Considering medical sociology and public health in the UK
Should we employ neo-Marxist theory, neo-Webarian or functionalist theory to conceptualise and position people in a hierarchy reflecting their relative advantage and material circumstances? Should a measure of occupational stratification be continuous, or should it be based on relational categories? These are some of the questions that have been fiercely debated within the sociology of class and stratification for decades. This debate has been described as raging, but bypassing other areas. More recently proponents of the cultural turn in sociology, citing the theory of Bourdieu, posited the basis for class resided in aspects such as cultural, economic and social capital. This approach informed the Great British Class Survey (GBCS) which also triggered an intense discussion, which might aptly be described as savage. Whether the influence of these years of empirical research and theoretical debate can be discerned beyond the sociology of class and stratification is an interesting question which speaks to the influence of empirical sociology. This blog considers the limited influence that the sociology of class and stratification has had beyond its own boundaries in the fields of medical sociology and public health.
Nearly twenty years ago Prandy wrote, in the journal of the Sociology of Health and Illness, that medical sociology was showing interest in more adequate measures of social class. This was partly in response to an article comparing the old a-theoretical standard measure, Register General’s Social Class (RGSC), with the then new, National Statistics Socio-Economic Classification (NS-SEC). This, it was ventured, signalled a change in how those involved in medical sociology would engage with social class. It may have been hoped (at least by scholars in the field of class and stratification) that this would have foreshadowed a shift in approach towards standardised measures, informed by reference to debate within the sociology of class and stratification. If this was a hope then a review of articles published in the journal, from the last ten years (2008-2018), which have included ‘class’ in the title, suggests a shift did not materialise.
A search using the term class in this journal returned 552 instances (at time of writing). Of these there were 18 articles where class appears in the title. Several applied a specific measure of class or was situated within a theoretical framework, especially that of Bourdieu. The majority (14) used an ad-hoc or undefined operationalisation of class. Two incorporated the RGSC scheme. None used NS-SEC. In practice several applied a definition of class based on income or geography. At least two operationalised class in a manner that was primarily conceptual (i.e. related to theory or a theorist, but not measured). None made reference to the existence of other, standardised specifications of class, or occupationally based stratification measures. The general use of extempore operationalisation of class, rather than standardised measures, suggests medical sociology has been little influenced by discussion emanating from the sociology of class and stratification.
This lack of engagement with how class could be robustly, empirically operationalised, even within sociology may have contributed to a position whereby those from overlapping disciplines, who might otherwise have engaged with social class, do not see the value in a class informed analysis. Let’s be blunt, if sociologists researching class are not using the sociologically developed measures of social class then why would scholars from other disciplines?
A recent paper examining mortality by occupation in the Lancet met with a critical response by a prominent public health professional. The response piece argued that categorising people by their main job is ambiguous and that other classifications may produce more useful insights, suggesting alternative measures based on hobbies or shopping location may be preferable. In part this mirrors debate within the sociology of class and stratification over whether, or how, to include Bourdieusian concepts such as cultural capital in class based analysis. What should worry sociologists however is that the conclusion advocated was to entirely dispense with class/occupational position as a viable approach to understanding issues of public health. Not only would this be detrimental to the wider influence of sociology, it would be to sweep aside the contribution of sociology in establishing occupation as the ‘most powerful single indicator of levels of material reward, social standing and life chances’.
Measures of class and occupational stratification are certainly not relevant in all circumstances. Social class and occupationally based measures of stratification, or hierarchy, do not enable analyses of direct causes of ill health, but they do offer considerable utility in facilitating the measurement of levels of inequality. There is a high correlation between occupationally based measures of class and stratification and health outcomes, such as mortality. It is also possible to identify direct testable hypotheses based on occupational analyses. For example, recent work has shown that it is likely that firefighters experience increased rates of cancer because of contaminated equipment. This built upon more general work noting a higher incidence of cancer amongst firefighters. To substitute this empirical, occupationally based approach and to replace this with simplistic indicators of cultural consumption would not be sensible.
Occupationally based analyses can provide insight to both highlight inequalities in health and to examine instances of specific causes of illness. Despite this, the influence of the sociology of class and stratification in how those beyond the field engage with class remains, perhaps, less than would be wished for. A notable exception to this was the Great British Class Survey which generated a high level of public engagement and mainstream attention. A key part of the GBCS involved the BBC in surveying people (161,400 respondents) and came up with a seven category social class scheme. Indeed, the interest generated by the GBCS has subsequently been flagged as one of its key contributions.
The considerable popularity of the GBCS does not yet appear to have influenced a ‘revival’ of class analysis in fields such as medical sociology. Indeed, the impact of the GBCS may be detrimental to the cause of systematic applications of class in analysis. Proponents of GBCS argued that the measurement of class should be based on economic, social and cultural capital. The measurement approach outlined by the GBCS is not readily actionable by researchers persuaded of the case. This is likely to make any call to replace occupationally based analyses with simple indicators of cultural consumption, such as hobbies or place of shopping, more attractive. If class is about access to ‘capitals’ and not related to occupational position, but no reasonable way to operationalise a model of class based on cultural consumption is available, then it may seem to some that a viable alternative would be to replace this with simple proxies, such as how often an individual may visit the theatre or shop at Iceland. According to this account occupationally based measures were not going to do what is wanted anyway.
The cases highlighted show something of the nature of knowledge silos. Work on measuring and defining social class, undertaken by those involved in the sociology of class and stratification, has clear applications in the areas such as medical sociology and public health. Yet the utility may be concealed within sociology by a culture which encourages conceptual and theoretical engagement which in turn enables potentially sub-optimal, ad-hoc operationalisations of class in empirical work. This is the case across sociology and is by no means especially prevalent in medical sociology. This blog takes medical sociology as an example simply because of its overlapping interest with public health. Indeed, the marginal influence of the sociology of class and stratification may be, at least partly, due to their focus within their own silos such as the RC28 conference or the Cambridge Social Stratification Seminar. In addition to this, the most eye catching study in the field, the GBCS, came up with a classification of social class that, owing to the novelty of the data collection (amongst other issues), is not likely to be widely applied.
Over years sociology has built evidence that occupation is the most powerful general indicator of life chances, social and material reward and status available. Yet the importance of class to disciplines which overlap sociology, such as public health, may be masked by non-replicable applications of extempore measures. Failure to take account of, and integrate, knowledge that exists within and between fields of sociology, mean we provide partial accounts in our own work and offer less than we could to those beyond our discipline. If there was one message to take from the sociology of class and stratification it would be, don’t invent a new measure of class, or apply an ad-hoc measure, when there is invariably a better one already available.
Acknowledgements: I would like to thank Dr Roxanne Connelly and Dr Chris Playford for commenting on a draft of this blog.
Kevin Ralston is a Lecturer in Sociology at York St John University. His research generally involves the study of inequalities and he has published papers examining inequalities in health, occupational and family outcomes. He is also involved in pedagogical projects which examine the teaching of quantitative methods.