From the 1990s and through the ‘noughties and beyond the main focus of my writing switched from long-term illness and stigma to health inequalities. There was a short interlude, however, during which I conducted or oversaw a few short projects on the sex industry, and these can be briefly summarised before the bulk of this sketch explores my explorations of the enduring and disturbing patterning of health inequalities. A former Intercalated B.Sc student, Adrian Renton, asked me back in the 1980s if I would be interested in collaborating in some AIDS-related research with female sex workers. In the event two subsequent intercalated B.Sc students, Rita Peswani and Rebecca Graham-Smith, went on to conduct small-scale studies for their projects and dissertations, work we were able to publish in the early 1990s. This fruitful link with Adrian also introduced me to epidemiologist Helen Ward and anthropologist Sophie Day, two London-based experts in health-related research with sex workers. All this led to an edited volume by Annette and I called Rethinking Prostitution,which saw the light of day in 1997 just before our departure to teach in Atlanta. This included contributions from several leading researchers in the field, including Helen and Sophie on their studies based at the Praed Street Clinic at St Mary’s Hospital in London. The central message of the text as a whole was that de-criminalising sex work would be the optimum policy. It was a book that attracted public attention and I was invited to contribute to several TV and radio discussions, though because it coincided with my US sojourn, I was unavailable for most of them. One occasion I was able to make on my return was an invitation to be interviewed on ‘Women’s Hour’. I was told I would be joined by a representative of the English Collective of Prostitutes. Sitting in the waiting room, I was soon joined by an amiable woman, and we chatted. But my assumption that she must be from the ECP proved false. By pure luck I had said nothing terrible or unretractable in my conversation with Joan Armatrading before she was called into the studio.
Rethinking Prostitution was succeeded by several journal publications, including one in Sociology in 2005. This was the result of a study with a snowball sample of a dozen ‘white but not quite’ female escorts who had travelled to London from Eastern Europe to work for London-based agencies (although the owners were typically Albanian). I was to call these women ‘opportunist migrants’ because they gave the lie to common stereotypes of ‘victims of traffickers’ by explaining that they had taken calculated decisions to improve their situations and future options by working as escorts for specific time periods to earn large sums of money simply out of reach in their cities of origin (I later checked and all 12 left their agencies to return home when they had told me they would). I confess that I had a lot of respect for these women. Referring once more to Margaret Archer’s types of reflexivity, I went on to characterise them as ‘transitory autonomous reflexives’, that is, as people who judged themselves dissatisfied with the lot accorded them by what Archer would call their ‘involuntary natal placement’ in their home societies, weighed up their options and resolved to take decisive action to improve their prospects. It is an analysis I returned to in a later book, entitled A Sociology of Shame and Blame: Insiders Versus Outsiders, which was to see the light of day much later, in 2020. I should also note passing that in a general paper on global sex work in Social Science and Medicine in 2008 Frederique Paoli and I returned to Habermas’ lifeworld/system dichotomy to reframe debates about sex worker interactions with economies, states and clients.
As has been alluded to, a handful of my early publications on health inequalities with Paul Higgs had planted the notion that it is vital to study the causal contributions of the wealthy and powerful to the persistent and increasingly cavernous gaps in morbidity and mortality between affluent and securely placed citizens and those struggling materially, culturally and psychosocially. There already existed multiple empirical studies demonstrating beyond dispute a strong positive association between senior managerial, professional and middle-class placements on occupational class classifications like the Registrar General’s Classification of Occupations (RG) and, since 2001, the National Statistics Socio-economic Classification (NS-SEC) and improved health status and enhanced life expectancy. As well as pointing out the undue neglect of the causal sway of the wealthy and powerful, Paul and I had insisted that neither the RG nor NS-SEC provided credible measurement of social class as a social structure or relation, notwithstanding the latter’s genesis in the neo-Weberian theories of John Goldthorpe and colleagues at Oxford University. Our contention, later to be underpinned by Roy Bhaskar’s critical realist philosophy (see the next sketch for more details), was that for these correlations between RG/NS-SEC and morbidity/mortality rates to hold with such unerring consistency, they must be the product of deeper structural relations of social class. Moreover, the concept of social class we invoked was explicitly neo-Marxist. This was a stance elaborated in my Health and Social Change, the first of my two contributions to Tim May’s ‘Issues in Society’ series for the Open University Press: this one was published in 2002.
Starting from a discussion of the transition from welfare state to rentier capitalism, and the resultant ubiquitous and multifaceted ‘de-standardisation of work’, I reiterated a point Paul Higgs and I had emphasised, namely, that within medical sociology ‘hard’ class theory had all but disappeared and been displaced by ‘soft’ class analysis. I also repeated our rejection of postmodern proclamations of the ‘death of class’. I then took my cue from a particular neo-Marxist approach to social class advanced by Wallace Clement and John Myles in their Relations of Ruling, published back in 1995. Central to their position was the conviction that classes are formed at the point of production and reproduced throughout social life. Central to class formation are the criteria of real economic ownership of the means of production and the appropriation of surplus value and/or value through the control and surveillance of the labour of others. The exercise of control and surveillance should be distinguished here from the accomplishment of coordination and unity, which is properly part of creating surplus value/labour. A concept I picked up and ‘borrowed’ from this approach was that of the ‘capitalist executive’, referring to real economic ownership. This group was contrasted by Clement and Myles with the ’new middle class’, which is responsible for coordination and unity; the ‘old middle class’, which owns its own means of realising its labour and works outside the dominant relations of production; and the ‘working class’, which has no command over the means of production, the labour power of others or its own means of realising its labour. The relationship that matters most, their argument runs, is that between the capitalist executive and the working class.
I must admit that I adapted – or, maybe better, developed or elaborated on – this broad notion of the capitalist executive. I did so by focusing on a much smaller, dynamic and strongly globalised hard core of significant players amongst its membership: these comprised cutting-edge bankers and financiers, major shareholders and the CEOs of leading transnational companies. I went on to proffer a sociological theory of health inequalities that I have since refined but neither abandoned nor compromised. My thesis was that this class fraction, the global hard core of the capitalist executive, was more able in rentier than in welfare state capitalism to put sufficient and telling pressure on nation-based governmental political or ‘power elites’ to make policy to their advantage. They were, to use Zygmunt Bauman’s word, ‘nomads’, with no particular base in, or loyalty to, any nation state, irrespective of any personal insistence to the contrary (follow the money). In the process of time this reduced to the simple formula that capital buys power to make policy. I did my best in the book to unpack, explicate and render as plausible as I could the two pivotal constituents of my analysis, namely: (i) the hard core of the capitalist executive, and (ii) the power elite of the state apparatus.
Here too I spelled out my greedy bastards hypothesis, or GBH. I had best explain the nomenclature at the outset. It was deliberately chosen to be provocative and to elicit a reaction, a plan that was in the event mostly frustrated. I had grown intensely tired and depressed at reading countless socio-epidemiological studies replicating linkages between material inequality and health but remaining fixated on multivariate analysis involving individuals/aggregates of individuals and entirely ignoring or making only passing and forlorn reference to social structures like class. This was okay for epidemiologists oriented to prediction rather than explanation in my reasoning, but it was a travesty for sociologists of health inequalities. I recall reading a chapter by the leading UCL-based British epidemiologist of health inequalities, Michael Marmot, making the point that sociologists presumably have their own questions to ask. You would think so! Anyway, the GBH asserted that the primary cause of health inequalities in the UK is strategic decision-making on the part of the hard core of the capitalist executive and subsequently imposed on the power elite of the state, resulting in the de-standardisation of work and all that implies for members of the working class in particular: I was thinking here of revocations of the legal protections long afforded trade union, lower pay, job insecurity, zero hours contracts, reduced benefits and so on, all of which were known to have deleterious effects of the health and longevity of those affected. This seemed to me at the time, as it does now, incontrovertible.
I also wrote of what I then called ‘capital flows’ but now term asset flows. The idea was that these were the ‘media of enactment’ of the GBH, or the way in which it exercised its force. Strong flows are protective for health and longevity, while weak flows present a threat to either or both. I discerned from the extant literature six distinct and salient capital/asset flows: biological, psychological, social, cultural, spatial and, pre-eminent among them, material (I have since added a status or symbolic flow). The biological flow is often described as ‘body capital’ and embraces genetic factors as well as others like low birthweight; the psychological flow refers to factors like coping and resilience; the social flow incorporates factors like social integration, networks and support; the cultural flow alludes to forms of socialisation that accrue from being ‘well connected’; the spatial flow refers to the character and wellbeing of communities and neighbourhoods; and the material flow denotes level of income and related aspects of standard of living. The material flow, I argued, is the most significant for health. I defended the idea of flows against socio-epidemiological and sociological researchers who openly worried about the challenge of operationalising ‘flows’ by insisting that these forms of capital or asset are rarely either held or not held but vary over time. Furthermore, there can be and often is compensation between flows: for example, a weakened material flow due to an unpredictable redundancy might be compensated for strong a social flow.
I suppose it should not have surprised me that the appearance of the GBH in several publications failed to gain much traction and was largely ignored by putative leaders in the field of the sociology of health inequalities. I grew accustomed to colleagues explaining in conference bars that while they referred to my ideas when teaching – ‘my students love the GBH’ – and were themselves sympathetic, they could not jeopardise their chances of future grant funding by giving it succour, or even addressing it, in print. I understood despite finding their remarks deeply depressing. I had thought that the articulation of the GBH would at least provoke an attack or two, giving me the opportunity to respond and for my response to leak into the wider community of researchers. I had first ventured on an analysis of the importance of a macro-sociology of financialised or rentier capitalism in general, and of the behaviours of the wealthy and powerful in particular, for population health and health inequalities in the late 1990s, and by the early noughties this had crystalised into neophyte expressions of the GBH. With hindsight I would stress two points. The first point is made with a mix of exasperation and irritation. It seems to me that it has taken the best part of two decades for mainstream sociology to refocus its attention on the major causal import of the strategic decision-making of the rich and powerful, and that it is taking even longer for this to impact on medical sociology. I am not of course implying that colleagues have been influenced by me or are ‘catching me up’; but I am suggesting that mainstream sociology has been tardy and medical sociologists interested in health inequalities culpably so. As for the former, a series of excellent investigations are belatedly underway under the guidance of Mike Savage at the LSE.
My second point is that this generalised tardiness is indeed tied to the enhanced pressures that academics find themselves working under, the more so since the advent of what I previously called the post-2006 corporate phase – and later amended to confine the corporate phase to 2006-2010 and to add a neoliberal phase from 2010 on – of university life. Subsisting on short-term contracts, bringing in grant revenues and publishing in high-impact journals, commonly now while still working on one’s Ph.D, are urgent matters affecting financial and family security, let alone the forging of careers. It can be an occupational or career hazard not only to take one’s eye off the ball but even more so to stand out as a suspect or controversial figure likely to upset not only potential funders but a variety of local apple carts. This was all to get significantly worse in the lead up to, and after, my retirement from UCL in 2013, but this is a narrative to be developed later in this chronicle.
So the sociology of health inequalities had deflected my theoretical attention away from long-term illness and stigma, for all that I was to return to the latter in due course. Above all, I wanted researchers to focus on the social structures, above all relations of social class, that delivered the greedy bastards, or, as I once put it, upon which they ‘surfed to their advantage’ while others drowned. But by the start of the twenty-first century my mining of the works of Habermas was being complimented by Roy Bhaskar’s critical realism, and it is to this that the next chapter turns.