for the public. The trust's work aims to raise the standards of science in all areas of public life and covers a wide range of contentious issues such as chemicals, radiation, vaccines and genetic modification. Tracey is a regular contributor to public and media debates on science, the public and progress.

    Alan Buckingham is Senior Lecturer at Bath Spa University. Alan has research interests in social inequality – particularly class inequality – and the social effects of welfare policy. He is co-author, with Peter Saunders, of The Survey Methods Workbook (Polity, 2004).

    Adam Burgess is Senior Lecturer in Sociology at the University of Kent where he lectures on the historical sociology of risk. His last book, Cellular Phones, Public Fears and a Culture of Precaution (Cambridge University Press, 2003) was widely praised internationally. He is currently researching British public inquiries, and belief in ‘drink spiking’.

    Mike Bury is Emeritus Professor of Sociology at the University of London. He was head of the Social Policy and Social Science Department at Royal Holloway from 1996 to 2001. Mike's main research interests have been in the sociology of chronic illness and in ageing. More recently Mike has been concerned with self-care in chronic illness, and wider aspects of health policy and medicine. Mike's most recent book is Health and Illness (Polity, 2005). He has served on a number of public bodies including the MRC and NICE. Mike was the co-editor of Sociology of Health and Illness from 1995 to 2001.

    Elizabeth Frayn is a specialist trainee in psychiatry, working in the NHS in London. She writes for http://www.spiked-online.com on medical matters, and has a particular interest in the impact of health awareness campaigns.

    Frank Furedi is Professor of Sociology at the University of Kent. His research is oriented towards the study of the impact of precautionary culture and risk aversion on western societies. In his books he has explored controversies over issues such as health, children, food and cultural life.

    Ellie Lee is Senior Lecturer in the School of Social Policy, Sociology and Social Research University of Kent. Her research engages the sociology of health and of the family. She is the author of Abortion, Motherhood and Mental Health (Aldine Transaction, 2003), and the editor of Abortion Law and Politics Today (Macmillan, 1998) and Real Bodies (Palgrave, 2002).

    Vanessa Pupavac is a lecturer at the University of Nottingham. Vanessa's recent research examines the influence of western therapy culture on international aid policy and the rise of international psychosocial programmes. Her research is underpinned by an interest in contemporary subjectivity and the crisis of meaning in international politics. Vanessa was awarded the Otto Klineberg Intercultural and International Relations Award 2003.

    David Wainwright is Senior Lecturer at the University of Bath. His research interests focus on the sociology of work and health. Previous publications have explored the social construction of the work stress epidemic, and he is currently researching the negotiation of health-related resilience within workplace social networks.

  • Conclusion

    Finally … some remarks are in order about how – or, indeed, whether – the practice of sociology would need to be different in my ‘re-imagined’ form. Certainly the word ‘sociology’ would recover its original normative voice, as disciplinary practitioners see themselves contributing to the constitution of the societies they study, typically by raising subjects' collective self-consciousness.

    SteveFuller, The New Sociological Imagination, 2006

    This book has spanned a broad terrain, from the putative health risks of mobile phones to the government's ‘expert patient programme’, and from the growing popularity of homeopathy to the construction of new maladies, such as fibromyalgia or work stress. Superficially, these phenomena appear to be independent and discrete, however, closer analysis reveals common threads, which when drawn together help us to understand what is unique and historically specific about the prevailing discourse of health.

    The unifying theme and the key to understanding contemporary health issues is the concept of fear. Fear is manifest at two interlinked levels of analysis, at the individual and the social, or to use C. Wright Mills's terminology, personal troubles and public issues.1 At both levels of analysis there are two aspects to this new wave of anxiety. First, is a heightened sense of vulnerability to mental and physical pathology and to the unchecked power of vested interests. The second aspect is a diminished sense of agency; the belief that we are largely powerless to overcome these external threats.

    The heightened sense of vulnerability can be seen in the epidemic of ‘health scares’ which suggests that previously taken-for-granted aspects of everyday life, such as, diet, paid employment, or the use of new technologies, pose a major threat to our physical or mental health. The list of perceived threats extends to institutionalised structures of power which were previously thought to be benign or even beneficent. The pharmaceutical industry, whose products have saved countless lives, is derided as ‘Big Pharma’ and the medical profession itself is constantly disparaged as a source of abuse, by reference to high profile ‘scandals’ such as the postmortem removal and retention (without parental consent) of children's organs by pathologists at the Alder Hay Hospital, or the furore around expert witness Professor Roy Meadows's erroneous evidence, which contributed to the wrongful conviction of several women accused of murdering their children. The point is not that such threats are false, or that they do not warrant investigation, but that their magnitude is grossly amplified; the personal and institutional responses they evoke are disproportionate to the actual threat posed; and that this over-reaction can generate adverse outcomes which outweigh those of the perceived threat.

    The individual and social responses to these perceived threats illustrate the second aspect of the contemporary form of fear, namely the diminished sense of agency or selfhood. Superficially, it appears contradictory to insist that examples of individual and social action illustrate a diminution of agency. However, by agency, we are not referring to any and all forms of activity, but to purposive human action to transform and humanise the external world. Thus when the Inquisition arrested Galileo and branded his support for heliocentrism heretical, they were not engaging in human agency, but trying to stifle it. The response to the contemporary culture of fear is equally conservative and counter to human agency. At both the individual and collective levels the response is characterised by the precautionary principle which holds that no action should be taken unless its consequences can be proven to be benign.

    As we have seen, at the institutional level this has led to new forms of regulation, which have placed constraints on scientific development and reduced the autonomy of the medical profession. At the individual level, the diminished sense of agency has generated an introspective and internalised response, characterised by risk avoidance and the tendency to translate social problems into medical complaints, giving rise to a host of new syndromes. Rather than trying to change the world, individuals attempt to resolve their problems by seeking therapeutic solutions or by calling for ever greater regulation of health risks and unhealthy lifestyles.

    Another aspect of the response to the culture of fear is the promotion of faux democracy, this impulse relates not so much to the political sphere as to professional and scientific hierarchies. It goes beyond the imposition of regulatory mechanisms, to challenge the authority of scientific knowledge and professional expertise, which are often dismissed as elitist or undemocratic. The notion of medical pluralism encapsulates this perspective, implying that clinical science is merely one voice which should possess no greater authority than that of the ‘expert patient’ or the alternative therapist. While this approach appears egalitarian it is essentially an entirely false form of democracy, as it runs counter to the production of rational discourse on which genuinely democratic decision making is based. It is also profoundly agency robbing, as it undermines the role of reason in transforming the natural and social world, in favour of partial knowledge and superstition.2 This retreat from reason marks a significant lowering of expectations regarding the capacity for human agency to transform the world we live in, which as we have seen is particularly bleak when applied to the process of Third World development.

    Taken together, the heightened sense of vulnerability and the diminished sense of agency reveal what is new and unique about the prevailing culture of fear. Other cultures really were vulnerable to external threats, the plague reduced the population of Europe by at least a third in the fourteenth century, and more recently up to 1 million people died in the Irish Potato famine of the late 1840s. The peasants of medieval Europe really were powerless to resist the spread of infectious disease, and in the mid-nineteenth century the Irish really were unable to overcome the food shortages caused by potato blight and English colonialism. Contemporary developed societies are not free from objective threats to health, but what is unique about the prevailing culture of fear is the mis-match between the magnitude of the threat on one hand, and on the other our heightened sense of perceived vulnerability and diminished sense of capacity to overcome these threats.

    It is in this context that the new discourse of health should be understood. Its central characteristics are both a product of and contributor to a broader anti-humanist current. Popular culture often asserts that humanity needs to ‘reduce its footprint on the Earth’, to intervene less in nature. The growing human population is frequently represented as a form of global disease that is stifling the planet. The achievements of modern medicine in extending life expectancy are often presented as part of this ‘problem’.

    Medical sociology has in some instances contributed to this anti-humanist world-view, however, it also has an important role to play in de-bunking it. The new discourse of health is very different to that of thirty years ago. Although new technologies and medical advances continue to emerge, they are often received with ambivalence and suspicion. The Enlightenment project of using science and reason to create ‘heaven on Earth’ is frequently dismissed as hubristic. There is a new culture of fear, vulnerability and uncertainty that threatens to undermine medical progress. These changes have sociological origins, and it is only by exploring those origins and bringing them into public consciousness that the prevailing anti-humanism can be challenged.

    References
    1 Mills, C.W. (1959) The Sociological Imagination. New York: Oxford University Press.
    2 Taverne, D. (2006) The March of Unreason: Science, Democracy and the New Fundamentalism. Oxford: Oxford University Press.

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