Health as a Social Lens.
In this second comment, I hope to do justice to Graham’s work here, and I urge you to read the book. Yes, indeed it does get a bit technical in places, but persevere!
The first chapter of ‘Sociology, Health and the Fractured Society: A critical realist account’ discusses the idea of understanding a society by looking at the health of its population. It draws us into thinking about our health and society. Health is not a purely individual, biological phenomenon. Thinking about health in this manner helps us to understand the much bigger context in which we live our lives. Of course, the implication here is not just that we begin to understand and explain health outcomes, but that we also take action not just at the individual lifestyle level beloved by many.
It is now almost universally accepted that for example the individual should not smoke, and we know most of the biological mechanisms at play in the development of lung cancer. If, however, and that ‘if’ is an assumption, we wish to drastically reduce the number of people dying prematurely of lung cancer, then knowing the biological mechanism and entreating people to stop smoking is only the start. A libertarian society would say “people are responsible for their health, not the government or public health busybodies, people know the risks, people should take that responsibility or face the consequences, it is not for anyone else to stop people from smoking, as long as they don’t harm others it is no one’s business but their own whether to smoke or not”. This is perhaps what is meant by understanding a society from looking at it how it deals with a health issue. A society that emphasises individual responsibility while ignoring deeper structural mechanisms is a society devoid of a sociological imagination. On smoking, we can see that this libertarian view has been largely tempered by a far more interventionistviewpoint that has introduced plain packaging, tax, bans in public spaces, advertising bans, age restrictions and funded public education campaigns over decades not the least of which is the current ‘make every contact count’.
I would assert that current UK social and political views on a range of health interventions can be thought of as a battle between libertarian and interventionist approaches. Note that we prohibit the sale of MDMA but not alcohol. The latter is a drug, many argue, far more harmful than MDMA or even cocaine and heroin, and yet for social, cultural and political reasons, is treated very differently.
So, if you wish to understand a society, look at its population’s health and the health care it designs and develops. Examine its health policies, what it thinks should or could be done to improve health outcomes. Look at who gets ill, who dies early, where they live and what resources they have to live well. Examine the role models they access and who the powerful influencers are. So, if you know that a person born today into a household which is struggling to pay the bills has a higher chance of an early death, or will probably experience fewer disability free years of life than another person born into affluence, you might want to ask why and what mechanisms bring this about?
Increases in Longevity.
The chapter starts by asking: What can we learn about society from learning about the increase in life expectancy over the past 10,000 years? To begin unpicking this, we need to understand the changing nature of social formations over the past 10,000 years.
There is a useful time line of human social formations (on page 9) since the ‘Neolithic revolution’ which began between 8,000 and 3,000 years ago and I suggest you consider this as a useful framework for understanding the much wider social formations that have existed rather than assume the current is the natural or only social form.
At this point, I might perhaps provocatively assert that we have a flawed idea of unending positive progress from hunter gatherer (if positive progress it is) to financial capitalism of the UK and the US. It could easily be dramatically reversed in perhaps just a few decades due to unknown events (contingencies) called ‘Black Swans’ by Nicolas Taleb, or perhaps known events such as the spread and use of nuclear weapons and world war 3, global pandemics, financial collapse, the degradation of the environment and climate catastrophe or the development of Artificial Intelligence into ‘Superintelligence’, but I digress.
A Chronology of Human Social Formations:
- 8,000 – 3,000 BC
- 3,000 BC – 1450 AD
- Fully fledged Agrarian States.
- 1450 -1640. The ‘Long 16thcentury’ the Transition to Capitalism:
- Private ownership of the means of production.
- Wage labour evolves.
- The profit motive and long-term accumulation of capital as a primary drive for production, overtaking notions of social subsistence, welfare and well-being as primary drives.
- 1640 – onwards. Capitalist States.
- Mercantile capitalism morphs into industrial capitalism.
- Industrial Capitalism has its Early (1760-1830), Liberal (1830-1870), Early Fordist (1870 -1918), Welfare (1918-1970) and Financial (1970 onwards) phases.
We are currently in the financial capitalist phase, with different countries at different stages and priorities but the global system is dominated by countries such as the United States, China, japan, India, United Kingdom, the Association of South East Asian States and of the European Union. Many countries in Africa are fast catching up. The actions of capitalist executives, and their political power elites, are primarily focused on capital accumulation and GDP growth and while some have woken up to issues such as climate changeand tax avoidance, it is arguable whether their fundamental assumptions about how an economy should be run has changed. The core of the Greedy Bastards Hypothesis is that the unintended consequences of their actions impact on health outcomes for billions.
Life expectancy and the major reasons for cause of death have changed in those phases. In short, we have witnessed the transition from infections to degenerative disease as the major causes of death, especially in what Hans Rosling calls level 1 and 2 countries known as Developed Countries. The main reasons put forward are:
- The reduction of human exposure to infectious organisms through reduced contamination of food and water supply.
- Increased human resistance to infection via improved nutrition and fitness.
- The invisible hand of ‘Capitalism’.
The influence of medical science has been overstated.
Capitalism is indeed involved but what comes with it, is social and health inequalities outlined and described in detail by social epidemiology and public health. Capitalism of course is not the only social formation characterised by inequality, but to ignore this as a feature of current experience would be to miss the glaringly bloody obvious.
The task however, is not just to describethe degree of inequality but to try and explainit, and then the suggestion of how to tackleit. This latter is of course contested, as some are quite happy with inequality and its effects. Epidemiological data clearly shows variablesof occupational class and gender, as well as ethnicity, as coming into play when we examine the social determinants of health. However, it is not enough to see them merely as ‘variables’ outlined by positivist methods of enquiry. We need to consider class, for example, as a social structure, as social relations. An issue preventing us from doing so is the quantitative methods and data of a positivist approach.
For a good example of descriptive epidemiological data on obesity, see Hruby and Hu (2015) ‘The Epidemiology of Obesity: A Big picture’. See especially section 5. ‘Risk Factors’, and its concluding sentence:
“So, while body weight regulation is and should be viewed as a complex interaction between environmental, socioeconomic, and genetic factors, ultimately, personal behaviors in response to these conditions continue to play a dominant role in preventing obesity. Importantly, apart from genetics, every risk factor (e.g. low education)discussed below is modifiable.”
Many health care professionals are au fait with just such methods and data, they know that people in the ‘top’ (no value judgment intended) social classes live longer and have fewer disability free life years than those in routine and unskilled occupations. What they often lack is a sophisticated explanatory theory for this data that goes beyond trying to connect the owning of wealth with increased life expectancy by pointing out the ability to buy good food and pay for decent gym memberships or sports clubs. This point says nothing about the nature of the society that results in this surface data described in many a text book and public health report. Positivist methods cannot do this, as it merely collects quantifiable data while blind to ‘below the surface’ social and psychological mechanisms. Hruby and Hu fall back on personal behaviour playing the dominant role, even after discussing the obesogenic environment. They accept that ‘socioeconomic disparities’ and ‘economic transitions’ are playing a considerable role in obesity risks across countries, but these are treated as variables in the data, not as explanations.
An examination of the risk factors outlined in the article lists individual, socioeconomic and environmental risk factors (table 2) but we can’t get beyond listing things such as low education and poverty to how and whythere is low education and poverty and how this leads to obesity. We don’t know the social structural relationships for example or why personal agency is exercised in particular ways. It is not for epidemiology to do this, hence the need for sociological analysis that goes beyond collecting quantifiable data
The Problems with Positivism.
At this point, the argument gets a little bit technical for those not schooled in philosophy or social theory. It also assumes a little knowledge about what positivism is. Reference here is made to Locke, Berkeley and Hume – the ‘British Empiricists’. The idea emerging from these thinkers is that knowledge of the world is to be gained by observation and measurement. Therefore, only those things that are available to the human senses are the objects of study. If you can’t count it, it does not count. From this position one can then begin to make causal inferences between variables that are being measured.
Hume is important here, in his idea of causality and ‘constant conjunctions’. Hume suggested that if we are to infer that A causes B, then A and B have to be constantly conjoinedin the past.
If we are to accept that poverty (A) causes obesity (B) then we have to see that, in the past, poverty and obesity are ‘conjoined’ – this does not provethe link, but if we consistently see the relationship, we rely on thinking that it does. Epidemiological data that consistently shows that low socio-economic status is linked to obesity indicates that link. This is ‘surface data’, things we can see and measure. This sort of reasoning underpins much of positivistic thinking that came after, such as that of Compte’s ‘positive science of society’ and J S Mill’s refinements of Hume.
There are three types of positivistic thinking:
- Accounting – the collection of data to see patterns (e.g. patterns of low education and obesity).
- Advising – this investigates those patterns in order to suggest policy. So, if we see patterns of low education and obesity, we may predict that the first may cause the other and so we might ask that something be done about low education.
- Prediction/explaining. Now, this is the problem. Studies here don’t just identifysocial patterns (e.g. the pattern of low education relating to obesity), but this is also used as explanation (low education causes obesity) using inductive probability. This mode of reasoning attempts to predict future events (if you see low education you will see higher rates of obesity) based on past events (we have seen low education linked to obesity before).
Why is this last position open to criticism? Well, the social world is not just a set of measurable empirical events (e.g. low education) out there waiting to be discovered and linked (e.g. to obesity) using statistical methods. There are underlying mechanismsat work whether they are detected or not by empirical observation, statistics and measurement.
In addition, ‘events’ in the social world, such as low education or obesity, are often ‘unsynchronised’ from the causal mechanisms that shape them. When we see obesity, we may not see that the mechanisms that give rise to it are directly and immediately apparent, they may be hidden from view and unmeasurable and have occurred in the past.
We have also to say that ‘events’ are also ‘conjointly determined’ by various mechanisms, some of which may also be countervailing. The sort of mechanisms we are talking about here is class, gender, ethnicity. Obesity cannot be reduced to a statistical relationship with certain factors or variables, without acknowledging that we may be unaware of the various mechanisms that give rise to it. A task of the sociologist, as opposed to epidemiologist, is not just to describe (i.e. positivist accounting) social patterns but to attempt to explain them by getting below the surface of observable phenomenon such as the link between low education and obesity.
It is very important to note that ‘society’ is an ‘open system’, rather than a set of natural substances in a laboratory in which we try to control all variables in a ‘closed system’, that allows us prediction and measurement and to establish casual laws.
In a lab (a closed system) you can add copper oxide as a black solid, to colourless dilute sulphuric acid to produce copper sulphate, a blue liquid. These two events (adding copper oxide and getting copper sulphate) are regular ‘constant event patterns’ – this will always happen, doing the first will lead to the second every time. In an open system however, event patterns like this are rare. We can’t do an experiment to prove that low education causes obesity. Noting that the two are statistically probable is the accounting functionof positivism but when used also as the prediction/explanation, we have overreached.
The chapter ends with discussing the need for explanation based on theory, after briefly discussing Hume’s is/ought dichotomy.
Hume asserted that one cannot infer an ‘ought’ from an ‘is’. For example, just because meat eating is widespread among a population, it does not automatically follow that it ought to be. Just because thereisa system of the private ownership of the means of production, it does not automatically follow that it ought to be.But, no case for ‘oughts’ should be made merely from the evidence of what is.
As seductive as this is, social phenomena are very complex and sociological theory requires us to examine the historical conditions in which people live their lives (their ‘is’) in order to clarify that in fact people may make decisions that are against their own interests, and if that is the case there is a ethico-moral imperative for sociological theory and analysis to argue for a different state of affairs…an ‘ought’ to move us beyond the Humean simple dichotomy of is/ought.
It is pointed out that people are born involuntarily into hierarchical social systems, ‘we make our own history but not in the circumstances of our own choosing’. It is also the case that accident of birth into a hierarchy can lead people to make decisions that are against their own interests and this is so because:
“powerholders and superordinate groups have both vested interests and the institutional and cultural capacities to disseminate their own self-justificatory beliefs across the rest of society, to misinterpret social relations as in the interests of everyone, or to justify publically their own oppressive or exploitative institutions in the eyes of the downtrodden or subordinate” (Creavan 2007 on p20).
Jacob Rees-Mogg has a powerful vested interest in keeping the investment environment as it is. He uses financial, social and cultural capital to try and persuade the rest of the UK population to accept that status quo, often by keeping it out of sight. His class argues it is for the good of everyone in the UK and not just for his own investment portfolio or of those of his clients. If that investment includes shares in the fossil fuel industry or ignores investment in green technologies or rebuilding deindustrialised towns, we could mount an argument that it is not in the interests of ordinary folk and that in getting their acceptance or even their votes to support this process is a case of a false understanding of where their true interests may be.
If you can get a population to believe that obesity is the result only of poor individual choices, that overweight people are either biologically determined to be so or who are morally weak willed, then you can direct policy towards changing individual behaviour (‘eat less – move more’) without having to address structural interests such as that of profit making from sedentary lifestyles or high sugar, high fat comfort foods. You may, as a policy maker, or shareholder in fast foods outlets, believe this yourself. In the latter case it is your interest to believe it.
If sociological theory and analysis can show why this is practice is self-serving in the interests of certain people and not of others…then a case can be made to assert an ‘ought’ from an analysis of an ‘is’. Certain propositions in sociology, if true, ‘deliver moral obligations by force of logical necessity’. If we uncover social practices, such as the ‘wage form’ and the unequal appropriation of value upwards to the 0.01%, through an application of a critical sociology we may see that this is both objectively andmorally wrong. It is the task of critical sociology of theory to undermine ideological justifications and to spell out how to change – to infer an ‘ought’ from an analysis of the ‘is’.
This statement lays the ground for the examination of ‘social mechanisms’ operating ‘behind our backs;’ posited by Critical Realism, and more specifically underpins the ‘Greedy Bastards Hypothesis’. But, I’m getting ahead of myself.
What is of importance is the use of theory – and not just assuming explanations rise out of quantitative data (the positivist or ‘epistemic’ fallacy, of which more later). If we note statistical associations between low education and obesity, the explanation requires an application of theory before we leap to assuming this relationship is an explanation. This requires more than the acknowledgment of the correlation/causation fallacy by positivists and some social epidemiologists, doctors and nurses.
Sociological theory is pitched at micro, meso and macro levels, all three being interdependent. No theory on for example individual decision making (micro theory) can be comprehensive without a macro analysis of the political economy (macro theory) in which that thinking takes place. Sociology also never ‘wraps things up’ in its explanations, but nor can it be reduced to the biological, psychological, genetic, and physical properties of the social and natural world. This is because it deals with social structures, relations, and processes over and above cognition or dopamine responses. We also have to accept the effects of contingency and personal agency in social affairs, this makes explanation always tentative. This calls for a more interdisciplinary approach as a result. For health professionals it means complimenting the biomedical model with the insights from psychology and sociology. For sociologists it requires understanding the complementary sciences of biology and psychology.
Sociology studies phenomena that ‘lie beneath the surface’ – inaccessible to the senses but to which we are alerted by their effects, just as it is with gravity.
“We cannot see the causal mechanisms of class or gender any more than we can seegravity” (p24).
This point will annoy many a natural scientist as they will claim that they can measure and test the effects of unseen natural mechanisms such as magnetism and gravity, and they will thus dismiss the social sciences as pseudo-science peddling in mysteries and faith. Many nurses steeped in biomedical science and unschooled in sociology will similarly be led down this path, dismissing out of hand that class may be a causal mechanism for many a health condition, preferring instead to rest their practice on changing the individual. It is in fact much easier to teach someone about healthy eating than it is to address the structural mechanisms that create obesity in the first place.
So, many will dismiss out of hand the idea of socialmechanisms especially that of class and gender. They have an ideological (vested interests in the status quo) or epistemological interest (the epistemic fallacy) in such denial. For once you admit the theoretical premise that class may have effects on health outcomes you have a choice to make: deal with those class affects or accept them and their consequences for people’s lives. It is surely much easier to deny their existence. Hence the requirement for Theory.