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Enduring theoretical legacies

Theory is important because it connects the subfield of the sociology of health and illness to the larger sociological landscape. Historically, this connection has been quite weak, chiefly because matters of health and illness were of limited interest within the wider discipline. This changed quite markedly in the mid-to-late 1990s when cracks started to appear in the terrain of wider social theory as it began to shift under the weight of new and then poorly understood matters such as embodiment, risk and the global biopolitics of health, all matters of longstanding interest within the subfield. The relationship between theory and research is reciprocal: extant theories gradually fall out of fit with societies as they change and new approaches are called for. For example, theories with a time-honoured reliance on a distinction between the social and the biological and upon fixed categories of gender, class and ethnicity now struggle to assist in the analysis of new diseases, new medical practices, and the meaning of health in today's complex global economy. Consequently, the sociology of health and illness has also changed its foci over the years. In the process it has secured an ever-firmer theoretical footing within the wider discipline.

This chapter covers the origins and early development of the discipline but it is intended to have much more than historical value. While different theoretical perspectives have arisen and held sway during different decades and therefore are to an extent 'of their time', this does not mean they are no longer relevant. Indeed, the applicability of the political economy and symbolic interactionist perspectives which we will consider here will be clear when we revisit them in the chapters which follow. Even Parsonsian structural functionalism, which many might dub the most antiquated of theories, has been reappraised and found more valuable than once assumed.

Medicine and sociology: critical connections

There is now a substantial body of reflective writing on the origins and development of medical sociology. Much of this is told from the vantage of the West, particularly the US and the UK, where the disciplinary roots are found in the two decades following World War II. The effect of this is that other countries tend to be positioned as 'coming late' to the field and as unintentionally authorizing Western history as the history. That said, accounts of how medical sociology took shape around the world often refer to three things: (i) to a shared desire to understand the social patterning of health in unequal societies and the implications for society of health-profiles shifting from acute to chronic illnesses; (ii) to a need to grapple with the dominant medico-centric approach to health and healthcare in the society concerned; and (iii) with some exceptions - such as Russia where early research was guided by Marxist-Leninist theory (Dmitrieva 2001) - to being stimulated by, but nonetheless remaining somewhat critical of, the structural functionalist concern with illness as social deviance (see e.g. Bloom 2002; Figlio 1987; Johnson 1975; Nuñes 2001).

These origins were distinctly double-edged. On the one hand, 'medicine nurtured, funded, and sponsored medical sociology early in its development' and structural functionalism made it academically respectable (Cockerham and Scambler 2010: 4). Yet, as commentators have been quick to point out, on the other hand, this led sociology into the arms of medicine, stunting its academic growth in the process. Back in 1957, in his analysis of US medical sociology, Robert Straus drew a heuristic distinction between the 'sociology of medicine' and 'sociology in medicine'. As he put it, in the former 'the sociologist stands apart and studies medicine as an institution or behaviour system', while in the latter, he - and the majority were indeed men, though Straus may not have intended to signal this - 'is collaborating with the medical specialist in trying to help him in the performance of his educational or therapeutic functions' (Straus 1957: 203). Straus depicted medical sociologists as chameleon-like as they traversed this divide in their research. He particularly cautioned against pressures from health practitioners for sociologists to recast their research findings in terms understandable to them, remarking that it is a small step from adopting medical language to eventually acting like and even coming to think like a physician (Straus 1957).

This warning was not necessarily heeded in the 1960s and 1970s. Writing twenty years on from Straus, Murcott looked back critically upon a period of 'medico-centrism' in which sociologists adopted the value-judgements of medicine, such as the belief that failure to recover from illness is a result of non-compliance with physicians' instructions. She explains that topics chosen for investigation were often defined against an implicit medical template - 'fringe medicine, lay definitions of illness, marginal professions, self medicine', and so on (Murcott 1977: 157). Yet, as Straus also remarked, if the sociologist 'sticks resolutely to pure sociology', typically this will be 'misunderstood, ignored or rejected' (1957: 104). Some years later, Horobin depicted this tenuous experience as inhabiting 'the interstices between the citadel of medicine and the suburb of sociology' (1985: 95). Many writers of the 1970s and beyond have felt that medical sociology should divorce itself from - or at least be sceptical of - medicine and develop an alternative social approach (see, e.g., Gold 1977). An agenda was therefore set: to turn away from the problematic 'biomedical perspective' to a 'social model' of health and healthcare. To consider how this occurred, we first need to look a little more closely at sociology's wider debate with biomedicine, both then and now.

The debate with biomedicine

In his (largely US-focused) history of the discipline, Bloom remarks that medical sociology has persistently 'developed in a trajectory that follows its parent discipline but with reference always to the changing institutional dynamics of medicine' (2002: 273). In other words, as the fabric of biomedicine changes, so too do the kind of critical analyses that sociologists weave, but the broad running threads remain consistent. Social scientists have argued that the conventional depiction of medical science as a progressive march forward in the conquest of illness fails to appreciate that medical knowledge is never disinterested. Rather, as we will see in the course of this chapter, it reflects and reproduces the dominant ideas of the society of its time.

Jewson (1976) charts this early process through the emergence of three distinctive medical cosmologies, or frameworks, within which practitioners make sense of the signs and symptoms of illness and formulate treatment plans, over the formative period between 1770 and 1870. He reveals that medical cosmologies are modes of social interaction embedded in the social relations of the production of medical knowledge. In the early period, which he characterizes as 'bedside medicine', medical practitioners worked within a person-oriented cosmology where judgements were made in terms of the personal attributes of the individual sick person. In order to survive in what was a competitive environment, at a time when medical practice was controlled by a coterie of rich fee-paying patients who had access to a wealth of practitioners of various kinds (Pelling and Webster 1979), the physician 'sought to discover the particularistic requirements of his patient in order to satisfy them to the exclusion of his ubiquitous rivals' (Jewson 1976: 233). The personal rapport that was necessary in order to secure business depended on the physician recognizing the patient as an integrated psychosomatic entity in which physical and emotional disturbance were indivisible.

This person-oriented cosmology was eclipsed with development of 'hospital medicine' in the early nineteenth century. With the development of hospitals, medical elites were no longer reliant on patronage; instead, they had a ready mass of indigent patients at their disposal. The control of medical knowledge passed from the patient, who was now expected to 'endure and wait', to the clinician. A new disease cosmology emerged within which any 'interest in the unique qualities of the whole person evaporated to be replaced by studies of specific organic lesions and malfunctions' (Jewson 1976: 235). This was consolidated in the mid nineteenth century with the development of 'laboratory medicine'. During this period, the patient as a sentient being moved out of the frame altogether to become a material thing to be analysed, and disease became 'a physio-chemical process to be explained according to the blind inexorable laws of natural science' (Jewson 1976: 238).

The modern form of biomedicine that eventually emerged has been typified in a variety of ways, but three characteristics are usually central. First, it is reductivist, assuming that disease is a problem of the individual body, rather than a result of the interaction of the individual and the social world. For example, recalling a grand-rounds presentation in a US teaching hospital, Scheper-Hughes and Lock recount the case of...