Copyright Sociological Research Online, 1998

Simon Williams, Ellen Annandale and Jonathan Tritter, (1998) 'The Sociology of Health and Illness at the Turn of the Century: Back to the Future?'
Sociological Research Online, vol. 3, no. 4, <http://www.socresonline.org.uk/3/4/1.html>

Abstract

A 'think piece' in both style and content, this article offers some thoughts and reflections on selected themes and issues which, we believe, provide some important indicators not simply of the sociology of health and illness' current status, but also of its future prospects. Four key themes have been chosen: (i) social inequalities in health; (ii) emotions and embodiment; (iii) (bio)technology, and finally; (iv) the shifting configuration of health care in Britain. Underlying these four themes, and running through the discussion as a whole, are two further key issues, namely, the contested nature of health and medical knowledge, and debates concerning consumption and risk in late modern society. The article concludes by suggesting that, in the era of the new genetics and the resurgence of biological explanations in the social and natural sciences, the charge of sociological imperialism constitutes both a constraint and opportunity for practitioners working in health and related fields.

Keywords:

Biology; Embodiment; Health; Health Care Reforms; Inequalities; New Genetics; Technology

1.1

Debates as to the nature, status and identity of medical sociology have been an abiding theme since its inception: itself a telling testimony to an uncertain, and at times turbulent, relationship with medicine^[1]. Contrary to arguments over its a-theoretical, policy-driven nature, ideas about health and illness have, as Gerhardt (1989) convincingly demonstrates, played a central role in the development of general sociological theory since the Second World War, including those of regulation and control, social order and social^[2].

1.2

Moving from medical sociology, through a sociology of medicine, to its current definition as the sociology of health and illness - an `autonomous' sociological position, reflecting on matters of health, illness and healing in a manner which extends far beyond the biomedical remit - this rapidly evolving sub-field, the largest single grouping of the British Sociological Association, now encompasses a wide variety of theoretical perspectives. These range, chronologically speaking, from: the 1950s dominance of Parsonian, structural-functionalism (i.e. illness as deviance, sick role incumbency (Parsons 1951)); through the 1960s and early 1970s resurgence of symbolic interactionism (i.e. the `labelling' of illness (Goffman 1961, Scheff 1966), and the `negotiation' of medical work and identity (Strauss and Glaser 1975, Strauss et al. 1982, Bury 1982)) and the phenomenological/ethnomethodological emphasis on illness as an `emergent' property and `intersubjective' accomplishment (Garfinkel 1967, Emerson 1970, Voysey 1975, Atkinson and Heath 1981); to more conflict-oriented perspectives, embracing neo-Marxist (Navarro 1976), medicalisation (Zola 1972, Illich 1975) and Foucauldian (Armstrong 1983, Nettleton 1991) critiques of medical power/knowledge/dominance. To this we may also add the important contribution of various feminisms here, perspectives which have critically explored the gendered nature of professional projects, including the nature and experience of medical treatment itself (Oakley 1984) and the formal/informal division of labour in health and healing (Stacey 1988).

1.3

Since the introduction of the conflict paradigm in the 1970s, no further paradigm has, Gerhardt (1989) suggests, been advanced which claims to reform the theoretical foundations of medical sociology. Rather, all theoretical approaches continued to be used, if only in the guise of particular concepts (e.g. sick role, stigma) - see also Scambler and Higgs (1998) recent volume.

1.4

A particularly pertinent issue here is medical sociology's connection with biomedicine. Back in 1979 Phil Strong raised the problem of sociological imperialism in relation to the profession of medicine. Although containing much that is of value, critiques of medical expansionism into arenas of everyday life (e.g. the medicalisation thesis) are Strong suggests, in some respects, misleading or exaggerated for this `young discipline' and its `ally' public health - both of whom, in building their empires, have a vested interest in the diminution of medical power/dominance. Moreover, the sociological model they advocate (i.e. health and illness as subjective social states), perhaps rather ironically, provides in fact a far better `vehicle' for medical imperialism than the much abused biomedical model. These problems have, in turn, been compounded, since Strong's paper, by a move beyond traditional disease (physical) -illness (social) distinctions, to a colonisation of disease and the body itself as a discursive or socially constructed entity (Armstrong 1983). It is time, therefore, to take stock of these developments, including the need, as Strong's (1979) critique suggests, to seriously confront the limits of our own explanatory frames of reference, particularly in the light of developments such as the advent of the new genetics and the resurgence of biological explanations within both the social and natural sciences.

1.5

It is within this context, and against this broad theoretical backdrop that our present paper is located. A 'think piece' both in style and content, our aim is not so much a full coverage of existing research in the field, nor to represent the views of all its members. Rather, our aim is to offer a series of personal thoughts and reflections on selected themes and issues which, we believe, provide some important indicators not simply of the discipline's current status, but also of its future prospects. To this end, four key themes have been chosen. These are as follows: (i) social inequalities in health; (ii) emotions and embodiment; (iii) (bio)technology, and finally; (iv) the shifting configuration of health care in Britain. Underlying these four themes, and running through the discussion as a whole, are two further key issues, namely, the contested nature of health and medical knowledge, and debates concerning consumption and risk in late modern society.

1.6

As we hope to show, despite various funding crises, a series of transformations (i.e. funding, teaching, research) currently sweeping through the academy, and the increasing emphasis placed upon evaluative health services research, the sociology of health and illness remains in remarkably `good shape', studies ranging from: the social construction of medical knowledge (Armstrong 1983), to the lay concepts of health and risk (Calnan 1987, Davison et al. 1991,1992, Crawford 1999,Williams 1998a); shifting configurations of professional power and dominance (Gabe et al. 1994) to the lay evaluation of medicine and health care, including the growth of complimentary therapies (Williams and Calnan 1996); the (emotional) dynamics of the medical encounter (Lupton 1995) to the gender division of labour in health and healing (Stacey 1988, James 1992,Witz 1994, Davis 1996). All bear testimony to the contribution that the field continues to make to the wider discipline of Sociology as a whole, although, as we shall see, tensions nonetheless remain.

Social Inequalities In Health

2.1

Social class inequalities in health has been one of the most enduring areas of research interest within British medical sociology dating back to the mid-1800s (Engels 1993 [1845]), although real momentum came over a century later with the publication of the Black Report (Townsend & Davidson 1982) which contained statistical evidence, alongside what has proven to be an extremely influential framework for its interpretation (see Macintyre 1997 for a discussion of the research consequences of this framework). A strong and seemingly intractable association has been found between socio-economic status, variously measured, and health status (by both self report and by more 'objective' measures), indeed there is evidence that differentials have been widening (McLoone and Boddy 1994, Phillimore et al 1994). Several large scale data sets such as the General Household Survey, the Health Survey for England, and the Health and Lifestyles Survey contain a wealth of socio-economic and health data from which to explore variations in health both cross-sectionally and longitudinally in Britain.

2.2

However, a question mark hangs over the theoretical meaning of socio-economic status as it relates to health status, particularly where social class is referred to. Empirical differences are clearly demonstrable. For example, the Health Survey for England 1996 (Department of Health 1998:189-90) shows a clear gradient in self-assessed health by social class of 'head of household' for adults where, for example, 87% of men and women in social class 1 reported 'good' health, compared to 67% of men and 65% of women in class V. Yet, we are left with a number of questions about the real meaning of aggregates, such as the Registrar General's (RG) schema which is used here. As Westergaard (1995:148) has put it for the discipline of sociology as a whole, research is beset with disputes about 'the relative significance of this facet of inequality versus that, and about boundary lines in the hierarchy or hierarchies of inequality.' The RG schema is self-consciously no more than 'an undefined proxy for the effects of unknown socio-economic differences' (Wilkinson 1986:18), which as Bartley et al (1996) relate, leaves gradients in health open to a diversity of explanations.

2.3

In classical terms, a concern with social class involves both a 'structural account of relations of power, inequality, and exploitation, and simultaneously an account of consciousness, group formation, and social movements as emancipatory change' (Holton & Turner 1989: 161). Within the wider discipline, it has been argued that as the links between market position and life chances are uncoupling due to economic change, class in these strong terms needs to be put aside in favour of a focus on non-class based consumption cleavages. From this perspective (see Esping-Anderson 1993), class refers not to collective identity, but to a range of inequalities which distinguish a set of relatively autonomous individuals along a number of axes which are unlikely to align to form a strong collective economic or social identity. Taken a step further, it could be argued that pushing people into constructed 'class groups' creates divisions and hides the heterogeneity of social life. These issues, in turn, have been further complicated by debates over the transition to the so-called `risk' society (Beck 1992), and the implication of these changes for health and medicine (Gabe 1995).

2.4

While we do not argue for one or other position here, we wish to highlight the point that such debates are self evidently important for research on health inequalities, including the importance of time and biography (Blaxter 1999), but that until very recently researchers in the field have been far from clear on what theoretical position they actually want to take on class/inequality. Lack of reflexivity in these terms is arguably even more apparent in research on gender and 'racial' inequalities in health.

2.5

Research on gender inequalities in health grew out of the surge of interest in health issues amongst feminists in the 1960s and 1970s as they sought to establish the fundamentally social and political, rather than biological, nature of women's higher morbidity. A project of gendered difference in health was established which led to a strong equation between women and ill-health and men and good-health. While it remains imperative to explore the associations between patriarchy and health (arguably as they affect some men as well as women), as with research on social class (which is made even more complex when gender is taken into account) researchers have been less than clear on what patriarchy consists of theoretically and how it operates empirically. Moreover, there has been a strong and persistent tendency to both make a priori gendered assumptions about which social roles and experiences are relevant for women's and which for men's health, and to avoid truly comparative research( Annandale 1998, Hunt and Annandale, forthcoming). In a much quoted recent article, Macintyre et al (1996) question the received wisdom of a consistent female excess in illness, demonstrating instead through the use of two major British data sets a complex and subtle pattern of gender differences across the life course. Indeed the only area in which a persistent pattern of higher rates of illness for women seems to emerge more generally is in mental or psychosocial ill health, although debate continues as to whether such differences are 'real' or 'artefactual' i.e. the result of a higher propensity among women to 'over report'/among men to 'under report' symptoms (see Verbrugge 1985). In summary, at the current time the theoretical question mark that hangs over the assumptions built into research on gender inequalities in health is as significant as it is for social class, with increasing recognition of a need to be as sensitive to potential similarities by gender as to differences.

2.6

Interest in ethnic and racial differences in health in Britain is of far more recent origin than research on social class and gender, undoubtedly reflecting racism within the sub-discipline (Ahmad 1993), and arguably epitomising the political concerns that underpin the field more broadly. However, equally, if not more so than for class and gender, research grapples with the vexed question of how to signify axes of inequality while not creating falsely universal categories which distort the complex reality of individual experience. Racial subject positions, such as those contained in the 1991 Census which are a mixture of racial, national and ethnic classifications, are essentially ideological fabrications which construct the terms in which we view health status. Objections can be raised that to fix racialized identities under labels, no matter how nuanced they may be, will inevitably do violence to the sheer complexity of the ethnic identities that are forged by individuals. However, many researchers are prepared to live with the injury to the representation of diversity that occurs in the process of classification, recognising that a classificatory schema is the best way to signify the stark realities of oppression that are revealed in the social and material inequalities that are attached to minority ethnic status (see Smaje 1995, 1996). Research using such schema defies easy summary; although it is possible to point to a broad pattern of lower morbidity among the 'white' ethnic numerical majority, variations in rank order among variously defined minority ethnic groups emerge depending on the sample and the health issues of concern. To take one illustration, age-standardised data on self-reported limiting long-standing illness from the 1991 Census (see Charlton et al 1994), show the lowest rates amongst 'Chinese' men and women. The category 'Other Asian' and 'white' men and women, and 'Black African' men also fare relatively well. Rates are notably higher for 'Pakistani' men and women and for 'Bangladeshi' men. The search for an answer as to why such differences emerge is in its infancy and centres around the not inconsiderable conceptual and empirical difficulties of taking into account the interacting affects of biology, culture, social class, and racism - see Smaje (1999) for a recent attempt to theorise these issues.

2.7

Health inequalities is one of the most vibrant areas of research within British medical sociology. Its sheer breadth and complexity means that it defies easy summary. For this reason we have emphasised here some of the conceptual issues that currently engage the attention of researchers in the field. Other areas of equal and integral concern include current debates over income distribution, social cohesion and the psycho- social pathways to disease - see, for example, (Wilkinson 1997), (Macintyre 1997) and (Williams 1998b).

Emotions And Embodiment

3.1

A second key area of recent discussion and debate in the sociology of health and illness is the problem of human embodiment. As a variety of commentators have suggested, the sociology of health and illness provides a particularly fertile terrain upon which to fashion newly evolving debates on the body and society, dealing as it does with fundamental features of the human condition such as disease and illness, pain and sickness, disability and death.

3.2

On the one hand, this has enabled sociologists of health and illness to re-read existing themes and traditional concerns in a new corporeal light, from the problems of health and the medicalisation of everyday life (Crawford 1998), to the dilemmas of chronic illness and disability (Williams 1996a,b, Kelly and Field 1996, Williams and Busby 1999), and debates over death and dying in late/post-modern society (Prior 1998). On the other hand, it has opened up some promising new avenues of inquiry, including emotions and health (James and Gabe 1996), and children, health and the social order across the public/private divide (Mayall 1996).

3.3

Underpinning these developments lie deeper ontological questions concerning the nature and status of the body, and the ability of these new-found corporeal concerns and emotionally suffused issues to transcend former dichotomised modes of Western thought, including a cautious re-opening of biology/society debate. An `uncontainable' term in any one domain or discourse, the body lies ambiguously across the nature/culture divide. Emotions too, like the body to which they are so closely tied, befuddle traditional categories of Western thought; divisions which have sought to separate mind from body, the public from the private, and the so-called `reasonable' from the `unreasonable'.

3.4

Whilst debates continue to rage as to what precisely the body is - foundationalists vying with anti- foundationalists, constructionists with anti-constructionists - and how best the emotions might be `in-corporated', an emphasis upon the lived, emotionally `expressive' or `mindful' body provides what is perhaps the most fruitful and promising way forward in this respect. From this perspective, contra Descartes, mind and body are thoroughly interfused, emotions radiating through the body as an on-going structure of lived experience and the existential basis of culture and self. Emotions, in other words, are thinking, moving, feeling `complexes' which, sociologically speaking, are relational in nature and linked to `circuits of selfhood'; comprising both corporeal, embodied aspects, as well as socio-cultural ones (Burkitt 1997: 42).

3.5

Pain, as Morris states, is never the sole creation of human anatomy or physiology, rather it emerges only at the `intersection of bodies, minds and cultures' (1991: 1). An emphasis on the `lived' body, therefore, provides an important means of reclaiming pain from exclusive biomedical jurisdiction, striking at the heart of the Cartesian split between mind and body and serving, in the process, to redress the `neglected encounter between pain and meaning' (Morris 1991: 2).

3.6

The fact that mind and body are fully interfused also points to another fundamental issue: namely, that physical experience is inseparable from its cognitive and emotional significance. Pain can be used, for example, to describe not only physical agony but also emotional turmoil and spiritual suffering (Leder 1984-5). Emotions, as Scheper-Hughes and Lock (1987) observe, affect the way in which the body, illness and pain are experienced and are projected in images of the well and the poorly functioning social and body politic. Explorations of sickness, madness, pain, disability and death are human events which are literally `seething with emotion': existential forms of suffering unified through the notion of the `mindful' body (Scheper-Hughes and Lock 1987). Grief, for instance, is an example of emotional pain which is inseparable from its 'gut churning, nauseating experience', whilst physical pain bears within it a `component of displeasure, and often of anxiety, sadness, anger that are fully emotional' (Leder 1984-5: 261).

3.7

Pain effects a radical transformation in the relationship between mind and body; one in which, sometimes quite suddenly, a shift occurs from a largely taken-for-granted state of embodiment characterised by a kind of bodily dis-appearance, to one involving varying degrees of dis-embodiment, and feelings of bodily betrayal and alienation (Leder 1990, Williams 1996a); thus perpetuating the very Cartesian dualism from which we, a moment ago, we had been trying to escape. Suddenly we may come to feel dis-embodied, alienated and betrayed by our bodies (Vrancken 1989: 442).

3.8

Loss of confidence in the body is quickly followed by a loss of confidence in the self. The self, as Leder (1990) observes, is shattered into a series of `lived oppositions' in the context of pain and suffering. More generally, as Kelly and Field suggest, biological and physical facts are sociologically significant because (i) they impinge directly on self; (ii) they provide signals for identity (re)construction, and; (iii) they act as `limiting' factors on social action for the sufferer (Kelly and Field 1996: 251).

3.9

It is in this context that narrative plays a central role, providing a symbolic bridge which serves to repair the ruptured relationship between body, self and society (Williams 1984). As Kleiman (1998) notes, culture fills the space between the immediate embodiment of disease as a physiological process and its meaning-laden experience as a human phenomenon. Here, the `process of narratization' encourages the individual to turn this alien 'it' of illness which imposes itself so unwelcomingly upon his/her life, into a meaningful story which he or she tells. In this sense narratives are fundamentally embodied and are essential to the coherence of our bodies and lives. In focusing on narratives one is able to shift the dominant cultural conception of illness away from passivity (i.e. the sick person as a helpless `victim of disease') to activity, thus transforming `fate' into `experience', and joining bodies together in a `shared sense of vulnerability' (Frank 1995: xi). In short, stories as well as physicians and other health carers `can heal', and it is through narrative that, in the absence of overarching metaphysical systems of `containment', bodies are joined and transformed in their search for meaning, legitimacy and a lost ethics of existence.

3.10

Beyond this search for meaning and legitimacy, however, attempts to negotiate a settlement or realignment between body, self and society also occur through the various coping mechanisms, strategies and styles of adjustment which individuals develop in the face of chronic illness (Bury 1991). Whilst `coping', in this context, refers to the personal `sense of coherence' which individuals are able to maintain in the face of their illness, `strategy' captures the practical steps taken in order to mobilise resources and minimise problems in everyday life (Locker 1983). `Style', in contrast, refers to differing symbolic ways in which individuals respond to a present their illness, both to self and others, and to how this various across differing segments of the cultural order (Radley and Green 1987).

3.11

Issues surrounding embodiment and the emotions are also, of course, central to a number of other key issues within the sociology of health and illness, from debates over social structure and the social causes of disease (Williams 1998b) to the (psychoanalytic) dynamics of the therapeutic encounter (Lupton 1996) and the importance of `emotion work' within the health care division of labour (Stacey 1988, James and Gabe 1996).

(Bio)technology

4.1

Another key area where issues surrounding the body are proving central concerns the dilemmas of medical technology. This constitutes our third core feature of recent work within the sociology of health and illness. The proliferation of new technologies designed to (re)shape and control our bodies and relations with others have all meant that our sense of what the body is and what it might become is increasingly uncertain.

4.2

Within all this, it is clear that developments in biomedical science, from cosmetic surgery to genetic engineering, and advancements in nanotechnology, have played a central role (Featherstone and Burrows 1995: 3), leading some to contemplate that the next generation may well be the last of `pure' humans (see Deitch 1992). Indeed, even the `quickest tour' of the human body, from head to toes, reveals the great variety of ways in which medicine can turn humans into `cyborgs' - from restorative or normalising, to reconfiguring or enhancing technologies (Gray 1995: 3). It is here that the (postmodern) figure of the cyborg (half human, half machine) can be seen to render previous forms of human embodiment problematic (Haraway 1991). In particular, we can see this process occurring at a number of different levels within the technological clinic or `transhuman bodyshop' of late twentieth century medicine.

4.3

First, advances in medical science and technology have meant that the bodies are becoming increasingly plastic (i.e. able to be moulded at will). Technologies of cosmetic surgery, for example, have greatly expanded the limits of how the body may be restyled, reshaped and rebuilt (Davis 1994). Amongst the rapidly growing array of technologies on offer are facelifts, rhinoplasties (nose contouring), otoplasty (ear surgery), eyelid corrections, lip enlargements, chemical peeling and dermabrasion, breasts correction (mastopexy, reduction, augmentation), the stripping of varicose veins, fat removal, body contouring (liposuction or suction lipectomy) and penile enlargement. In these `body sculpting clinics' flesh is either added or taken away, wrinkles disappear, breast become increased or decreased, and body shape is transformed (Davis 1994). As a consequence, notwithstanding frequent complications - from scarring, bleeding, secondary infections and skin discolouration to nerve damage, loss of sensation and impaired motor ability (Glassner 1995: 170, Zimmermann 1998).

4.4

Moving from its surface to its interior, the body also becomes increasingly bionic with cardiac pacemakers, valves, titanium hips, polymer blood vessels, electronic eye and ear implants and even polyurethane hearts. Closely allied to this, bodies are also becoming increasingly communal/interchangeable through developments such as organ donation and transplantation surgery (Synnott 1993). Not only are bodily organs interchangeable at the human to human level, they also now cross species boundaries, as in xenotransplantation - the use of animal organs for transplant surgery.

4.5

Developments in modern medical technology also mean that the body becomes increasingly engineered through new forms of gene therapy, and even chosen or selected from a growing number of ovum and sperm banks (Synnott 1993: 34-5). Whilst today's understanding of the precise genetic bases for many diseases is sketchy, knowledge is expected to increase enormously in the next few decades. By the year 2,000, for example, scientists working on the Human Genome Project should have determined the chromosomal location of, and deciphered parts of the DNA code in, more than 99 per cent of active human genes. Similarly, research aimed at uncovering the function of each gene is progressing rapidly. Such information should make it possible to identify the genes which malfunction in various diseases (Anderson 1995: 97-98).

4.6

Discussion of genes, in turn, key into broader debates concerning the new reproductive technologies. As Clarke (1995) argues, in contrast to `modern' approaches to reproduction - techniques which centered on achieving and/or enhancing control over bodies and reproductive processes for a variety of purposes via monitoring, planning, limiting, bounding and the setting up of boundaries - postmodern strategies, centered around so-called new reproductive technologies (NRTs), concentrate instead upon the `re/de/sign' and transformation of reproductive bodies and processes to achieve a variety of goals.

4.7

Certainly, these issues have been hotly debated by feminists in particular. For some, the creation of NRT's is seen as the end-stage of men's desire to control women and appropriate reproductive power (Corea 1985, Corea et al. 1985. Viewed from this perspective the danger is that biological mothers will eventually be reduced to `mother machines' (Corea 1985) or `living laboratories' (Rowland 1985), eroding still further women's bodily and metaphysical privacy. Others, however, have argued that it is not so much the technologies themselves which are problematic, but the context in which they are developed and applied, including the thorny issue of `access' (i.e. `who' is allowed to conceive). The call for a return to so-called `natural motherhood' is therefore resisted, and it is argued instead that women must themselves participate in both the development and (re)evaluation of these technologies, rather than leaving them in the hands of `malestream' (biomedical) science (Stanworth 1987, McNeil et al. 1990).

4.8

More broadly, poststructuralist feminists have also rejected the notion that the `real female body' is passively `acted upon', instead preferring to view it as being both inscribed and constituted through (re)productive discursive practices and processes (Steinberg 1999). From this perspective these new reproductive technologies are themselves viewed as producing subjectivity rather than `false consciousness' (Lupton 1995). Consequently, there is a focus on the struggles and resistances between men and women and the shifting configurations of knowledge/power which this involves (Sawicki 1991).

4.9

Many of these developments, as suggested above, do indeed lend themselves to a postmodernist reading; one in which a more direct concern with human corporeality is slowly giving way to a `digitally mediated' concern with hyperreality and the growing imbrication of humans and machines (i.e. cyborgology). Yet it is also possible to stress an alternative interpretation, namely that medicine continues to be a thoroughly modernist enterprise, and that these technological developments enhance rather than diminish the rational control of bodies and selves in an increasingly reflexive age. Indeed, as suggested earlier, it is these very trends of rational control which, paradoxically, create the crisis of meaning and uncertain status of the body in late modernity. Modernity, in other words, as a reflexive social order, `manufactures' its own (i.e. internally referential) risks and uncertainties. Medicine, reflects and reinforces these dilemmas in acute corporeal form. Perhaps on a more rhetorical note, it is also possible to argue that postmodernism is really only an option for the `healthy' rather than the sick. As Charlton (1993) argues, when the `chips are down', when illness renders our contingent relationship to our bodies problematic, then modernist medicine offers us a candle of hope flickering precariously in the wind of our malaise. Modern medicine, in short, despite its limitations and iatrogenic consequences, is both a fountain of hope and font of despair. This, in turn, suggests that lay voices should be the final arbiters in these broader theoretical debates concerning the role of medical technology as liberation or oppression, opportunity or constraint (see, for example, Williams and Calnan 1996). Indeed, it is this concern, rhetorical or otherwise, with patients and lay voices which has underpinned many of the recent reforms sweeping through health care systems, both in Britain and elsewhere. It is to this issue that we now turn.

Health Care In Transition

5.1

For the last decade a key focus of the sociology of health and illness has been the analysis of the underlying causes and implications of the plethora of health care reforms in the UK (Annandale, 1998,Allen, 1992; Butler, 1994, Strong and Robinson, 1990). While cost containment and notions of efficiency have been highlighted in public debates, academic understandings of the continued reforms have focused mainly on responses to changing power relations and dominance within health-care linked to a shift in the underlying health care paradigm (i.e. the conceptualisation of health, illness and health care).

5.2

A key aspect of the reforms of the NHS has been the privatization and marketization of health care. The creation of trusts, establishment of health care commissioning, rise in the number and powers of hospital managers, have all transformed the acute-care sector. The increasing push towards primary-care and the new GP Commissioning Groups provide evidence of the growing status and importance of this sector, perhaps at the expense of doctors and other health care providers in the acute sector. They have also been dramatic changes in the fortunes of both nurses and members of the professional clinical services (PCS) as increasingly their training, credentialling and roles are shifting to incorporate more of the tasks historically associated with doctors. The growth of specialist nursing, such as breast care nurses, nurse practitioners and the acceptance and integration of a range of PCS into both the acute and primary sectors may begin to affect the balance of power between doctors and those they work with (Walby et al. 1994).

5.3

Similarly there has been a growth, at least in lip service, paid to patient/consumer involvement and empowerment. Beginning with Working for Patients (DoH 1996), members of the NHS have been called upon to be more sensitive to patient's own expressions of their need and to consult with them when planning shifts in service provision (see NHSME 1992,NHSE 1996). This has resulted in a plethora of patient satisfaction surveys, 'citizen juries' and the growth in 'patient' representation on a variety of committees associated with health care. These have ranged from increasing patient representation on Community Health Councils, and non-executive directors of NHS Trusts, to more recent proposals to have patients dominate the Committee on Distinction Awards which approves merit pay for senior NHS consultants. While patient participation may permit empowerment, concerns about co-optation and the lack of ability to provide any real alternative voice are frequently raised (Winkler 1987, Barnes and Cox 1997).

5.4

Simultaneously, the overhaul of the complaints system (NHSE, 1996) based, at least on some of, the recommendations of the Wilson committee and the recategorising of complaints from something to be avoided to `a jewel in the crown of the new consumer consciousness' (Cole 1995: 24) appears, on the surface, to argue for the actual `empowerment' of patients (Allsop and Mulcahy 1996). While all of these shifts have served to promote the visibility of patients and provide a rhetoric of inclusion, they have done little to shift power to patients (see Barnes and Cox 1997). Instead they provide a setting in which different sectors and different types of health professional and health service managers vie for superiority. Patients' views can provide the justification for changing the organization and provision of services benefiting one or other of the competing groups within the NHS: the net result being little overall change in term of real `patient empowerment'.

5.5

Closely allied to this shift in the fortunes of primary care, an increasing emphasis has been placed on health education and health promotion. This, in turn, has been linked to the emergence of the so-called `New' Public Health (Ashton and Seymour, 1988; Martin and McQueen, 1989). The social and environmental determinants of health and the isolation of `risk' factors are part and parcel of this shift in the orientation of the NHS towards new priorities. In this sense, whilst further strides forward are doubtless necessary, the `individualism' of previous approaches has, at least in relative terms, been tempered through public health concerns in which material inequality is now recognised (cf. DoH 1998) Our Healthier Nation, and DoH 1997). In service provision terms this has led to an expansion of well-woman and well-man clinics as well as a range of specific, usually nurse-led, clinics for chronic illnesses and advice on diet and exercise. At a broader level, it also keys into new forms of `surveillance' based medicine (Armstrong 1995), as well as more general debates over health, consumption and risk in the `epidemiological clinic' of late modernity (Bunton, Nettleton and Burrows 1995).

5.6

This shifting of responsibility for both health and illness on to the individual is closely linked to the rhetoric of `empowerment'. This is perhaps most apparent in the 'Patient's Charter' (DoH, 1995) which explicitly ties patient's rights to patient's responsibilities and at the same time individualizes them (Tritter, 1994). The promotion of non-legally enforceable rights has, it is argued, raised patient expectation and fuelled consumerism, but at the same time undermined the collective assumptions of the NHS and replaced them with an individualistic and competitive model.

5.7

This re-definition too, is visible in the expansion of private health care (Calnan et al. 1993). While private health care has always been a part of the existing provision in Britain, the population that is covered by private health insurance has grown from 5.25 million in 1986 to 6.09 million in 1996. It is worth noting here that in 1996 this represented only 1.29 million actual individual purchasers and 1.87 million company purchasers, thus the remainder of those covered were relatives and dependants . The dominance of only three companies, BUPA, Guardian Royal and Norwich Union has fuelled concerns about marketing, inflation in premiums and exclusionary terms leading the Office of Fair Trading to threaten direct government regulation (Independent 30 May 1998). This growth has been linked to the inclusion of health insurance as part of employment perks since the 1980s, but has also been fuelled by concerns about long waiting lists and the willingness for those with money to 'queue jump' (Davey and Popay, 1993).

5.8

Thus, the increasing importance of patient's voices, the centralization of government oversight, the changing role of nurses and the PCS and managerialism all hint at continued shifts in the distribution and organization of power within the contested terrain of health care in the UK. Similarly, the promotion of the new public health and the individualization of risk and responsibility, together with the increased role of primary care and the utilization and integration of complementary and alternative therapies in to mainstream health care, all suggest a shift in the underlying social paradigm of health. These factors are intertwined and integrally related to the timing, motivation and direction of the ongoing health policy reforms.

5.9

So where does the sociology of health and illness go from here in its contribution to these debates? Certainly the continued focus on the relationship between policy shifts and the organization and distribution of power within the health service, together with the impact on patients will remain a primary concern. This has clear implications in terms of a number of historic debates including (de)professionalization, health inequalities, power, bureaucracy and control. Both the underlying forces leading to policy reforms, and the changing relationship between the individual and the state apparent in the NHS, hint, however, at larger issues that hitherto have received relatively little attention. Some scholars have suggested that these shifts are evidence of a move from a modern to a postmodern world and pluralized medical marketplace for health care (Bakx, 1991). Others, however, have suggested that they are merely an outcome of a change in Britain's capitalist system (Jefferys, 1991). The critical role of sociologists of health and illness in this very process of transformation has also been noted (Nettleton, 1995).

5.10

Health reform is not new or confined to Britain, however, it is also increasingly apparent throughout the world (WHO 1996). In the US, for example, the Clinton administration's unsuccessful attempts to expand the coverage of basic health care to the majority of the population, together with the increasing domination of health care provision through a small number of corporate run health maintenance organizations (HMO's) illustrates many of the same concerns about access, profit and the role of large corporations (e.g. private health insurers) apparent in the NHS. On the other side of the world in New Zealand, health care has gone through as series of reforms since initial restructuring in 1992 which, as with all of the public sphere, is promoting services run along `business lines' with only macro policymaking and funding from government. Most recently this has involved the attempt to define what 'core' services should be publicly funded, together with the development and implementation of national criteria for assessing priority for medical and surgical procedures; an approach which is being hailed as a successful move away from long waiting lists and varied systems of rationing (Hadorn and Holmes, 1997; Smith, 1998).

5.11

Given these broader developments sociologists of health and illness in the UK need to expand their horizons. Our research and theoretical concerns no longer simply involve the NHS but must be located within a more global understanding of health care. Public sector reform around the world is redefining the responsibility of the nation state and the relationship between citizen, consumer, user or patient and the government. Sociologists, we argue, should play a part in this process, critically analyzing, understanding and engaging with these shifts in health care at the turn of the century.

Discussion And Concluding Remarks

6.1

Where then does this discussion leave us with respect to the nature and status of the sociology of health and illness, and what future trends does it signal?

6.2

First and foremost, the sociology of health and illness, as we have attempted to show in the scope of this short article, is indeed a thriving sub-field, with significant points of overlap with other evolving sub-fields such as the sociology of the body and emotions, alongside broader debates concerning social inequalities, consumption and risk (Williams, Gabe and Calnan 1999). In this respect, the lines of influence between mainstream sociological theory and the sociology of health and illness appear to flow both ways; the latter providing a series of both theoretical and substantive checks, as in Parsons' classic treatment of the sick role, on broader claims and generalisations (see, for example, Williams and Calnan 1996, Nettleton and Watson 1998).

6.3

Tensions, nonetheless remain within the discipline, a situation in which the spectre of old crises and debates over disciplinary identity again threaten to loom large. In this respect, the institututional base from which sociologists of health and illness work (i.e. academic departments of sociology, medical schools, health services research units etc.), together with the broader political economy of funding opportunities and the switch to more evidence-based, evaluative research, could again serve to drive a wedge between a `sociology in-the-service-of' medicine and those with a relatively `freer hand' to ply their own trade, remaining faithful to the `sociological imagination' (Mills 1959).

6.4

At the beginning of this article the charge of sociological imperialism was noted. Clearly, on the basis of the evidence presented here, it seems that many of Strong's (1979) concerns, voiced nearly twenty years ago, have materialised. In this respect, his message, on the whole, does not appear to have been heeded. Rather, like medicine itself, and in symbiotic fashion, the sociology of health and illness, as we have seen, has continued to expand, colonising/contesting the very nature of disease itself, without due recognition of its limits and the associated problems of the social model of health itself. On the one hand, of course, these developments are to be applauded. The sociology of health and illness does indeed have a legitimate voice and valuable role to play in these debates and this should be encouraged. On the other hand, however, any properly constituted, reflexive discipline, must also confront the `limits' of its own explanatory frames of reference, tackling head on the twin charges of relevance and expansionism.

6.5

Part of the problem here, no doubt, concerns the relationship between this sub-discipline and mainstream sociology as a whole. Whilst developments in the latter domain may indeed have a more `reflexive' ring about them - from debates over class, gender and ethnicity, to the politics of everyday life and the `opening up' of sexuality itself - points of contact, to date, have been less than optimal, due in no small part, as mentioned above, to the politics of health research and relationship to medicine, particularly when funding comes from the very service under investigation. Seen in this light, it may in fact be the kinds of sociology that medical sociologists have used, which makes the charge of sociological imperialism relevant, and that tackling issues of relevance and expansionism means taking on board the `limited' nature of the exchange with sociology to date: a situation in which reflexivity becomes a central theme and guiding concern.

6.6

That this is now imperative, as we have suggested, is signalled by the advent of the new genetics: a development which provides a powerful new explanation, rightly or wrongly, morally or immorally, for a multitude of human traits and characteristics from disease to personality, sexual preference to social behaviour. Clearly sociology has a role to play here, and a critical one at that, but an open, informed debate as to what precisely this constitutes - rather than knee jerk reactions and crude accusations of `biological reductionism' - is only now beginning to emerge (Benton 1991, Shakespeare 1997, 1998, Dickens 1998). Biology can no longer simply be dismissed as a sociological irrelevance. Nor can it simply be reduced to a discursive construction. Rather, as Benton (1991) and others has argued, a more reciprocally informed dialogue needs to occur: one which involves a recognition of both the constraints and opportunities this affords, including new inter-disciplinary alliances and collaborative research agendas. Within this context, a commitment to critical realism looks set to replace the more `linguistic turn' of the last decade or so, both in health (Williams 1998c) and in social theory more generally (Layder 1996).

6.7

Whatever the outcome of these (hotly contested) debates, one thing remains clear, namely that if, as Gerhardt (1989) rightly suggests, it is society which (ultimately) shapes the sociological research agenda, health related or otherwise, then the flurry of AIDS related research in the 1980s and early 1990s looks set to be eclipsed by a new wave of (interdisciplinary) studies on the new genetics as we move into the twenty-first century: back to the future or a `return of the "repressed"' perhaps?

Notes

¹See, for example, Straus (1957), Gold (1977), Stacey and Homans (1978), Strong (1979), Clarke (1981), Claus (1983) Scambler (1987), Gerhardt (1989), Turner (1992, 1996).

²According to Claus (1983), whilst medical sociology is usually regarded as a post-Second World War phenomenon, originating in the USA, in Europe - especially in France, Britain and Germany - its roots can be traced back to the social aspects of health and disease studied within disciplines like social medicine, public health and anthropology since the eighteenth century (c.f. Foucault's (1973, 1977) claim that sociology is merely a branch of social medicine). Modern European medical sociology, in short, bears the hallmarks of its antecedent or `pre-modern' phase.

Acknowledgements

Acknowledgements: Thanks to Liz Stanley and the anonymous reviewers - one in particular - for helpful comments on an earlier draft of this article.

References

AHMAD, W. (1993) Making black people sick: 'race' and health in research. In W. AHMAD (ed.), 'Race' and Health in Contemporary Britain, Buckingham: Open University Press, 11-33.

ALLEN, J. (1992) "Post-industrialism and post- Fordism", in S. Hall, D. HELD and T. MCGREW (eds.) Modernity and its Futures. Oxford; Polity/Open University Press: 177-220.

ALLSOP, J. and MULCAHY, L. (1996) Regulating Medical Work: Formal and informal controls. Buckingham: Open University Press.

ANDERSON W.F. (1995) Gene therapy. Scientific America. September: 96-98b.

ANNANDALE, E. (1998) The Sociology of Health and Medicine: a Critical Introduction. Cambridge: Polity Press.

ASHTON, J. and SEYMOUR, H. (1988) The New Public Health. Milton Keynes: Open University Press.

ATKINSON, P. and HEATH, C. (1985) Medical Work: Realities and Routines. Aldershot: Gower.

ARMSTRONG, D. (1983) Political Anatomy of the Body. Cambridge: Cambridge University Press.

ARMSTRONG, D. (1995) The rise of suveillance medicine. Sociology of Health and Illness 17, 3: 393-404.

BAKX, K. (1991) The 'eclipse' of folk medicine in Western society. Sociology of Health and Illness. 13, 1: 20-38.

BARNES, C. and COX, D. (1997) Patients, power and policy: NHS management reforms and consumer empowerment. In K. ISSAC-HENRY, C. PAINTER and C. BARNES (eds.) Management in the Public Sector: Challenge and Change (2nd Edition). Andover: Thompson Business Press.

BARTLEY, M., CARPENTER, L., DUNNELL, K. and FITZPATRICK, R. (1996) Measuring inequalities in health: an analysis of mortality patterns using two social classifications. Sociology of Health & Illness, 18, 455-74.

BECK, U. (1992) Risk Society: Towards a New Modernity. London: Sage.

BENDELOW, G. and WILLIAMS S.J. (1998) Emotions in Social Life: Critical Themes and Contemporary Issues. London: Routledge.

BENTON, T. (1991) Biology and social science: why the return of the repressed should be given a (cautious) welcome. Sociology. 25, 1: 1-29.

BLAXTER, M. (1999) Class, time and biography. In WILLIAMS S.J., GABE, J. and CALNAN, M. (eds.) Theorising Health, Medicine and Society. London: Sage (In Press).

BUNTON, R. and BURROWS, R. (1995) Consumption and health in the `epidemiological' clinic of late modern medicine. In R. BUNTON, S. NETTLETON and R. BURROWS (eds.) The Sociology of Health Promotion. London: Routledge.

BURY, M. (1982) Chronic illness as biographical disruption. Sociology of Health and Illness. 4: 167-82.

BURY M. (1988) . Meanings at risk. In: ANDERSON P. and BURY M. (eds.) Living with Chronic Illness: The Experience of Patients and Their Families. London: Hyman Unwin.

BURY, M. (1991) The sociology of chronic illness: a review of research and prospects. Sociology of Health and illness. 13, 4: 451-68.

BURKITT, I. (1997) Social relationships and emotions. Sociology. 31, 1:37-55.

BUTLER, J. (1994) "Origins and Development", in R. ROBINSON and J. LEGRAND (eds.) Evaluating the NHS Reforms. London: King's Fund Institute: 1-12.

CALNAN, M. (1987) Health and Illness: the Lay Perspective. London: Routledge.

CALNAN, M., CANT, S. and GABE, J. (1993) Going Private. Why People Pay for their Health Care. Buckingham: Open University Press.

CHARLTON B. (1993). Medicine and post- modernity. Journal of the Royal Society of Medicine. 86: 497-99.

CHARLTON, J., WALLACE, M., and WHITE, I. (1994) Long-term illness: results from the (1991) Census. Population Trends, 75, 18-25.

CLARKE, A. (1995) Modernity, postmodernity and reproductive processes, ca 1890-1990, or `mommy where do cyborgs come from anyway?'. In C.H. GRAY (ed.) The Cyborg Handbook. London: Routledge.

CLARKE, J. (1981) A multiple paradigm approach to the sociology of medicine, health and illness. Sociology of Health and Illness. 3 (1) 89-103.

CLAUS, L. (1983) The development of medical sociology in Europe. Social Science and Medicine. 17, 1: 591-7.

COLE, A. (1995) Should complaints be treasured? The Health Services Journal. 105 (28 September) 24-27.

COREA, G. (1985) The Mother Machine. New York: Harper and Row.

COREA1, G., KLEIN, R.D. et al. (eds.) (1985) Man-Made Women: How New Reproductive Technologies Affect Women. London: Hutchinson.

CRAWFORD, R. (1998) The ritual of health promotion. In WILLIAMS S.J., GABE J. and CALNAN M. (eds.) Theorising Health, Medicine and Society. London: Sage (In Press).

DAVEY, B. and POPAY, J. (eds.) (1993) Dilemmas in Health Care. Buckingham: Open University Press.

DAVIS, K. (1994) Reshaping the Female Body: the Dilemmas of Cosmetic Surgery. London: Routledge.

DAVIES, C. (1996) The sociology of professions and the profession of gender. Sociology. 30, 4: 661-78.

DAVISON, C., DAVEY SMITH, G. and FRANKEL, S. (1991) Lay epidemiology and the prevention paradox: implications for coronary candidacy and health education. Sociology of Health and Illness, 13, 1, 1-19.

DAVISON, C., FRANKEL, S., DAVEY SMITH, G. (1992) The limits of lifestyle: re-assessing `fatalism' in the popular culture of illness prevention. Social Science and Medicine, 34, 6,675-85.

DEITCH, J. (1992) Post Human. Amsterdam: Idea Books.

DEPARTMENT OF HEALTH (1995) The Patient's Charter and You. London: HMSO.

DEPARTMENT OF HEALTH (1989) Working for Patients Cmnd. 555. London: HMSO.

DEPARTMENT OF HEALTH (1997) The New NHS: Modern, Dependable. London: The Stationary Office.

DEPARTMENT OF HEALTH (1998) Our Healthier Nation (Green Paper). London: The Stationary Office.

DENZIN, N.K. (1984) Understanding Emotions.

DICKENS, P. (1998) Soapbox: Don't throw the baby out with the bathwater. BSA Network. 69, (January) 32.

EMERSON, J.P. (1970) Behaviour in private places: sustaining definitions of reality in gynaecological examinations. In H.P. DREITZEL (ed.) Recent Sociology No. 2: Patterns of Communicative Behaviour. New York: Macmillan. ENGELS, F. (1993 [1845]) The Condition of the Working Class in England. Oxford: Oxford University Press.

ESPING-ANDERSON, G. (1993) Post-industrial class structures: an analytical framework. In G. ESPING- ANDERSON (ed.), Changing Classes, London: Sage, 7-31.

FEATHERSTONE, M. and BURROWS, R. (1995) Cultures of technological embodiment: an introduction. Body & Society, 1, 3-4: 1-19.

FINEMAN, S. (1993) Emotion in Organizations. London: Sage.

FOUCAULT, M. (1973) The Birth of the Clinic: an Archaeology of Medical Perception London: Tavistock.

FOUCAULT, M. (1977) Discipline and Punish: the Birth of the Prison. London: Tavistock.

FOX, N. (1993) Postmodernism, Sociology and Health. Milton Keynes: Open University Press.

FRANK, A.W. (1995) The Wounded Storyteller: Body, Illness and Ethics. Chicago/London: University of Chicago Press.

GABE, J. (ed.) (1995) Medicine, Health and Risk. Oxford: Blackwell.

GABE, J., KELLEHER D., and WILLIAMS G.H. (eds.) (1994) Challenging Medicine. London: Routledge.

GARFINKEL, H. (1967) Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall.

GELLNER, E. (1992) Reason and Culture. Oxford: Blackwell.

GERHARDT, U. (1989) Ideas About Illness: an Intellectual and Political History of Medical Sociology. London: Macmillan.

GLASSNER, B. (1989) Fitness and the postmodern self. Journal of Health and Social Behaviour. 30, 180-91.

GLASSNER, B. (1995) In the name of health. In R. BUNTON, S. NETTLETON and R. BURROWS (eds.) The Sociology of Health Promotion: Critical Analyses of Consumption, Lifestyle and Risk. London: Routledge.

GOFFMAN, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Harmondsworth: Penguin.

GOLD, M. (1977) A crisis of identity: the case of medical sociology. Journal of Health and Social Behaviour. 18: 160-8.

GRAY, C.H. (ed.) (1995) The Cyborg Handbook. London: Routledge. HADORN, D. and HOLMES, A. (1997) "The New Zealand priority criteria project . Part 1: Overview", British Medical Journal. 314 7074: 131-134.

HARAWAY, D. (1991) Simians, Cyborgs and Women. London: Free Association Books.

HOCHSCHILD, A.R. (1983) The Managed Heart: the Commercialisation of Human Feeling. Berkeley CA: University of California Press.

HOCHSCHILD, A.R. (with MACHUNG A.) (1990) The Second Shift: Working Parents and the Revolution at Home. London: Piatkus.

HOLTON, R. (1996) Has class analysis a future? In D. LEE and B. TURNER (eds.) Conflicts about Class. London: Longman.

HOLTON, R. and TURNER, B. (1989) Max WEBER on Economy and Society. London: Routledge, 38-48.

HUNT, K. and ANNANDALE, E. (1998) Gender and health. Social Science and Medicine (see special issue) (In Press).

ILLICH, I. (1975) Medical Nemesis. London: CALDER and BOYARS.

INDEPENDENT (1998) "Health insurers get a poor report", 30 May.

JAMES, N. (1992) Care = organisation + physical labour + emotional labour. Sociology of Health and Illness, 14, 4, 488-509.

JAMES, V. and GABE, J. (eds.) (1996) Health and the Sociology of Emotions. Oxford: Blackwells.

JEFFERYS, M. (1991) The agenda for sociological health-policy research for the (1990) s. In J. GABE, M. CALNAN, M. BURY (eds.) The Sociology of Health Services Research. London: Routledge.

KELLY, M. (1991) Colitis. London: Routledge.

KELLY, M. and FIELD, D. (1996) Medical sociology, chronic illness and the body. Sociology of Health and Illness, 18, 241- 57.

KLEINMAN A. (1988) . The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books Inc.

LANGER R. and VACANTI J.P. (1995) Artificial organs. Scientific American. September: 100-103.

LAYDER, D. (1996) Review essay contemporary sociological theory. Sociology. 30, 3: 601-08. LEDER, D. (1990) The Absent Body. Chicago: Chicago University Press.

LEDER, D. (1984-5) Toward a Phenomenology of Pain. The Review of Existential Psychiatry, 19, 255-66.

LOCKER, D. (1983) Disability and Disadvantage. London: Tavistock.

LUPTON, D. (1995) Medicine as Culture. London: Sage.

LUPTON, D. (1996) `Your life in their hands': trust in the medical encounter. In James, V. and Gabe J. (eds.) Health and the Sociology of Emotions. Oxford: Blackwell.

LYOTARD, J-F. (1984) The Postmodern Condition. Manchester: Manchester University Press.

MACINTYRE, S. (1997) The Black Report and beyond: what are the issues? Social Science and Medicine. 6, 44, 723- 746.

MACINTYRE, S., HUNT, K., and SWEETING, H. (1996) Gender differences in Health: are things as simple as they seem? Social Science and Medicine, 42, 617-24.

MCLOONE, P. and BODDY, A. (1994) Deprivation and mortality in Scotland, (1981) and (1991) . British Medical Journal, 309, 1465-70.

MCNEIL, M., VARCOE, I. and YEARLEY, S. (eds.). (1990) The New Reproductive Technologies. London: Macmillan.

MARTIN, C.J. and MCQUEEN, D.V. (eds.) (1989) Readings for a New Public Health. Edinburgh: Edinburgh University Press.

MAYALL, B. (1996) Children, Health and the Social Order. Buckingham: Open University Press.

MILLS, C. WRIGHT (1959) The Sociological Imagination. New York: Oxford University Press.

MORRIS, David. (1991) The Culture of Pain. Berkeley CA: University of California

NATIONAL HEALTH SERVICE EXECUTIVE (1996) Patient Partnership: Building a Collaborative Strategy. Leeds: DoH.

NHSME NATIONAL HEALTH SERVICE MANAGEMENT EXECUTIVE (1992) Local Voices. Leeds: NAVARRO, V. (1976) Medicine Under Capitalism. New York: Prodist.

NAVARRO, V. (1994)The Politics of Health Policy: the US Reforms (1980) - 1994. Oxford: Blackwell.

NETTLETON, S. (1991) Power, Pain and Dentistry. Buckingham: Open University Press.

NETTLETON, S. (1995) The Sociology of Health and Illness. Cambridge: Polity Press.

NETTLETON, S. and Watson, J. (eds.) (1998) The Body in Everyday Life. London: Routledge.

OAKLEY, A. (1984) The Captured Womb. Oxford: Blackwell.

PARSONS, T. (1951) : The Social System. London: Routledge and Kegan Paul.

PHILLIMORE, P., BEATTIE, A. and TOWNSEND, P. (1994) Widening inequality of health in Northern England, 1981-1991. British Medical Journal, 308, 1125-8.

PRIOR L. (1998) Reflections on the 'mortal body' in late modernity. In WILLIAMS S.J., GABE J. and CALNAN, M. (eds). Theorising Health, Medicine and Society. London: Sage.

RADLEY, A. and GREEN R. (1987) Chronic illness as adjustment: a methodology and conceptual framework. Sociology of Health and Illness, 9, 2, 179-207.

ROWLAND, R.A. (1985) child at any price? Women's Studies International Forum. 8, 6: 539-46

SAWICKI, J. (1991) Disciplining Foucault: Feminism, Power and the Body. London: Routledge.

SCAMBLER, G. (ed.) (1987) Sociological Theory and Medical Sociology. London: Tavistock.

SCAMBLER, G. and Higgs P. (eds.) (1998) Modernity, Medicine and Health. London: Routledge.

SCHEFF, T.J. (1966)Being Mentally Ill. Chicago, Ill: Aldine.

SCHEPER-HUGHES, N. and LOCK, M. (1987) The Mindful Body: a Prolegemonon to Future Work in Medical Anthropology. Medical Anthropology Quarterly. 1, 1, 6-41.

SHAKESPEARE, T. (1997) Soapbox: Social genetics - a polemical issue. BSA Network. 68, (September) 32.

SHAKESPEARE, T. (1998) Back to basic biology: reductionist trends in social explanation. Paper presented at the BSA `Making Sense of the Body' conference 6-9 April, University of Edinburgh.

SHARMA, U. (1996) Using complimentary therapies: a challenge to biomedical hegemony? In WILLIAMS S.J. and CALNAN M. (eds.) Modern Medicine: Lay Perspectives and Experiences. London: UCL Press.

SHILLING, C. (1997) Embodiment, emotions and the sensation of society. The Sociological Review. 45, 2: 195-219.

SMAJE, C. (1995) Health, 'Race' and Ethnicity. London: King's Fund Institute.

SMAJE, C. (1996) The ethnic patterning of health: new directions for theory and research. Sociology of Health & Illness, 18, 139-71.

SMAJE, C. (1999) A place for race? Medical sociology and the critique of racial ideology. In WILLIAMS S.J., GABE J. and CALNAN, M. (eds.) Theorising Health, Medicine and Society. London: Sage.

SMITH, R. (1998) "New government, same narrow vision", British Medical Journal. 316 7132: 643.

STACEY, M. (1988) The Sociology of Health and Healing. London: Routledge.

STACEY, M. and HOMANS, H. (1978) The sociology of health and illness: its present state, futures and potential for health research. Sociology. 12: 281-307.

STANWORTH, M. (ed.) (1987) Reproductive Technologies: Gender, Motherhood and Medicine. Cambridge: Polity Press.

STEINBERG, D.L. (1999) Recombinant bodies: narrative, metaphor and the gene. In WILLIAMS S.J., GABE, J. and CALNAN, M. (eds.) Theorising Health, Medicine and Society. London: Sage (In Press).

STRAUS, R. (1957) The nature and status of medical sociology. American Sociological Review. 22: 200.

STRAUSS, A.L. and GLASER, B. (1975) Chronic Illness and the Quality of Life. St Louis: Mosby.

STRAUSS, A.L., FAGERHAUGH, S., SUCZEK, B. and WIENER C. (1982) Sentimental work in the technological hospital. Sociology of Health and Illness. 4: 254-78.

STRONG, P. (1979) Sociological imperialism and the profession of medicine: a critical examination of the thesis of medical imperialism. Social Science and Medicine. 13A: 199-215.

STRONG, P. and ROBINSON, J. (1990) The NHS: Under New Management. Milton Keynes: Open University Press.

SYNNOTT A. (1993) The Body Social: Symbolism, Self and Society. London: Routledge.

TOWNSEND P, and DAVIDSON N, (1982) Inequalities in Health : The Black Report ;Harmondsworth Penguin

TRITTER, J. (1994) "The Citizen's Charter: Opportunities for Users' Perspectives?", The Political Quarterly. 65 4: 397-414. TURNER, B.S. (1992) Regulating Bodies: Essays in Medical Sociology. London: Tavistock.

TURNER, B.S. (1996) The Body and Society (2nd Edt.). London: Sage.

VERBRUGGE, L. (1985) Gender and Health: an update on hypotheses and evidence. Journal of Health and Social Behavior, 26, 156-82.

VOYSEY, M. (1975) A Constant Burden. London: Routledge and Kegan Paul.

VRANCKEN, M. (1989) Schools of thought on pain. Social Science and Medicine. 29, 3: 435-44.

WALBY, S. and GREENWELL, J. with MACKAY L. and SOOTHILL, K. (1994) Medicine and Nursing. London: Sage.

WILKINSON, R. (1986) Socio-economic differences in mortality: interpreting the data on size and trends. In R. WILKINSON (ed.) Class and Health. London: Tavistock, 1-33.

WILKINSON R. (1997) Unhealthy Societies: the Afflictions of Inequality. London: Routledge.

WILLIAMS, G.H. (1984) The genesis of chronic illness: narrative reconstruction. Sociology of Health and Illness, 6, 175- 200.

WILLIAMS, G.H. and BUSBY H. (1999) The politics of 'disabled' bodies. In WILLIAMS S.J., GABE, J. and CALNAN M. (eds.) Theorising Health, Medicine and Society. London: Sage (In Press).

WILLIAMS, S.J. (1996a) The vicissitudes of embodiment across the chronic illness trajectory. Body & Society, 2, 2, 23-47.

WILLIAMS S.J. (1996b) Medical sociology, chronic illness and the body: a rejoinder to Michael KELLY and David FIELD. Sociology of Health and Illness, 699-709.

WILLIAMS S.J. (1997) Modern medicine and the uncertain body: from corporeality to hyperreality. Social Science and Medicine. 45 (7) 1041- 9.

WILLIAMS S.J. 1998a: Health as moral performance: ritual, transgression and taboo. Health. (in Press).

WILLIAMS S.J. (1998) b: `Capitalising' on emotions: rethinking social structure and health. Sociology. 32, 1: 121- 39.

WILLIAMS S.J. (1998) c: Sociological imperialism and the profession of medicine revisited: one step forward two steps back? Working paper: Centre for Research in Health, Medicine and Society. University of Warwick, September (1998) .

WILLIAMS S.J. and BENDELOW G.A. (1998) The Lived Body: Sociological Themes, Embodied Issues. London: Routledge.

WILLIAMS S.J. and CALNAN M. (eds.) Modern Medicine: Lay Perspectives and Experiences. London: UCL Press.

WILLIAMS, S.J., GABE, J. and CALNAN M. (eds.) (1999) Theorising Health, Medicine and Society. London: Sage.

WINKLER, F. (1987) "Consumers in Health Care: Beyond the supermarket model", Policy and Politics, 15 11: 1-8.

WITZ, A. (1994) Professions and Patriachy. London: Routledge.

WORLD HEALTH ORGANISATION Regional Office for Europe (1996) WHO Conference on European Health Care Reforms: Proceedings from the Conference. Ljubljana, Slovenia, June. Copenhagen: WHO.

ZIMMERMANN, S. (1998) Silicone Survivors. Philadelphia: Temple University Press.

ZOLA, I.K. (1972) Medicine as an institution of social control. Sociological Review, 20: 487-503.

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