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Introduction: theory, theorists and the sociology of health

ByGRAHAM SCAMBLER

There is a sense in which medical sociology, indeed all sociology, is necessarily a theoretical project. It can neither begin nor end in a social vacuum: we are products of our times and places. Moreover to assent to any one proposition about social phenomena is to dissent from others; and to assent is to sign up wittingly or otherwise to a particular way of seeing or presenting the social world within which we are all actors and agents. Sociologists’ degree of reflexivity about their theoretical baggage or commitment is variable. When not actually in denial, the positivist is often non-reflexive. For a vast array of non-or post-positivists, however, the theoretical nature of the medical sociological project is incontrovertible, a matter for open conjecture and evidence-based debate. In the introduction to a collection entitled ‘Sociological Theory and Medical

Sociology’ published in 1987 I echoed what was at the time a popular lament, namely that medical sociology remained largely detached from mainstream sociological and social theory. I did not mean by this either that medical sociology was merely positivistic or that it had no history of reflexive theoretical engagement. Such assertions would have been manifestly false. My point was that there seemed particularly scant interest in those theories that ranged from macro-through meso-to micro-phenomena in the health domain, theories that linked societal order and change with everyday thoughts and behaviour. Once the heady early days of (structurally oriented) Parsonian structural functionalism versus (agency-oriented) symbolic interactionism were over, medical sociology’s more pluralistic or ‘multi-paradigmatic’ ambitions seemed to wane. It was as if medical sociologists in North America, Europe, and Australasia aspired, at best, to theories of Merton’s middle range. Most hostility was directed towards one of Wright Mills’ (1963) two perils, ‘abstracted empiricism’, there being little evidence of any post-Parsonian predilection for ‘grand theory’. A lack of ‘sociological imagination’ appeared self-evident. There also seemed to be a lot of positivist research about. On the whole it is a judgement I stand by, albeit with a qualification or two.

It is questionable, for example, whether I made sufficient allowance for my own background and interpretation of events as a philosophically trained sociologist. I may have been too readily seduced by macro-theory, or even, in unguarded moments, by grand theory. As a medical sociologist closeted and isolated in a series of London University Medical Schools I may also have been overexposed to

abstracted empiricism. Moreover there was more going on than perhaps I appreciated, especially in mainstream sociology departments in the US, where there was growing acknowledgement and application to health of schools of thought and perspectives outside of functionalism and interactionism, including systems theory, critical theory, rational choice theory, and so on (Cockerham, 2000; Cockerham & Scambler, 2010). But how do things stand nearly a quarter of a century after? It makes sense to

introduce what is in many ways a revisiting of territory some of us felt we needed visas to enter in 1987 via a brief reconsideration of the role of theory in medical sociology, or the sociology of health and illness. Accomplishment and tensions are both apparent. There is clear evidence of greater reflexivity and of more and increasingly sophisticated dialogues between social and sociological theorists and ‘specialists’ committed to understanding and/or explaining behaviours around health, illness and healthcare (de Maio, 2010). Some of these dialogues are explicitly theoretical, others implicitly so. The former seek to knowingly apply, develop, or innovate around theories whose origins and foci lie outside of the health domain, while the latter are more fortuitously indebted to this same body of work. For example, the work of Parsons and Merton survive respectively in the systems-theoretical perspectives of Luhmann and in the theories of the middlerange that characterize much of contemporary professional medical sociological enquiry. Interactionism too remains a vital ingredient of the sub-discipline: much of the continuing research on chronic illness is premised on the work of Mead, via Bulmer, Roth, Glaser and Strauss, and others. The genius of Foucault has proved inspirational, principally via assorted, strong versus weak species of social constructionism. Conflict theory born of Marx and developed by the critical theorists of the Frankfurt School (among others) has also informed select branches of medical sociology. Bourdieu has his advocates, as have feminist and neo-colonialist thinkers and the critical realism inspired by Bhaskar’s challenge to orthodox scientific enquiry. Against this narrative of steady, growing accomplishment should be set novel

institutional pressures on occupationally insecure medical sociologists to be circumscribed or ‘cost-effective’, that is, one way or another to underwrite their salaries. Social and sociological theorists tend not to raise money through research and can find themselves under pressure to justify their posts ‘in difficult times’. There is evidence too of a related ‘McDonaldization’ of (medical) sociology, an often counter-productive emphasis on uniformity in the delivery and assessment of disciplinary products. Journal impact factors prevail, and peer-reviewed articles have typically to comply with strict parameters of format, length, and even orthodoxy. Appraisals of work and worth must be quantified (Ritzer, 2001; Scambler, 2005). There is a threat of theoretical ‘taming’ here (Scambler, 1996). Paradoxically, in the immediate aftermath of the 2008/2009 ‘global financial

crisis’, which is witnessing an aggressive rearguard action on the part of neo-liberalism’s beneficiaries and a predictably virulent pro-workfare anti-welfarism, an urgent need for theoretical engagement coincides with heavy constraints on its delivery. In my view, theoreticians’ contributions to ‘critical’, and even more,

‘public’ medical sociology are as vital now as they are personally challenging to deliver (Burawoy, 2005). So it is perhaps an appropriate juncture to nourish an explicit, theory-oriented

medical sociology. But adopting the same format as in 1987 requires additional justification: it is not axiomatic that selecting noted theorists and either underwriting or positing their salience for professional and policy medical sociology is an optimal device. Maybe, however, it is a useful heuristic device. In its predecessor, ‘Sociological Theory and Medical Sociology’, the theorists picked as a result of a dialogue between editor and contributor, were: Marx (David Blane), Durkheim (Steven Taylor and Clive Ashworth), Parsons (Uta Gerhardt), Foucault (David Armstrong), Freud (Karl Figlio), Goffman (Simon Williams), Habermas (Graham Scambler), Weber (Sheila Hillier), and Offe (Ray Fitzpatrick). An equivalent dialogue this time round has led to the inclusion of: Foucault (Alan Peterson), Bauman (Paul Higgs), Habermas (Susan Edwards), Luhmann (Barry Gibson and Olga Boiko), Bourdieu (Sasha Scambler), Merleau-Ponty (Nick Crossley), Wallerstein (Martin Hyde and Anthony Rosie), Archer (Graham Scambler), Deleueze and Guatteri (Nick Fox), and Castells (Simon Williams). The second appearance of Foucault, a continuing major influence on medical sociology internationally, requires little defence, while that of Habermas draws in a new and subtle commentator. The remaining contributions, I suggest, speak for themselves, although a case could undoubtedly have been made for a dozen other theorists. It is doubtful if there are more informed, perspicacious and engaged com-

mentators on Foucault’s relevance for understanding health and healthcare than Alan Petersen. He opens this collection with a sharp, fair-minded yet critical review of Foucault’s work, charting his input into theory and research in the multiple arenas of health whilst also pointing out his silence on others. He locates him as a key twentieth-century social theorist before surveying the role and reach of later Foucauldian scholarship in enriching our grasp of the health ‘field’. But there is a critical edge to his exposition and evaluation: there are ‘blind spots’ in Foucault’s work. There are problems issuing from the ‘vagueness’ of Foucauldian terminology; he under-theorized group agency, contestation, and counter-discourse; and he was ‘inattentive’ to political economy and what might be called the structures of class, gender, ethnicity, and so on. To take Foucault at his own evaluation, he suggests, is to adopt his work as a ‘toolbox of ideas’, and it is an orientation Petersen continues to find rewarding. Paul Higgs dips into the striking insights to be found in Zygmunt Bauman’s

ever-expanding body of work to emerge with a distinction between ‘fitness’ and ‘health’. He maintains that this is especially salient for a credible theory of embodiment in contemporary consumer society. Fitness is not for Bauman an extension of health but a going beyond or transcendence of it. He points to a new relationship between illness, health, and fitness. It is one that challenges the conventional dichotomy between ‘normal’ and ‘abnormal’ by emphasizing the ‘unrealisable demands of fitness’. A complex and subtle case is made that the preoccupation with survival characteristic of producer society has been succeeded by a preoccupation with quality of life in consumer society; and that it is in this

context that the desire for fitness has emerged as the light at the end of a tunnel of indeterminate length. Habermas, like Foucault, featured in ‘Sociological Theory andMedical Sociology’.

Gemma Edwards affirms the relevance of his theory of society and social action for health and healthcare in her contribution. She offers an eloquent summary of his theory of communicative action, focusing on the complex social differentiation of modern societies and the ‘de-coupling’ of system and lifeworld. Extending her own previous work, she rehearses and critiques Habermas’ system/lifeworld distinction. It makes little sense, she argues, to allocate a healthcare service to either system or lifeworld. System and lifeworld are best seen as two different ways of doing things – two logics of action – that exist everywhere. Health movements in the past have agitated for more not less state engagement. Embodied health movements in the present, however, are principally significant because they compel consideration of how questions of health and healthcare are, ‘first and foremost, questions about politics and morality’. Luhmann’s work is notoriously resistant to summary, and because of this critiques

of his social systems theory can seem unduly arcane and esoteric. Barry Gibson and Olga Boiko grasp the nettle. They offer a succinct account of Luhmann’s narrative of modernity, showing how systematic communications eventually specialize to the point where systems ‘separate or differentiate themselves’. This results in self-referentiality or ‘autopoiesis’. Autopoietic systems have their own dynamics: they are organizationally ‘closed’ but energetically ‘open’. They then document how this ‘high-level’ theoretical orientation has been of service to the fields of health and illness. They close their chapter with an account of how Luhmann’s work might inform mundane everyday events like patterns of communication about dentine sensitivity. Bourdieu’s contributions to social theory have been a strong if intermittent

resource for medical sociology. Sasha Scambler acknowledges this in her general exposition. She explicates core concepts – ‘field’, ‘capital’, ‘habitus’, ‘bodily hexis’ – prior to showing how these might help frame sociological accounts of the impact of chronic and disabling conditions on the lifeworld. She does this through a detailed and research-based consideration of how (typically young) people face a foreshortened life with Batten disease. Crucially this experience occurs in the intimate company of their parents/families and/or significant others, who summon up and put to use the various forms of capital at their disposal. It is a poignant as well as a suggestive sociological narrative. It is also a narrative that favours further integration between sociological and disability theory (Scambler & Scambler, 2010). Nick Crossley’s chapter on Merleau-Ponty may be a less obvious source of

sociological inspiration, at least to those under a certain age. To others the latter’s ‘Phenomenology of Perception’ and ‘The Structure of Behaviour’ are under-utilized texts. Merleau-Ponty is presented here as a significant philosopher of embodiment. The chapter offers a succinct summary of this philosophy before discussing the challenges it represents to orthodox (Cartesian) conceptualizations of the ‘medical body’: it is a philosophy favouring constructionist and holist approaches, but with qualifications. When we fall ill, our bodies cease to be ‘blind spots’

for us: they become available for objectification and observation. The final paragraphs, however, move on from the ramifications of the lived bodies of people-aspatients to raise intriguing questions about the embodiment of medical practice itself. Wallerstein’s world system theory transports a Marxist orientation to modernity

beyond the nation-state and insists on an engagement with historical and comparative research. The importance of the astonishingly wide-ranging and influential research of the French historian Braudel is noted. After briefly reviewing world systems theory, Martin Hyde and Anthony Rosie ask how world systems theory might inform and – sociologically speaking – invigorate ‘epidemiological transition theory’. Epidemiological transition theory is introduced and critiqued. The authors suggest that while epidemiological transition theory affords a serviceable framework for examining changes in the health of a population, it neglects interconnections between states and the impact these have on the epidemiological transition. Population health, they contend, is ‘relational’, insofar as the factors that determine it are part of the world system. To buttress their case they deploy a mix of data on trade and mortality, focusing on the region of West Africa to illustrate their argument. Margaret Archer’s writings are unlikely to be known by medical sociologists.

She is most eminent as a theorist and a sociologist of education. She is my theorist of choice in this volume: she has over the years proved a subtle, shrewd and independent-minded disciple of a (critical) realist orientation to sociological research and practice. The focus here is on her recent work on those ‘internal conversations’ we all recognize and count as integral to our humanity. I mount a case that the wealthy and powerful in our society, neglected causal progenitors of health inequalities in the UK and elsewhere, display a socially structured, if not structurally determined, cast of mind. Drawing on Archer’s analysis, they comprise an ideal type of ‘focused autonomous reflexives’. A broader thesis is that medical sociology has paid insufficient attention to the socially structured mindsets and predispositions of key actors in the field of health inequalities. The chapter committed to the theories of Deleuze and Guattari and authored

by Nick Fox also focuses on the body. It is essential, he insists, that sociologists of health, illness, and medicine come to terms with the dual – biological and social – character of the body. Deleuze and Guattari’s analyses are premised on a link between body, subjectivity, and culture. An eloquent, select exposition of these analyses follows. The concept of the ‘body with organs’ is introduced, together with those of its ‘de-’ and ‘re-territorialization’. Deleuze and Guattari align themselves with the de-territorialization of, or resistance to, the body-with-organs, which gives rise to the notion of (a process of) ‘nomadology’ as a strategy for living. It is a model that is here applied as well as announced. At this point the ‘body without organs’ features: this denotes the limit of what a body can do in terms of its relations and the ‘play of forces’ of those relations. Embodiment is not the passive outcome but a dynamic and reflexive ‘reading’ of the social by an active, motivated human being. The final chapter by Simon Williams takes the influential sociologist Castells as

his point of departure. This is a notably original piece of work in that only rarely

have medical sociologists drawn, even circuitously, on Castells’ framing of the network society to better describe and/or explain phenomena of health, illness, or healthcare. Considerable potential is discerned in Castells’ deepening of his analysis via the idea of communicative power. The unfolding of his published work is reflected. At the core of the argument is the idea that Castells is important because his theories offer: (a) key theories relating to the dynamics of the information age (embracing global complexity, networks, flows, mobilities, and so on), and (b) resources for a ‘renewal’ of (medical) sociology. Illustrations in support of this case are offered for continuing discussion. This book, in the vein of its predecessor, will have served its purpose if it acts as

a catalyst, provoking or tempting medical sociologists, students, and others interested in the multiple arenas of health to turn expectantly to established and challenging bodies of social and sociological theory to frame or deepen their research or understanding. It may be a less urgent project than in the Thatcherite mid 1980s: medical sociology is a more sophisticated sub-discipline now than it was then, at least in the UK. But on the other hand, in the ‘new England’ of a neo-Thatcherite, Cameron-led ‘coalition’ committed to the re-commodification of all things health related, including the National Health Service, maybe not. In any case, and independently of one’s (Weberian) value reference, the call for reflexivity and theory remains undiminished.