One point of frustration for sociologists reading or listening to journalists opining on our changing world is their fixation on events. Sociologists, I have long argued, should delve beneath the surface in search of the mechanisms – ‘social structures’ – that help cause or shape events. If we can’t quite match the physicists’ precise formulation of the laws of gravity and such like, we can nonetheless expose social structures that must exist and persist for events to unfold as they have done, are doing and are likely to continue to do.
My own work has focused on structures of class and command in the fields of stigmatising illness and health inequalities. In my early research on the stigma associated with diagnoses of epilepsy, conducted in the 1970s and published in the 1980s, I was at one with colleagues in medical sociology at the time in adopting an interactionist perspective and accenting how individuals coped in the face of this ‘threat’.
I distinguished between stigma, an infringement of norms of shame denoting an ontological deficit, and deviance, an infringement of norms of blame denoting a moral deficit. Stigma had to do, in other words, with shame consequent upon an imperfection of being (Goffman: with non-conformance rather than non-compliance). What I found in my study, in a nutshell, was that the perceived threat of stigmatisation (what I called felt stigma) had a more damaging effect on the lives of adults with epilepsy than did actual incidents of stigmatisation (or what I termed enacted stigma). I delineated a three-part model of the ‘hidden distress’ associated with epilepsy. First, the presence of felt stigma led people to avoid disclosing their seizures, and more so the diagnosis of epilepsy; second, this policy of non-disclosure reduced the opportunities for enacted stigma; and third, the net effect was that felt stigma proved more disruptive of people’s lives than enacted stigma.
Later I revisited these findings and conclusions, compelled to do so by a burgeoning literature in the field of disability studies. I confessed to short-changing people with long-term conditions, or ‘symptoms’ like epilepsy, or disabilities. I had too unthinkingly joined the 1980s orthodoxy and concentrated on individuals who had been labelled rather than the labellers. A political economy of labelling of the kind advocated by Freidson was required.
It was not so much that my earlier conclusions were ‘wrong’ as that they needed re-contextualizing. They were part of the story, but my neglect of another part amounted to near-wilful negligence. I have since emphasized that it is vital that we research the social origins of norms of shame and blame (I was of course reinventing the wheel as far as disability theorists like Mike Oliver and his divergent successors were concerned). If I made a contribution it was to consider the structural underpinning of these norms by relations of class, which I linked with exploitation, and relations of command, which I linked with oppression. Stigmatisation, I maintained, is rarely to be found in isolation; it is almost always in a mix with exploitation and oppression. Okay, I was a late convert.
As far as health inequalities were concerned, my interest was spurred by what I judged to be the non-sociological input, or at least paucity of aspiration, of our community of sociologists. I was fed up with endless studies re-asserting an association between socio-economic position and health status and longevity. My criticism was not of epidemiologists (Michael Marmot was down the road from me at UCL, a major force and a ready ear) but of sociologists. There were exceptions to my strictures naturally, but too few. From the late 1990s I attempted to make good this lack.
I developed a thesis that the ‘widening gap’ in health inequalities during the lifetime of financial capitalism (mid-1970s to the present) could not be explained without reference to enduring social structures like class and command. And this is the case I have concentrated on making. I do not believe for a moment either that health inequalities reduce to these structures or that alternative structures, particularly those adduced via Mertonian middle-range theories, are also crucial components of a credible sociology of health inequalities. In the Eliasian figuration of nation-states like Britain, I would suggest, relations of class and command remain pivotal; but there are many other figurations in which other structures are undoubtedly dominant. I abhor determinism in al its guises.
Blogs are helpfully constraining, so I will summarize my claims briefly. I would maintain that financial capitalism has witnessed a new class/command dynamic. ‘Justified’ by a ubiquitous ideology of neo-liberalism, it has reinvigorated capital’s sway over power. Objectively, class relations exercise a newfound grip on the command relations of the state. If money has always bought power in capitalism, then it gets better value for its investments in its latest financial phase. And this has occurred despite the reduced salience of class for identity-formation. So objectively class has become more important even as subjectively it has become less so.
My greedy bastards hypothesis (okay, I was trying to irritate) asserts that the strategic action of a hard core of Britain’s capitalist executive (CE), underwritten by the power elite (PE) at the core of the state apparatus, has led to our present government by oligarchy (GO) and is the primary structural driver of health inequalities. So CE + PE = GO ® health inequalities. This, and other (and of course there are other, figuration by figuration) structures and combinations of structures impact via ‘media of enactment’, namely asset flows. I can only list them here. Biological, psychological, social, cultural, spatial, status and material asset flows – objectively and subjectively – are of documented pertinence for health and longevity. Moreover there can be compensation. A strong flow of social or spatial capital, for example, can compensate for/annul a weak flow of material assets. The fact that flows are difficult to study, especially via cross-sectional studies, has no bearing on the potency of their causal bite.
Macro-theory and social structures have been imprudently sidelined in medical sociology!
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