Sociology of Health in the UK

Jonathan Gabe

Royal Holloway, University of London (UK)

Two roles for sociology of health & illness

Employ a sociological perspective to increase understanding of

- experience of health - social distribution of health disorders - role of institutions that provide care/cure Use sociology of health & illness to

understand changes in society generally – e.g. consumption and consumerism

Sociology in medicine v sociology of medicine (1)

Sociology in medicine - somewhat accepting of medical categories - trying to satisfy objectives of health care

providers & policy makers - improving effectiveness of practitioners - e.g. evidence of social causes / consequences

of disease - similar to social medicine, health services

research

Sociology in medicine v sociology of medicine (2)

Sociology of medicine Adopts a more critical / analytical

approach Questions categories of biomedicine Questions the power of medicine Employs sociological theory Sometimes delivers critical political

messages (Straus 1957)

Three levels of analysis for IN / OF medicine (Turner 1995)

1. Individual – analyses of perceptions / experiences of health & illness

2. Social – social creation of illness (construction / causation)

3. Societal – health care systems national/global

Individual level

In medicine / health

Health behaviour Lay beliefs Lay referral Compliance Social support and stress / psycho-social perspectives Of Medicine / health

Social construction of disease categories / medical knowledge Narratives of self and identity Sociology of body

Social Level

In medicine/health

Social causes of disease Social epidemiology Evaluation of health care effectiveness Managerial effectiveness and efficiency Health promotion and education Health inequalities

Of medicine/health

Medical dominance / power / inter-professional rivalry Conflict perspective on lay-professional relationship Medicalisation Managerialism as an ideology or discourse

Societal level

In medicine / health

Improving the effectiveness and efficiency of policies and government initiatives Building social capital in the community

Of medicine / health

Relationship of capitalism / globalisation and health care systems Health social movements Social construction of the community via disciplinary surveillance / governmentality

Development of Sociology of Health in the UK

In part a history of 2 sociologies IN Medicine v OF medicine In part a history of the social/political climate in

which it is operating & history of sociology 4 eras1. Immediate post WW22. The break with consensus3. Retrenchment4. Consolidation

1. Immediate post Second World War

Post war re-construction 1945-60 Establishment of welfare state / NHS Sociologists interested in social class, poverty &

community life Social policy analysts – focusing on equitable

distribution & uptake of welfare Social theorists – dominated by Parson & Shils

from the US

Medical sociology post war

Embryonic Concerned with consolidating the health service

– how it operated, inhibitors to equal access Most problems defined by others

- public health interests and medically dominant funding agencies

Curiously incurious about assumptions behind health care

2. The break with consensus

1960s/1970s Time of student unrest, increasing economic & cultural

power of youth Sociology took a more critical turn – influenced by

French & German Marxists & micro sociology from USA Resurgence of feminism and growth of deviancy theory Some sociologists critical of shift to left, others positive –

new found energy/breaking relationship with establishment

Anti- authoritarianism meant policy related work out of favour.

UK Medical sociology in the 60s & 70s (1)

Developed rapidly, influenced by mainstream sociology

Sociology of medicine became popular Macro level critical of medical power –

medicine as oppressive agent of social control – masking professional power (Freidson 1970) or wider class interests (Navarro 1976)

UK Medical sociology in the 60s & 70s (2)

Micro level - interactionists (Bloor 1976) and feminists (Barrett & Roberts

1978) Also saw doctors as oppressive Focus on how strategies & routines in different settings - reinforced professional power and control - minimised opportunities for patient involvement Criticised by others as imperialist – exaggerating negative

aspects of medical practice – for own professional purposes (Strong 1979)

Policy issues ignored – helped by lack of public conflict over health care

3. Retrenchment in adversity

Late 70s - mid 90s cold political climate for sociology

Neo-conservative politics – support for sociology absent

Sociologists returned to classics in theory & method (the nature of capitalism, quantitative methods/secondary analysis

- qualitative v quantitative distinction now false

UK Medical Sociology – late 70s – mid 90s (1)

Mirrored developments in parent discipline Focused on how theory illuminates health,

disease & medicine – Scambler 1987 What theoretical paradigms used to explain

illness & relationship to general theory – Gerhardt 1989

Growing influence of Foucault – renewed debate about illness / its definitions (Armstrong 1983)

Secondary analysis of health care data from UK census (Arber & Gilbert 1989)

UK Medical Sociology – late 70s – mid 90s (2)

Medical sociology protected from cold political climate (unlike parent discipline) by social medicine

Positives – job opportunities Negatives – working `in’ medicine meant surrendering

selecting topics to research to doctors and civil servants e.g. HIV / AIDS

Few opportunities for rigorous, reflexive analysis of health policy even though now central in debates about

- future of welfare state - impact of consumerism - social consensus over NHS strained

4. Consolidation

Mid 1990s- milder political climate (under threat in 2010 with change of government?)

Some sociologists helping to shape public culture & political agenda – Giddens

New interests in sociological theory - embodiment - emotions -biotechnologies & communication technologie - risk & trust - consumption, lifestyle & identity – cultural turn Call for a more publically engaged sociology (Burawoy 2005)

Consolidation in Medical Sociology

Medical sociology mirrored main stream developments & mirrored them E.g. Trust conditional in medicine and now needs to be earned – new

professionalism (Calnan & Rowe 2008). E.g. Cultural shaping of risk perception about hazards to health & its

management (Green 1997) E.g. Consumption and health promotion – how consumption of alcohol,

fitness & leisure services shape body image / sense of health (Bunton & Burrows 1995)

Call for a publically engaged medical sociology – providing a sociological perspective on health policy & organisation of health care

E.g. Evidence-based medicine as a social movement (ideology & strategy (Pope 2003)

E.g. sociologists mediating between lay participants and published evidence of health impact assessment of housing development in a former mining community (Elliott & Williams 2008)

Comparison between UK and US medical sociology

US medical sociology began earlier More influenced by psychiatry than social medicine - Mental health a dominant concern of Journal of

Health & Social Behaviour US more concerned with investigating social

problems & social divisions UK more focused on theoretical issues and micro

sociology – Sociology of Health & Illness (founded 1979) established to provide platform this approach.

Medical sociology abstracts in general sociology journals

Britain and America compared 1992-2007 (Seale 2008)

American journalsAJS/ASR/SF/SP

British journalsSR/BJS/SOC

Concepts(infant) mortality; (mental/ public/national/infant) health (care/status/behaviour); (labor force) participation; fertility, stress, (social) integration; religious (involvement)

Conceptsbody/ies; trust; sociology/ical; discourse/s/ursive; modernity; identity; governance; (social) movement; Weber; citizenship; ethics; Giddens; feminist

Illness conditionssuicide; mental

Illness conditionsSleep; disability/ables; death

Social divisionsWhite/s; Black/s; birth; age; socioeconomic status; children; racial/race; sex [for gender]; African American; men;

Social divisionsNO KEYWORDS

Journal of Health and Social Behavior and Sociology of Health and Illness:

Journal of Health and Social Behavior Sociology of Health and Illness

Concepts: social psychology(social / emotional) support; psychological; (perceived / racial) discrimination; (differential) exposure (to vulnerability / to stress); anger; roles; parental (separation / divorce / behavior)

Concepts: social construction of selfaccounts; body/ies; discourse/s; lay; everyday (life / experiences); moral (responsibility); (social and / socio-) cultural (values); stories

Illness conditionsdepression/ive; distress; mental; stress/ors

Illness conditions(chronic / mental) illness (experience / narratives); cancer

Social divisions(African / Mexican) American’s; marital (status) / married / marriage; adolescent/s; (socioeconomic / marital / health / social) status; (sociodemographic / socioeconomic) characteristics; adults; socioeconomic; White/s; age; racial; race; income; differences; job; African (American/s); Black

Social divisionsinequalities; (social / middle / working) class (differences / inequalities)

The medical professionNO KEYWORDS

The medical professionmedical (profession / practice / knowledge; work); (general / medical / clinical) practice; (general / medical) practitioners; doctors; nurses; (medical / professional) knowledge; medicalisation; GPs; managers; clinical; professional; medicine; biomedical; NHS

Changes over time: 1992-1999 compared with 2000-2007General sociology journals: all abstracts

AJS/ASR/SF/SP(family / social / opportunity / network) structure; unionization; (black / current) population (growth / size / density); cognitive (skill); (social) organization; (resource) mobilization; labelling; historical; theory; cohabitation; ethnic (groups / economy); self-esteem; economy; (collective) action; premarital (birth / childbearing); strategies

(white / blue) collar; families; metropolitan (area/s); lesbian; earnings

AJS/ASR/SF/SPGlobal/ization; transnational/ism; neighborhood/s; (perceived / racial) threat; peer; (social / friendship) network/s; migration/ants; civil (rights / society); civic (engagement / organization); (adolescent / mental) health; (civil / human) rights; (child / health) care; trajectories; international; (work) hours; (voluntary) associations; managerial; (religious) involvement; communities

adolescent/s; college (completion); (black) students; couples

SR/BJS/SOCPrivatisation; Weber; organisations/al; regimes; (social) movements; crime; policing; ideological; discourse

unemployed/ment; underclass

SR/BJS/SOCBody; identity/ies; Bourdieu’s; (social / cultural) capital; space; global; experiences; cosmopolitan; complexity; caring; aesthetic

poverty; migrants

1992-1999 2000-2007

SHI

conceptsbehaviour; health; structural;

social divisionsmortality differentials; differences; classes; spouses

health care/knowledgeteam/work; complaints; preventive

health behaviourcondom; safer (sex)

health conditions / treatmentspain; AIDS; accidents

SHI

conceptswellbeing; transition; lived (experience)

social divisionsNONE

health care/knowledgeCAM; science; midwifery

health behaviourNONE

health conditions / treatmentsMenopause; cancer; Viagra; sleep

Changes over time: 1992-1999 compared with 2000-2007Sociology of Health and Illness

1992-1999 2000-2007

Sociology / medical sociology in the USA and UK

USA UK

race class

social issues social theory

accept cultural critical of culturalauthority of medicine authority of medicine

epistemological conservatism social constructionism

quantitative methods qualitative methods / argumentation

mental conditions chronic illness

change over time little change over time

How might Sociology of Health and Illness develop in the UK?

(a) Use concepts from general sociology more:

In particular, globalisation, internationalism in health care, social systems-level analysis.

For example:

• analysis of the role of the global pharmaceutical industry in influencing medical practice and population health beliefs and behaviour.

• cross national comparative work on health care systems and policies.

• Internationalise medical sociology by studying medicine as an institution globally, not just in richer countries.

• Migration and health

How might Sociology of Health and Illness develop in the UK?

(b) Make use of the concept of social capital

either of the conflictual Bourdieusian type (ie: as a marker of class distinction, together with cultural capital)or the social consensus-style Putnam variety (ie: its role in community-building -neighbourhoods, social networks, civic engagement; voluntary association)

(c) Relate to social issues more directly / address a wider range of social divisions. For example, race, migration, human rights.

(d) Use more quantitative methods (?)

(e) Create a more ‘public’ sociology of health and illness.

Public sociology is an approach … which seeks to transcend the academy and engage wider audiences. [It is] a style of sociology, a way of writing and a form of intellectual engagement.

Michel Burawoy has contrasted it with professional sociology, a form of academic sociology that is concerned primarily with addressing other professional sociologists.

(Wikipedia 4th July 2007)

References (1)

Arber, S. and Gilbert, N (1989) Men: the forgotten carers, Sociology 23, 111-18. Armstrong, D. (1983) Political Anatomy of the Body, Cambridge University Press,

Cambridge. Barrett, M. and Roberts, H. (1978) Doctors and their patients. In Smart C. and Smart

B. (eds) Women Sexuality and Social Control. Routledge, London. Bloor. M. (1976) Professional autonomy and client exclusion. In Wadsworth, M. &

Robinson, D. (eds) Studies in Everyday Medical Life. Martin Robinson, London. Bunton, R. & Burrows, R. (1995) Consumption and health in the `epidemic clinic of

late modern medicine. In Bunton R et al. (eds) The Sociology of Health Promotion. Routledge, London.

Burawoy, M. (2005) For sociology. American Sociological Review 70, 4-28. Calnan, M. and Rowe, R. (2008) Trust Matters in Health Care, Open University

Press, Buckingham. Freidson, E (1970) The Profession of Medicine, Dodd Mead, New York.

References (2)

Elliott, E. and Williams, G. (2008) Developing public sociology through health impact

assessment. Sociology of Health & Illness 30, 1101-16. Gerhardt, U. (189) Ideas about Illness, Macmillan, Basingstoke. Navarro, V. (1976) Medicine under Capitalism, Prodist, New York. Green, J. (1997) Risk and Misfortune. A Social Construction of Accidents. UCL Press,

London. Pope, C. (2003) Resisting evidence: the study of evidence-based medicine as a

contemporary social movement.Health 7, 267-82. Scambler, G. (1987) Sociological Theory and Medical Sociology. Tavistock, London. Seale, C. (2008) Mapping the field of medical sociology. Sociology of Health & Illness

30, 677-95. Straus, R (1957) Nature and status of medical sociology. American Sociological Review

22, 200-4. Strong, P. (1979) Sociological imperialism and the profession of medicine. Social

Science & Medicine 13A, 613-19. Turner, B. (1995) Medical Power and Social Knowledge. Sage, London