In 2005 I was invited to give a plenary lecture at the annual autumn meeting of the Medical Sociology Group of the British Sociological Association. This represented, and represents, a kind of coming of age for medical sociologists in the UK. The title I chose was ‘Social Structure and Health: A Narrative of Neglect?, and the intention was to invite more attention to the structural substrates of phenomena of interest to medical sociologists. The lecture was probably overly ambitious: I focused on the potential contributions of critical realism to examine structurally-oriented causal-explanatory accounts of health inequalities and stigma attribution: an abbreviated summary of can be found in Medical Sociology News (Vol 31, No 3, Winter, 2005). I remember two moments, the first when I quoted Galbraith, who once said that when lecturing he would periodically say ‘and in conclusion’, not because he was finishing but because ‘it gave people hope’; and the second when daughter Sasha’s newborn son, Elliot, was so bored that within two minutes he had to be taken out bawling.
The following day I was approached by a Norwegian attendee, with a touch of the Viking in his appearance, who asked me if I might be willing to give a talk to a neophyte Norwegian Medical Sociology Workshop in Trondheim in April of 2006. This was my introduction to Aksel Tjora. I replied in the affirmative and my visit to Trondheim in 2007 was to prove the first of many to this annual festival. From 2008 onwards, well into my retirement post-2013, Annette was to accompany me as a participant. Aksel proved a relaxed host as well as being an excellent sociologist with flair in abundance. He is also a ‘fixer’, someone who makes things happen: there is more of the autonomous reflexive about him than there is about me! We have since collaborated on a number of projects and a number of publications including two books. Trondheim is a delightful town, and I have grown very fond of the close group of Norwegian colleagues I have met over the years. I have learned much about their local health services research in general and about eHealth and telemedicine in particular. In a subsequent meeting in Tromso I was shown a control room from which physicians were able to dictate celebrated, precise and life-saving surgery to preserve the life of a young man who had been attacked by a polar bear. It may well be the contemporary neoliberal desire to cut costs that prompts much investment in innovative information and communication technologies (ICTs), but in a country that stretches into lonely, isolated spaces of the Arctic Circle they can facilitate vital modes of healthcare delivery.
Aksel, as a fellow enthusiast, introduced me to Trondheim’s cafes. It was in one of these that we conceived the idea of an edited collection on Café Society, which eventually saw the light of day in 2013. Some years later, in 2020, I was to become his co-author in producing an English version of his Norwegian book Communal Forms: A Sociological Exploration of the Concept of Community. In the early years of our friendship I was to discover the Norwegian habit of buying alcohol to drink at home prior to going out to bars and clubs late evening. It was a habit born of the steep price of alcohol. During my first visit I boldly offered to buy a round of drinks for local sociologists and was instantly warned off such extravagant gestures. Aksel and I used to drink and chat until around 3am in the early years, which was the common closing time. We were invariably joined by Ph.D students and postdocs. At the close of the noughties, however, the authorities were ‘tightening up’ and in any case I, and even Aksel, had since aged a bit.
It would be tedious here to wade through my various Norwegian talks, which took up themes readers will already be familiar with, but four episodes warrant mentioning. The first notes an Aksel initiative that impressed me enormously. It was the establishment in the very centre of Trondheim, and at some distance from the NTNU out-of-town campus, of a ‘Sociology Clinic’ (one of Aksel’s postgrads at my invitation wrote a blog about it for the journal Social Theory and Health). The Clinic was designed to provide a space for municipal and commercial exploratory and planning meetings – several community studies have been based there – as well as a fantastic postgrad teaching resource. At the time of writing the Clinic is still going strong and remains a model for academic excursions into the community and for public engagement. Aksel got it off the ground as a strictly personal initiative. Revealingly, he did so without going through the normal departmental and institutional channels. How would UCL respond to such a project? Defensively, proprietarily, and ultimately negatively I suspect.
A second significant event arose out of meeting Dag Album in Trondheim. Dag had a longstanding research interest in the ‘prestige’ attached to different medical diagnoses. He subsequently acquired funding for Annette and I to visit him at Oslo University, where I was able to discuss this further and to meet with his Ph.D students as a kind of informal adviser. Back at UCL I was encouraged to undertake a small study of ‘disease prestige’ with an intake of my medical students. What the results indicated, I inferred, was that disease prestige is, if not a function of, very much associated with the differential status and rewards of the medical specialities involved; but this is an inference that I think Dag remains sceptical of. I analysed and sent my results to Dag, and we later met up in London, but I didn’t attempt to publish anything myself. It remains on a back-burner I guess. Dag, a much-respected medical sociologist in Norway, moves slowly and surely. But our trip to the wonderful city of Oslo, to Ibsen’s house, to its cafes, and to a superb modern ballet at its impressive Opera House, stick in the memory.
A third episode recalls another meeting of medical sociologists, not this time at Trondheim but aboard a ferry departing from Tromso. I had agreed to give a talk that was outside my comfort zone: on ‘eHealth and Social Theory’, and this took place ‘at sea’ and in the company of a stellar cast of colleagues better informed on the topic than me. As well as the Trondheim contingent and representations from Oslo and Tromso, with us were Sue Ziebland, Cathy Pope, Susan Halford and Alex Broom. I redefined my relative ignorance as detachment and ploughed on. I noted that eHealth covers a wide range of ICTs, including electronic health records, telemedicine, health informatics, health knowledge management (Medscape), virtual healthcare teams, mHealth (mobiles), medical research using ‘grids’, and healthcare information systems. I discussed different approaches to sociology and went on to posit certain ‘issue clusters’ with which social theory might usefully resonate. I split these between micro-, meso- and macro-orientation. As far as micro-theory is concerned, I stressed the salience of demarcating virtual from face-to-face interaction. Many ICTs come under the umbrella of eHealth and are characterised by the ‘mediation’ of information storage and transmission by technologies. The virtual abbreviates, codes and sometimes re-inscribes the actual. Indeed, the virtual can trump, supercede and, as Baudrillard might express it, be ‘more real’ than the actual. eHealth can involve dealings with ‘familiar strangers’ who are present but absent. The hinterland of Tromso is very different, I insisted, from South London. Commenting on meso-theory, I suggested that eHealth technologies are an important vehicle for Foucault’s ‘technologies of the self’. They may epitomise a new ‘power/knowledge disciplinary’, but they also offer effective modes of transmission of an ‘ideology of personal responsibility’ (maybe leading to a pervasive policing of the responsible self). Finally, I appended a remark or two on the relevance of macro-theory. Faith in ICTs, I intimated, can be interpreted as a core tenet of neoliberal ideology. Rhetorics of ‘choice’ facilitate this ideology, offering up for sale in our consumer society a false but lucrative prospectus to would-be patients. If only I had known then of the sequelae of the Conservative Party’s calculated underfunding of the NHS post-2010 to promote for-profit providers, namely, the explicit introduction of ICTs into routine medical practice! More important than my talk, however, was the trip up the Norwegian coast and into the Arctic Circle. The views were stunning and an exceptional cruise culminated in coffees together in the awe-inspiring Lofoten archipelago.
A final comment jumps ahead to 2017 and a conference in Paris, one of my favourite cities, not least for its famous cafes. I include it here because it was another gathering organised by Aksel. It was here that I introduced the idea of a neoliberal phase of university education from 2010 on. This, I argued, is epitomised by a privatisation agenda, that is, the displacement of public funding by fund-raising in an open and increasingly commercial marketplace. I emphasised five themes: we have witnessed a system colonisation, and a shift in the character of higher education from bureaucratisation to commodification; this system colonisation has with gathering momentum taken on the character of McDonaldisation, with standardised formats being applied to teaching, examining and assessments of academic performance; a new and insidious cultural relativity has permeated higher education, making it difficult to provide compelling critiques of what Ritzer in The McDonaldisation of Society calls ‘the irrationality of the rational’; education has ceded crucial ground to the inculcation of job-oriented ‘skill-sets’; and, a far-reaching and worrying shift this, sociology has become progressively tamer.
I then drew on Bourdieu’s theory to take this thesis a step further. I had better briefly lay some groundwork. Bourdieu’s notion of ‘habitus’ refers to the mental structures, or schemes, by which people deal with the social world. Habitus is the internalisation of the structures that comprise the social world. Thus, it reflects objective divisions around class, gender, race and age (for example). It varies in other words with an individual’s position in the social world. Those who occupy similar positions will tend to have a similar habitus, giving rise to a ‘collective habitus’. Habitus emerges over time and acts like a durable ‘structuring structure’. It comes from practice, and it shapes practice. It predisposes people to think and act in patterned ways, but without determining their action. A companion concept is that of ‘field’. This is most satisfactorily explicated ‘relationally’ rather than structurally. The field is a family or network of relations among the objective positions within it. The occupants of positions can be either agents or institutions. The social world has multiple semi-autonomous fields, of which higher education is but one example. All of them have their own specific logics and all generate among actors a belief about the things that are at stake in a field. A field is an arena of struggle, or competition, with people or collectivities occupying positions and oriented to defending/improving them. The field, in short, is a kind of competitive marketplace in which agents or institutions or both employ various types of ‘capital’ – economic, cultural, social and symbolic – to defend or further their interests. However, the field of power (politics) is of the utmost significance: the hierarchy of power relationships within the political field serves to structure all the other fields.
The obvious questions posed by Bourdieu are: first, what is the relationship between any given field and the political field; second, what is the objective structure of the relations among positions in the field; and third, what is the nature of the habitus of the agents/collectivities who occupy the various types of position within the field? The positions in the field are determined by the extent and strength of ‘flow’ of each type of capital (economic = wealth, income; cultural = taste, connections; social = social relations; and symbolic = status). Occupants of positions employ (structured but not structurally determined) strategies to defend or enhance them. Bourdieu also, finally, used the notion of ‘symbolic violence’. The state, he contends, is the site of struggle to secure a monopoly of symbolic violence. Symbolic violence is a form of what he calls ‘soft power’. The education system, for example, is a major conduit for exercising power over people.
In my talk I drew on a mix of these ideas to venture a habitus of compliance characterising teachers and researchers in higher education in the UK in the neoliberal phase. It is a habitus, I suggested, that is a product of Bourdieu’s political field directly shaping the semi-autonomous field of higher education. I drew attention to the introduction of university fees, initially by Blair’s New Labour regime in 1998 (fees up to £1,000 per annum), extended by this same government in 2004 (fees up to £3,000 pe annum), and then extended by the Conservative/Liberal Democrat coalition in 2010 (fees up to £9,000 per annum), and finally extended yet again by the Conservatives in 2017 (fees up to £9,250 per annum). Fees for overseas undergraduates had by then stage reached £10-35,000 per annum. I also referred to the Higher Education and Research Act, England, which received its royal assent on 27 April 2017. This Act: heralded the privatisation of higher education; removed direct funding of undergraduate programmes in the humanities and social sciences; opened the door to for-profit providers via an ‘Office for Students’; required research to be governed by a (utilitarian) ‘impact agenda’; and tied raising fees in the future to teaching appraisals in universities (TEF).
Universities had become businesses in financialised or rentier capitalism. I used a few fictitious but very familiar quotations to evoke this shift to a habitus of compliance: ‘the job description says’; ‘I’ve been set specific goals’; ‘it’s the stakeholders who matter’; ‘come on, we live in tricky times’; sociology is a broad church and I’m doing my bit’; and ‘I’m no collaborator’. But, I concluded, we are, sociology is, what we – between us – do. The taming process has been profound.
One of the criticisms of the theories of Bourdieu that I have briefly outlined and used in this sketch is that he privileges structure, and maybe culture too, over agency. It is a criticism made by Margaret Archer among others. Given her relevance to the development of my own take on critical realism, it is appropriate, not last chronologically, that I consider aspects of her considerable body of work next.