Dyp181 1.4

Int. J. Epidemiol. Advance Access published May 11, 2009
Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2009;1–4 ß The Author 2009; all rights reserved.
Commentary: The appearance of new medicalcosmologies and the re-appearance of sick andhealthy men and women: a comment on themerits of social theorizing Published 32 years ago in the British Sociological Judging by the guidelines and resource allocation of Association’s journal Sociology, Nick Jewson’s paper some of the main funding councils who support ‘The Disappearance of the Sick-Man from Medical health, medically related and even social research in Cosmology, 1770–1870’1 is something of a classic.
the UK, there seems to be an imperative to support A search using the Thomson ISI Web of Knowledge applied and policy relevant empirical research that Service reveals that, within this database, the article can generate clear outcomes. There is no doubt that has some 133 citations and rate of citations have such research can make an important contribution remained consistent over time. Furthermore, the to patient well being, but in a world steeped in the impact is not limited to sociology; the top six subject evidence-based culture this could mean that larger areas that return the highest citation scores are ‘his- and possibly more important questions and insights tory and philosophy of science’ (29.3%); ‘social may be overlooked. Indeed, Jewson’s historical mate- sciences, biomedical’ (23.3%); ‘public, environmental rialist analytic strategy of ‘modelling’ different histor- and occupational health’ (21.1%); ‘sociology’ (20.3%); ical periods may well be considered to be to abstruse ‘health care sciences and services’ (12.8%); and ‘med- by many working in public health, epidemiology or icine, general and internal’ (6.0%).
It is intriguing that this conceptual paper should But Jewson’s modelling of historical forms of med- have such an enduring and broad significance. But ical knowledge and practices are both descriptive and herein lies its merit; as the sociologist Bryan Turner explanatory. To be sure the broad brush approach is notes: ‘Ultimately sociology can better serve the prac- invariably at the cost of historical detail. The medical tical problems and needs of patients by formulating cosmologies are what the sociologist Weber would sociological rather than medical questions.’2 This call ‘ideal types’; idealized versions or abstractions statement reflects Strauss’s well-known distinction that aim to capture the quintessence of social realities.
Arguably these abstractions enable us to see beyond between ‘sociology in medicine’ and ‘sociology of the messy veracity of day-to-day life; to use a well- medicine’.3 The former refers to research agendas worn metaphor they allow us to ‘see the wood for the that are professionally and institutionally driven, trees’. Such distancing can contribute at a societal whereas the latter implies a more critical approach, level to an appreciation of why decisions are made, wherein the philosophical and epistemological under- why certain forms of knowledge or practices are prior- pinnings of medical knowledge and medical practice itized and how social change comes about.
are open to scrutiny. Jewson’s analysis certainly scru- And, in fact, Jewson’s paper reveals a correspon- tinises the content of medical knowledge and reveals dence between broader socio-material changes, tech- how it is contingent upon socio-economic relations nological innovations and a privileging of particular between the patrons and producers. At a time when forms of knowledge. The value of this revelation is health and social researchers are increasingly encour- the confirmation that medical knowledge, practices aged to undertake empirically-based and policy- and technologies are socially contingent. They are orientated research it is useful to reflect on the mediated by ‘the social’, be that social interests, cul-tural preferences, economics or social hierarchies.
Salutatory reflections today in the context of health Department of Sociology, University of York, Heslington, York and medical care where we see claims and counter- claims relating the merits and demerits of, on the one hand, highly technical and hitherto unprecedently module I teach on the sociology of health and illness expensive, therapeutic interventions and, on the earlier this year, one student wondered if in the con- other hand, a diversity of complementary and alter- temporary context doctors working in general practice might find it difficult sometimes to implement the The central argument of the paper reveals how three findings of research. Treatments of ‘proven’ benefit medical cosmologies—‘bedside medicine’, ‘hospital might be at odds with the biography of the patient medicine’ and ‘laboratory medicine’—were differen- that becomes evident at the bedside. Spot on. Such tially privileged in distinct historical periods and tensions are of course increasingly apparent in the were conditional upon the sources of patronage; cru- context of the informatization of medicine wherein dely who influenced the mode of production of med- guidelines derived from ‘gold standard’ RCTs may be ical knowledge. This strand of the argument is at odds with clinicians preferred approach to disease articulated more fully in an earlier (though less management for given patients in the light of their cited) paper ‘Medical Knowledge and the Patronage personalized needs.6 As Stephen Harrison explains System in 18th Century England’.4 In the era of bed- there are epistemological (cosmological perhaps?) dif- side medicine the doctor had a close interpersonal rela- tionship with his client who, being the doctor’s which, we might add, mirror those between the pro- patron, exerted considerable influence over medical tagonists and the sceptics in Paris centuries ago. As knowledge, which in turn tended to be heterogeneous we know the proponents of EBM maintain that ‘evi- and biographical not least because doctors developed dence’ is based on an authoritative probabilistic their own styles and theories to suit their paying model of science in contrast with the ‘traditional model’, wherein clinicians seek to understand the The historical importance of the Parisian hospital natural history of the disease by observing how ‘dis- schools in post-revolutionary France was critical to ease processes develop over time and impact upon the formation of the next cosmology. The prime site normal physiological processes’.7 Today, however, of investigation shifted from the patients’ bedside to doctors’ recourse to the ‘clinical gaze’8 forged in the the hospital ward. Thus the ‘sick man’ was displaced era of hospital medicine is being marginalized; clini- by the ‘sick body’—the latter was an object of inves- cians are encouraged to heed the advice based on ‘the tigation and what s/he had to say was of little con- publication of meta-analyses of large numbers of sequence because the goal of the Parisian clinician cases’.6 Consequently, commentators are expressing was to impress his colleagues with his diagnostic concerns that experiential and intuitive knowledge— skills. Prognosis was of secondary interest and thera- the ‘art of medicine’—may be in jeopardy.9–11 peutic interventions positively shunned. The gold In Jewson’s terms, what we see here is a shift in the standard of medicine was to investigate the inner influence of the control over the production of med- reaches of the anatomy unsullied by the patients’ ical knowledge—no longer purely in the hands of the interpretation of their symptoms in order to identify clinician (as in hospital medicine) or the scientist (as accurately any pathological abnormality.
in laboratory medicine) but in a new hybrid fashioned Tensions, however, were manifest; protagonists of through the combined expertize of epidemiologists the physical diagnosis advocated the cultivation of and information scientists. These specialists are sup- an objective, proven body of knowledge that could ported by the state and, more significantly, in some be applied to all patients rather than individuals settings deployed by well-resourced biotechnology with all their idiosyncrasies. Sceptics of these new and pharmaceutical industries—who are keen to gen- schools, most notably those working predominantly erate convincing knowledge about the effectiveness or in private practice, remained keen to offer their cost-effectiveness of interventions.
patients prognoses and therapies. Thus the socio- The medicalization thesis that dominated sociological economic relations between practitioner and patient debates in the 1970s drew on Jewson’s account to were crucial; working in the hospital the patients explain the rise and dominance of the biomedical of the protagonists were poor, conditions often model in Western medicine. In the 1970s, sociologists’ wretched, and in fact, in such circumstances any ther- criticized medicine for medicalizing aspects of everyday apeutic interventions would have limited chance of life from birth to death. However, it is now suggested success. However, in post-revolutionary France it that the medical practitioners are merely ‘bit players’, was state support that transformed this pivotal insti- and it is the globalized and hugely powerful biotech- tution; as the historian Ackerknecht (who was closely nology and pharmaceutical enterprises that are more read by Jewson) put it: ‘The Paris hospital of our effective in creating and sustaining knowledge about period was, in its conception and organisation, no the presence of disease and need for treatments.12 A longer a medieval receptacle of all miseries. It had well-known example is David Healey’s work on the eventually become a medical institution and thus ways in which the psycho-pharmaceutical industry served as the cradle of a new medicine.’5 effectively markets and thereby constructs mental Sounds familiar? Well when discussing this paper health disorders.13 As Nikolas Rose has put it today: with students at the start of an undergraduate ‘Depression: not so much fluoxetine hydrochloride as A COMMENT ON THE MERITS OF SOCIAL THEORIZING Prozac. Generalized Anxiety Disorder: not so much par- now takes the form of an e-scape in the sense that oxetine as Paxil. ADHD: not methylphenidate or the spaces, sites and locations of the production of medical knowledge are now more diffuse and are Adderall. Premenstrual dysphoric disorder: not so invariably mediated by means of digital technologies.
much fluoxetine hydrochloride (again) but Sarafem.
We see a greater variation of sick men and women And some more names: Prozac and Sarafem: Eli today (Marxist sociologists made little mention of women in the 1970s!). These include the sick (CibaGeigy). Adderall: Shire-Richmond’.14 person, the passive patient, the expert patient, the Jewson was neither the first nor the last analyst to inert body, the responsible and the culpable indivi- identify a series of medical paradigms. Indeed, as dual and the health care consumer and, more recently noted above he is indebted to Ackerknecht for both the ‘prosumer’ (those who both produce and consume historical detail and the naming of the historical per- knowledge and information—perhaps most saliently spectives. Ackerknecht used similar labels such as within web 2.0 applications). New medical cosmolo- ‘Library Medicine’ (wherein a classical education gies emerge whilst others recede, but each leaves an was a pre-requisite of medical work), ‘Bedside enduring residue. The sick men who disappeared from Medicine’ and ‘Hospital Medicine’. David Armstrong, view in the 19th century have reappeared in a multi- adopting a Foucauldian orientation, suggests a further plicity of guises. Patients, health conscious (or not) form of medicine emerged during the early 20th cen- men and women, are concurrently both more influen- tury—what he calls surveillance medicine.15 Within this tial in the production of medical knowledge (e.g.
configuration of medical discourse, medical scientists they contribute to knowledge and information on not only study the bio-physical anatomy and physiol- the web) and are constructed by as consumers ogy but also analyse the distribution of disease, illness deployed by the pharmaceutical, biotechnology and patients are recruited to monitor their own health risks and encouraged to maintain their own health.
Conflict of interest: None declared.
Whilst Jewson had argued that the patient as aperson had all but ‘disappeared’ from medical dis-course, within surveillance medicine, the patient—and indeed ‘potential’ patients—reappear with a new (risk) identity. Responsibility, and increasingly culp- 1 Jewson ND. The disappearance of the sick-man from ability for health status, lies with the ‘person’ who is medical cosmology, 1770–1870. Sociology 1976;10:225–44.
impelled to become aware of, and act upon, the Reprinted in Int J Epidemiol 2009; doi:10.1093.ije/dyp180.
wealth of health information and advice to be found 2 Turner BS. Medical Power and Social Knowledge. London: not only in the health clinic, but also throughout var- ious forms of popular media, on supermarket shelves, 3 Strauss R. The nature and status of medical sociology.
Armstrong, however, talks not of a new form of 4 Jewson N. Medical knowledge and the patronage system in 18th century England. Sociology 1974;8:369–85.
use the language of Marxism) but rather, after 5 Ackerknecht E. Medicine at the Paris Hospital, 1794–1848.
Foucault.7 he uses the language of ‘spatialisation’.
Baltimore: The John Hopkins Press, 1967, p. 22.
But, fundamentally, both Jewson and Armstrong are 6 Armstrong D. Clinical autonomy, individual and collec- describing shifts in the way medical knowledge is tive: the problem of changing doctors’ behaviour. Soc Sci configured and sustained—they describe transforma- tions in the ways medicine conceives, constructs and 7 Harrison S. The politics of evidence-based medicine in the describes its objects of study. The moves from bedside United Kingdom. Policy Poli 1998;26:15–30.
to hospital, from hospital to laboratory; and from the 8 Foucault M. The Birth of the Clinic: An Archaeology of Medical micro-analyses of bodily components to the analyses Perception. London: Tavistock, 1976.
of epidemiological data derived from the community, 9 Greenhalgh J, Flynn R, Long AF, Tyson S. Tacit and are associated with differential technological forms encoded knowledge in the use of standardised outcome and materials. The stethoscope, the microscope and measures in multidisciplinary team decision making: acase study of in-patient neurorehabilitation.
statistical technologies are differentially privileged.
Perhaps today, networked computer systems comprise 10 McDonald R, Waring J, Harrison S, Walshe K, Boaden R.
the dominant technological form; since they impact Rules and guidelines in clinical practice: a qualitative not simply on the capacity to process data but also study in operating theatres of doctors’ and nurses’ influence our ways of thinking and arguably give rise views. Qual Saf Health Care 2005;14:290–94.
to a new medical cosmology namely, ‘e-scaped med- 11 Nettleton S, Burrows R, Watt I. Regulating medical bodies? The ‘modernisation’ of the NHS and the disem- and has ‘escaped’ from the formal institutions of the medical establishment. Furthermore, knowledge 12 Conrad P. The shifting engines of medicalization. J Health 15 Armstrong D. The rise of surveillance medicine. Sociol 13 Healy D. The latest mania: selling bipolar disorder. PLoS 16 Nettleton S. The emergence of e-scaped medicine? 14 Rose N. Neurochemical selves. Society 2003;41:46–59.

Source: http://ije.oxfordjournals.org/content/early/2009/05/11/ije.dyp181.full.pdf

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