Guide to the vibrant and



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sorts of ill-health than the native population.

Two aspects of the statistics on inequality have

attracted particular attention in recent decades.

One is that, measured by social class and by death

rates, inequality appears to be growing in many

developed nations. The second issue relates to

what is known as the “continuous gradient” or

“fine grain” of inequality. The “threshold model,”

suggesting that inequality only occurs at a level of

deprivation below which health is likely to be

affected, does not seem to be correct: there is no

sharp discontinuity between the minority who

lack the basic needs of life and the majority whose

living conditions meet at least minimum standards.

Rather, a straight line relationship between

socioeconomic status and health is found

everywhere.

The main issue of debate in inequality studies is

about causality, and especially causes of the apparent

increase in inequality in developed countries.

The 1980 Black Report in the United Kingdom

discussed three types of explanation of real inequalities,

if the social class differences were not,

as is generally agreed, simply artifacts of statistics

and the changing composition of social classes

over time. These explanations were: natural and

social selection and mobility (the healthy move up

the social scale and the unhealthy suffer occupational

disadvantage); the lifestyles and healthrelated

habits typical of particular groups (in particular

smoking, or general lack of health awareness

or preventive behavior); the direct materialist

effect of living and working conditions.

It is now generally agreed that the types of

explanation are interconnected, and each makes

a contribution. Simple models stressing only the

importance of behavioral patterns, for instance,

have to allow for the fact that lifestyles depend

on social relationships and the cultures of areas

and of groups. Cohort studies, following populations

from the day of their birth, have demonstrated

in Britain and in other countries how the

causes of unequal health begin at birth or even

before, and can accumulate through the lifecourse.

A poor start in life, associated with poorer

family circumstances and vulnerability to illness,

can be reinforced throughout childhood by inadequacies

in education and thus lower adult socioeconomic

success, less healthy behavior, and

poorer health.

This overview has shown that the sociology of

health and illness is multifaceted, ranging from

the statistical to the qualitative and philosophical,

health health

266

and from concern with social structures and historical



processes to individual experience and

social psychology.

Subspecialities flourish, some with their own

institutions and journals. Some of the most

important topics have been noted, but others include:

the sociology of nursing and the professions

allied to medicine; social pharmacy; the sociology

of mental health; media and cultural studies of

medicine and health; community care; death

and dying; the sociology of reproductive behavior

and the social epidemiology of fertility; health

promotion; and health service organization and

evaluation.

Discourses of risk are pervasive in health, as in

other areas of life. Risk assessment is a key element

of public health, and the perception and management

of voluntary risks to health, and the

relative importance of lifestyle factors and environmentally

and socially imposed risks, are central

questions of health promotion. Expert and lay

concepts of health risk are a topic of particular

sociological interest, and Ulrich Beck’s Risk Society

(1986) [trans. 1992] has been influential in discussions

of attitudes and responses to global ecological,

genetic, nuclear, and economic risks to

health.


Currently, sociological research and discussion

focuses especially on the consequences of the explosive

rate of change and development in medical

science and technology. Techniques such as

microsurgery and nanotechnology (technology at

the level of molecules), and new technologies of

imaging, change attitudes to the body. It has been

argued that the image is becoming privileged over

the actual body: simulations have come to constitute

reality. Other technologies which are

changing the practice of medicine relate to the

information revolution. Telemetry (the transfer

of measurements at a distance) and telemedicine

(distant, or even automated, contact between patient

and professional), alter the doctor–patient

relationship.

The application of genetics is a very important

topic. There is, for instance, much discussion of

predictive genetic testing for disease as an ethical

issue, how it is perceived by the public, and what

changes it may bring to medical practice, family

life, and social relationships. Developments in reproductive

technology call into question when a

new life commences. Technologies such as in-vitro

fertilization, cloning, surrogate motherhood or

the use of fetuses for genetic therapy raise questions

about the family and person-hood. At the

end of life, modern techniques of keeping alive,

especially in the context of transplant surgery,

blur the boundaries between life and death. The

replacement of body parts, including xenotransplantation

(where animals are bred to carry genes

from another species) and stem cell technology

(which is capable of supplying transferable tissue),

also blur the distinction between the body and

not-body and call human identities into question.

The integration of machine parts into the body is

sometimes called cybermedicine.

MILDRED BLAXTER

health care systems

Health care can be divided into primary care,

taking place in the community as a point of first

contact, and secondary care, usually taking place

in hospitals and delivered by specialists. The term

tertiary care is sometimes used to indicate rehabilitation,

or restorative rather than curative

care. Community care is used to indicate care

provided outside institutions, not only by doctors

but also by social carers. Preventive care systems

(such as immunization) are also distinguished

from curative care. A distinction is also made between

personal clinical health care, provided for

the cure or care of the individual, and public

health, directed at populations.

The ways in which health care is organized, in

different societies, range from the extreme of a

pure market system in which health is treated as

any other commercial commodity, to universal

free services provided entirely by governmental

funding. In most nations of the world, however,

the distinction is becoming increasingly blurred.

Patterns of health provision are converging, because

aging populations, changing disease patterns,

advances in biotechnology, growing public

expectations, and increasing costs, all introduce

common pressures. Market systems have to make

provision for those who cannot pay, as in the

Medicare for old people or Medicaid for the poor

in the United States. In wholly or predominantly

state-organized systems, there is a tendency to

shift some costs onto the consumer, and introduce

types of rationing. In order to gain some of the

advantages of a market system, “free at the point

of need” services may introduce elements of managed

competition, separating the funding of services

from their supply while retaining universal

access, as in the internal market of the British

National Health Service.

In most systems, insurance of various forms acts

as the buffer between provider and consumer.

Health insurance is commonly obtained through

employers’ schemes, and in some countries these

health health care systems

267


are compulsory. Insurers can limit consumer

choice by cost-contained health services, as in the

Health Maintenance Organizations of the United

States.


In recent decades, all industrialized nations

have tried to reform health care. Growth in expenditure,

commonly exceeding growth in Gross

Domestic Product, has created a heightened interest

in efficiency and effectiveness. There is also

general interest in increasing patient choice and

public participation in the organization of services.

A further factor in change is some dissatisfaction

about the priority given, in the past, to

hospital services at the expense of community

care and public health.

However, a wide range of international studies

(notably from the regular publications of the

World Health Organization and the Organization

for Economic Cooperation and Development) suggest

that the way in which services are organized,

and indeed the level of provision, have little effect

on the health status of populations, once a country

has reached an advanced stage of development.

This is not because medical services are

ineffective, but is thought to be due to the overwhelming

weight of other, principally economic

and social, factors. Nevertheless, the equity and

efficiency of services, patterns of patient usage,

and medicine as an institution, are important

topics within the sociology of health.

MILDRED BLAXTER

health inequalities

– see health.

Hegel, Georg Wilhelm Friedrich

(1770–1831)

Born in Stuttgart, the son of a government clerk,

Hegel studied theology at the university in Tu¨bingen,

working as a private tutor in Berne and

Frankfurt, before becoming a university lecturer

at Jena, a post he held until 1807.

It was here that he published The Phenomenology

of Mind (1807 [trans. 1931]) – a work generally

regarded as his masterpiece, in which he argued

that the power of reason itself is unlimited. While

reality is the entire development of everything, it

consists ultimately of a world soul or mind. In The

Science of Logic (1812 [trans. 1929]), which he published

in 1812, he elaborated upon the dialectical

categories through which this absolute reality

passes.


He edited a newspaper during the Napoleonic

occupation and was headmaster at a school in Nuremburg

until 1816. Hegel was appointed Professor

at the University of Heidelberg for two years in

1816, and then acquired the Chair of Philosophy

in Berlin that he held until his death in 1831.

He published the Encyclopedia of the Philosophical

Sciences in three volumes (1817, 1827, and 1830

[trans. 1927–30]), and his lectures on history, philosophy,

and religion were published posthumously.

But arguably his most important work

was The Philosophy of Right, which appeared in

1821 (trans. 1942). Here he built upon his earlier

philosophical work to argue that the modern state

is an ethical entity. The state incorporates the

altruism of the family and the self-interestedness

of civil society, and its universal outlook is guaranteed

by a hereditary monarch, by an assembly

representing social interests, and by a civil service

that constitutes a “universal class.” Hegel’s philosophy

of history had a profound influence on the

sociology of Karl Marx. JOHN HOFFMAN

hegemony

The process by which a ruling group secures the

consent of the ruled, this term is identified with

the Italian Antonio Gramsci. Writing in prison

under Benito Mussolini (1883–1945), Gramsci

employed an idiosyncratic vocabulary to avoid

censorship. However, this term proved a viable

alternative to the more commonly used term

ideology, because it describes a process rather

than a result of rule. Faced with the question,

“Why has the Italian working class accepted fascist

rule?” Gramsci outlined a process of negotiation

between rulers and ruled. To secure power,

rulers may use coercion, but to maintain it they

require the active participation of the ruled in the

processes of economic and, in many instances,

civil life.

With the exception of periods of revolutionary

activity, societies are characterized by dynamic

equilibria in which, normally, one hegemonic

group holds sway over several subaltern groups.

Subaltern groups may be formed from the residues

of a previously hegemonic social class or

classes, from newly emergent social groups such

as the proletariat that emerged during the industrial

revolution, or from class fractions striking

alliances either against some abuse of power

or to gain a particular goal. Hegemony passes

through cycles of emergence, establishment, renewal,

and decline, and the hegemonic process

will necessarily involve alliances and therefore

compromises with groups outside the hegemonic

class itself. Typical alliances struck by Mussolini’s

fascist party included those with the Catholic

Church, with residues of semifeudal landowners,

health inequalities hegemony

268

with the military, with the civil-service bureaucracy



based in Rome, and with some elements of

the skilled working class, all in the interests of the

industrial bourgeoisie of northern Italy. Compromises

included recognition of religious values,

protection of inherited property rights, extensive

military expeditions and budgets, and enhanced

employment prospects.

Gramsci’s term was initially specific to the political

life of society. The word was taken up, after

Gramsci’s notebooks were translated as Selections

from the Prison Notebooks in 1971, in British cultural

studies. In the Birmingham Centre for Contemporary

Cultural Studies especially, cultural life

could be examined as a dynamic equilibrium in

which mass media offered entertainment in exchange

for loyalty to the nation and a sense of

belonging. At the same time, television and popular

music provided subaltern groups with the

means to assemble alternative and competing

subcultures. In certain instances, these subcultures

served the purposes of hegemony by encouraging

disaffected school students to opt for lowpaid

employment. In others, cultural resistance

formed social bonds that allowed emergent subaltern

groups, such as black Britons, to articulate

their social and political interests. The concept of

rule as dynamic equilibrium also served as a

powerful analytical tool in analyses of education

policy, sports studies, and gender studies. A more

political variant appeared in the Indian journal

Subaltern Studies, notably in analyses of the way

in which Hindi nationalist histories of the

struggle for independence from Britain subordinated

non-Hindi and working-class achievements,

in the interests of securing the postindependence

hegemony of the ruling bloc. Similar concerns

engage the Latin American Subaltern Studies

Group. The theoretical turn of cultural studies in

the 1990s displayed some return to ideological

determinism, in Gayatri Spivak’s query in her article

“Can the Subaltern Speak?” from Cary Nelson

and Lawrence Grossberg (eds.), Marxism and the

Interpretation of Culture (1988), rather than a dynamic

process of ideological exchange. Some of

the most trenchant contemporary scholarship

describes hegemony as that which is taken for

granted, uncontested, and unnoticed in social

life, leaving ideology to describe the active contests

over meaning and interpretation.

SEAN CUBB I TT

heredity

This incorporates the idea that characteristics

such as intelligence, strength, or criminality have

a biological basis and can be transmitted between

generations. Some versions, following the pre--

Darwinian biologist Jean-Baptiste Lamarck (1744–

1829), suggest that acquired characteristics can

be inherited. The idea was highly influential in

early forms of sociology, such as the social Darwinism

promoted by William Sumner and Herbert

Spencer, the latter emphasizing transmission of

acquired characteristics. Heredity remains significant

today in the social sciences, though it is

widely considered an ideology justifying the social

order as natural. There is still no evidence of

genes directly affecting intelligence or behavioral

characteristics.

In 1865 a Moravian monk, Gregor Mendel

(1822–84), established the key principles of genetics.

He discovered that when plants are crossed

the outcome is not simply a blending of characteristics.

Discrete characteristics are passed on down

the generations, resulting in, for example, a

purple plant transmitting inherited white characteristics

from future to later generations. Some

twenty years later, though not having encountered

Mendel’s work, Charles Darwin’s cousin

Francis Galton (1822–1911) coined the term eugenics,

derived from the Greek “good in birth.” This

new science appeared to show that intellectual

success runs in families; the Galton, Darwin, and

Wedgwood families, for example, producing a

relatively large number of offspring that were

“brilliant.” Such insights led to proposals for the

active management of human reproduction. This

would favor the reproduction of the fittest and

discourage the reproduction of the less fit.

The new science received widespread support

(including encouragement from a broad range of

political opinion) during the late nineteenth and

early twentieth centuries. Some branches of contemporary

social science incorporate, at least

tacitly, a notion of heredity as the basis of social

structure. R. Herrnstein and C. Murray’s The Bell

Curve (1994) was, for example, highly influential

and generated considerable debate among those

exploring links between genes and intelligence

(see, for example, R. Sternberg and E. Grigorenko,

Intelligence, Heredity and Environment, 1997).

As a political practice, eugenics reached its most

horrific conclusion with the Nazi mass extermination

of the Jews. The killing of thousands of

Croats and Muslims by a Serbian elite in the early

twenty-first century shows that eugenics persists

as an idea. But, despite its deeply sinister history,

it would be wrong for sociologists to completely

reject biological understandings of heredity.

There is, for example, some evidence of genes

heredity heredity

269


generating predispositions to certain afflictions,

such as Huntington’s disease and cystic fibrosis.

And some biologists – for example, E. Steele, R.

Lindley, and R. Blanden in Lamarck’s Signature

(1998) – claim that certain forms of immunity

(even acquired immunity) can be genetically transmitted.

Meanwhile, more mainstream epidemiological

work – for example, D. Barker in The Best

Start in Life (2004) – is showing that bad health can

indeed be inherited, but as a result of undernutrition

in utero, rather than the passing on of specific

genes. Genes, according to this literature, are

important in terms of governing overall developmental

processes. Illnesses are mainly a product of

environment, especially as encountered in the

earliest stages of life, combined with genetically

driven processes of development. PETER DICKENS

hermeneutics

The art of interpretation, hermeneutics was originally

meant to adjudicate disputes concerning the

authenticity of religious texts. Later, its role was

extended to a method or set of tools that help to

understand writing in general. Later, again, hermeneutics

dealt with the understanding of any

type of human action – not just writing.

In the nineteenth century, hermeneutics

became a prominent philosophical tradition in

Germany with central figures like Friedrich

Schleiermacher and Wilhelm Dilthey. Influenced

by Immanuel Kant (1724–1804), Herder, and

Georg Wilhelm Friedrich Hegel, hermeneutic

authors emphasized the differences between the

study of historical, social phenomena and the natural

sciences. The former deal with the understanding

(Verstehen) of unique events, whereas

the latter aim at explaining (erkla¨ren) and generalizing.

The reliving (Nacherleben) of people’s aims

and assumptions is crucial in the understanding

of historical phenomena. The nineteenth-century

hermeneutic authors became involved in the wellknown

Methodenstreit over the method of the

historical sciences. Influenced by positivist views,

the opposite camp advocated a unity of method

between the social and the natural sciences. Max

Weber was influenced by hermeneutics but took a

balanced view in the debate. For Weber, social

scientists need to rely on Verstehen (or “interpretative

understanding”) but this re-enactment of

individuals’ purposes and assumptions does not

exclude the possibility of causal analysis. He was

also skeptical of the view that the emphasis on

understanding makes history or social science a

hopelessly subjective endeavor. Although historians

and social scientists always adopt a selective

viewpoint, this does not make their research less

objective.

Hans-Georg Gadamer’s Truth and Method (1960

[trans. 1975]) heralded a major shift in philosophical

hermeneutics. Influenced by Martin Heidegger,

he criticized Enlightenment philosophers for

failing to acknowledge the pivotal role of tradition.

In contrast with nineteenth-century hermeneutics

and its emphasis on methods, Gadamer was

more preoccupied with ontology. He suggested

that we conceive of understanding in a dialogical

fashion: we cannot help but rely on our presuppositions

to make sense of what we encounter, but

the very same presuppositions are also affected by

this interaction. In Philosophy and the Mirror of

Nature (1980), Richard Rorty refers extensively to

Gadamer’s dialogical model to back up his notion

of an edifying philosophy beyond epistemology.




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