ABSTRACT
In 1899 Thorstein Veblen published The Theory of the Leisure Class (Veblen 1899). A commentary on the consequences of capitalism as manifest in late-nineteenth century America, Veblen noted that wealthy industrialists developed lifestyles largely modelled on how they imagined previous historical elites had spent their leisure. The conspicuous consumption of non-productive time helped distance this group from the work-like activities of the masses and was taken as evidence of wealth and power. Sport in particular was envisioned as a noble activity and thus bolstered the elite’s social status. For the majority of the population, however, the essential physicality of daily life meant that sport and exercise were largely confined to brief and infrequent leisure time, especially during public holidays. There was, it should be noted, a small section of society for whom sport had become a form of employment, but on the whole participation was more closely linked to notions of belonging than distinction, and the primordial motivation stemmed from the quest for exciting significance (Elias and Dunning 1986). Sport was one of the few spheres of social life in which relatively high degrees of emotional spontaneity were afforded relatively high degrees of tolerance. For both elites and non-elites sports participation was highly gendered. It was an activity strongly contoured by age; normal for children, acceptable for young adults, unusual for their elders. This pattern of sport participation relates to a time when the medicalization of sport was in its infancy. The primary health benefits of participation were perceived to be in relation to building character rather than shaping one’s body, extending one’s life or managing illness. Healthcare provision for the emerging class of sports professionals was rudimentary and frequently para-medical if not anti-or non-medical. When people became injured through sport they simply ceased to take part. This was assumed to be the natural life course. As demonstrated throughout this book, the contemporary landscape of sport, medicine and health is clearly rather different. In most countries, and indeed a growing number, sports medicine is recognized as a distinct
specialism, available to many competitive athletes and, to a greater or lesser degree, the public. Across the planet governments are instigating policies to facilitate/encourage/cajole citizens to become more physically active and, in so doing, they invariably conflate a whole range of everyday activities with both exercise and sport. A smaller but still significant and growing number of countries further regulate their populations through pre-participation screening. National and international governing bodies include an increasing array of medical issues within their ever-expanding bureaucratic regulations, defining such things as minimum levels of healthcare provision for competitive athletes and providing protocols for the management of particular conditions across their respective sports. Elite sports organizations continually seek to gain a competitive advantage by investing in the ‘team behind the team’. Such is the ubiquity of the sportmedicine-health nexus that the media is replete with stories that illustrate their intersection, ranging from the innovation and organization of elite sport healthcare to ‘new’ scientific discoveries of the beneficial impact of exercise on the human condition. The reach of these ideas is such that significant proportions of the population structure their lives and identities around sport and exercise. At the very least, people do not fundamentally question the sport-health ideology, even if they do not feel guilty at their non-compliance. Without doubt, this medicalization process was primarily instigated in relation to elite sport and the pursuit of competitive success. As Hoberman (1992) has amply demonstrated, physiology came to serve sports as the pursuit of performance heightened demand for scientific knowledge of the body. Yet these instances were numerically limited, culturally contested and thus, as a consequence, not as coherent and rational as has previously been proposed. Just as sport remained relatively autonomous of broader commercial developments in retaining the hegemony of amateurism, so it did when the requirements for ‘fair play’ necessitated a greater engagement with medicine over, e.g. drug and sex testing and when medical and scientific knowledge of training and performance came to compete against lay sporting knowledge (Carter 2009a). Here, the traditions and underlying ethos of medicine restricted its practitioners relative to less prestigious but comparably less tightly (self-)regulated professions and served to limit the contextually-evaluated worth of medicine. Moreover, once physiologists had come to something of a consensus that vigorous levels of activity were not fundamentally health-harming (Heggie 2009) there was limited scope for medicine to jurisdictionally creep into the forms of sport and exercise that were seen as natural aspects of everyday life (i.e. frequent exercise during youth and increasing ‘inactivity’ in adulthood). Opportunities for greater medicalization primarily arose in relation to the definition of certain practices as deviant; notably injuries, in particular those incurred in contact team sports such as football
and rugby and combat sports such as boxing. But medicine’s limited restorative efficacy and physicians’ broader ideological orientations towards the hierarchy of treatment priorities (within which SRI sat towards the bottom), represented significant barriers to the more substantive development of either medical performance-enhancement or the day-to-day service of a population conceived as fundamentally healthy. Medicine’s central input was to recommend prohibition of certain practices rather than to advocate, and subsequently exert, a monopoly over treatment. The educational and class backgrounds of physicians meant that many had been deeply inculcated into the sport-health ideology, or at least the view that sport was an essential part of character building. It was therefore not surprising that concerns about the potential harm of sports participation were relatively muted. Indeed, as the case of boxing shows, medicine was as fundamental to the defence of the sport as it was to its critique. Indeed, it seems highly likely that the relative autonomy of the elite sport sector would have continued to significantly constrain medicalization had it not been for the evocation of a broader public health remit. Within capitalist societies, medicine’s ultimate dependence on state mandate restricted medicalization until a broader social worth for a specific speciality in ‘sports medicine’ could be demonstrated (or at least claimed). However, when a mandate did come, evident primarily as PAHP and to a lesser extent as exercise as treatment for existing conditions, the broader environmental conditions were rather less conducive to effective medicalization than they had been in the past. De-professionalization and proletarianization processes were relatively advanced and the golden age of doctoring was in clear decline (McKinley and Marceau 2002). Somewhat paradoxically, the social role of sports medicine has ultimately developed and been enabled due to bureaucratic control over state expenditure on health, the desire to rationalize and restrict the power of the medical profession, and a shift to more consumer-based, consumptive models of medicine. The sum of these processes is that the medicalization of sport is far more apparent (or at least extensive) at the conceptual level than it is in relation to the actual practice of medical techniques and/or the engagement of patients. In many respects this is a function of the changing conceptualization of health in contemporary society (Crawford 2006) which, allied to the historic significance of the sport-health ideology, has seen a wider belief in and application of ideas that link exercise to medicinal outcomes. Pace Armstrong (1995), we might say that the medicalization of sport has been facilitated by the development of surveillance medicine, without necessarily first developing bedside or hospital forms. Constraining the more holistic medicalization of sport has been the triad of sport’s relative autonomy, intra-medical conflicts which have retarded the development and restricted the jurisdictional domain of sports medicine, and state concerns to harness escalating healthcare costs. Medicine has, therefore, been
more central to defining aspects of sport using its own nomenclature and paradigmatic assumptions than it has been in public intervention and implementation.
