Beyond Medicalization Healthicization

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Sociology of Health & Illness Vol. 26 No. 4 2004 ISSN 0141–9889, pp. 453–459

© Blackwell Publishing Ltd/Editorial Board 2004. Published by Blackwell Publishing, 9600 GarsingtonRoad, Oxford, OX4 2DQ, UK and 350 Main Street, Malden MA 02148, USA

Blackwell Publishing LtdOxford, UKSHILSociology of Health & Illness0141–9889 © Blackwell Publishing Ltd/Editorial Board 200420042641000Original ArticlesA rejoinder to Hislop and ArberSimon J.Williams

Beyond medicalization-healthicization?A rejoinder to Hislop and ArberSimon J. Williams

Department of Sociology, University of Warwick

Sleep has undoubtedly been a neglected topic of sociological discussion anddebate, both past and present. Further reection, however, as I have arguedelsewhere (Williams and Bendelow 1998, Williams 2001a, 2003a,b), revealsthe rich sociological signicance of sleep at many levels and in many differ-ent ways. How

, when

and where

we sleep, let alone what

we make of it, areall, to a large degree, socio-cultural and historical matters. Sleep is crucialto any given society, acknowledged or not, permeating its institutions andthe capacities of its embodied agents, its spatio-temporal arrangements andits discursively constructed boundaries, its rituals and its mythologies, itspolicies and its practices. The fact that sleep is ‘lived through’, moreover,underlines its sociological signicance as a role and event we continually, if not ritually, prepare for or rehearse, schedule or organise, manage or mis-manage, as part and parcel of our normal (waking) everyday lives.

Sleep, to put it more formally or schematically, is irreducible to any onedomain or discourse, arising or emerging through the interplay of biologicaland psychological processes, environmental and structural circumstances(

i.e.

facilitators and constraints), and socio-cultural forms of elaboration,conceived in temporally/spatially bounded and embodied terms. Studyingsleep therefore enables us critically to interrogate a series of deep-seated

(sociological) assumptions about the relationship between wakefulness,consciousness, temporality and sociality, raising important new embodied

themes and issues along the way (Williams forthcoming).Clearly these sociological issues extend far beyond the province of health

and illness, yet the relevance of sleep to on-going medicalization-healthic-ization debates opens another potentially rich vein of research (Williams2002). It is in this context that Hislop and Arber’s (2003) paper – entitledUnderstanding women’s sleep: beyond medicalization-healthicization? – arises. The aim, we are told, is to explore my contention that sleep may

provide yet ‘another chapter’ in the medicalization-healthicization story(Williams 2002), drawing upon data collected in an empirical study of women’s sleep. The nub of Hislop and Arber’s argument, it seems, based onthis small-scale study (from which generalisations should not be drawn), isthe proposition of a so-called ‘alternative’ model for the management of



454 Simon J. Williams

© Blackwell Publishing Ltd/Editorial Board 2004

women’s sleep which incorporates a ‘core’ of ‘personalised activity’ linkedto strategies associated with healthicization and medicalization: a sortof three-tier model in which medicalized solutions are deemed the mostextreme, if not ‘deviant’, when all else fails. Hislop and Arber’s study, in thisrespect, is timely, welcome and illuminating. It is also, I venture, problematicor contentious on a number of counts.

What then of these alleged ‘problems’? What is ‘contentious’ about thestudy? First and foremost, what we have here is at best a partial and at worsta misleading

portrayal of my own position on these dormant matters. It isclear, for example, as my previous work attests, that the degree or extent of medicalization-healthicization concerning sleep remains an open question

rather than a foregone conclusion. It is also clear, as my other writings onsleep (Williams and Bendelow 1998, Williams 2001a, Williams forthcoming)

and the ‘limits’ of medicalization suggest (Williams 2003a, 2001b, Williamsand Calnan 1996), that this in no way precludes or denies the writing of other important chapters on sleep that take us (far) beyond medicalization-healthicization debates: far from it. Hislop and Arber, in other words, seemto be constructing something of a ‘straw man’ here, a caricature in effectwhich on closer inspection is more apparent than real.

A second, closely-related set of issues, concerns Hislop and Arber’s ownportrayal of/engagement with medicalization debates, both in general termsand in relation to sleep. Medicalization, it is clear, to the extent that it does

occur, may take place at different levels

(

e.g.

conceptual, institutional, inter-actional) with or without the (direct) involvement or expressed intent of doctors, let alone the harbouring of ‘imperialist’ ambition (Conrad 1992,Conrad and Schneider 1980, Williams 2001b, Williams 2003a). The upshotof this, as far as Hislop and Arber’s paper is concerned, is, on the one hand,a certain tension between their own limited empirical focus on lay-professional

perspectives

and doctor-patient relations

, particularly the ‘medicalization’ of sleep through tranquillisers, and, on the other, the broader more generalconclusions they draw (based of these limited level ndings) about the(de)medicalization of sleep. This is a confusion of part for whole, in effect,which conates different levels of analysis in the process. The argument, onthis latter count, appears to be that sleep was

medicalized in the past (

i.e.

from the 1960s onwards) – a process referred to as the ‘“core” of women’ssleep management’ (Hislop and Arber 2003) at this time – but is now (

i.e.

over the past 20 years) becoming demedicalized. Even if we buy into thisargument, which is debatable, it needs substantial qualication, given thatwe are really only talking about certain types of sleep problem, in this case(with all due caution) ‘insomnia’, rather than sleep per se. Changes at thelevel of the doctor-patient relationship, or the GP-patient relationship to bemore precise (medicine, remember, has many branches and specialisms),cannot simply or unproblematically be equated with ‘demedicalization’ forthe reasons outlined above. The medicalization of sleep ‘problems’, torepeat, let alone their demedicalization, is a complex, multi-level process that



A rejoinder to Hislop and Arber 455


requires further detailed sociological investigation before any hard and fastconclusions can be reached. The jury, in the meantime, is still (in large part)‘out’ on this count.

These problems are compounded when other key contentions such asthe ‘inner core’ of ‘personalised strategies’ unreexively enter the debate.Whilst I have considerable sympathy with what these authors are trying todo here, particularly in resisting an over-drawn picture of medicalization-healthicization to date, one is duty-bound to question the analytical statusor merits of any such reference to ‘inner core’, and compelled to ask just how‘personalised’ these personalised strategies really are? Where indeed do wedraw the line? The unquestioning (

i.e.

face value) attitude toward what thewomen surveyed have to say on these matters is also not without its problems,particularly where sleep is concerned, raising important theoretical and meth-

odological questions alike, including the knowledgeability of agents and thesociological status of their accounts, the relationship between the discursive,the practical and the unconscious, not to mention the relationship betweensubjective reports and objective measures of sleep time and quality. Refer-ence to sleep as a ‘natural’ process, and discussion of the shift toward ‘hol-istic’ approaches as (further) evidence of demedicalizing trends, is equallyproblematic. For some authors, it should be remembered, the shift towardholistic approaches, particularly those of a doctor-sponsored kind, has moreto do with remedicalization

than demedicalization (Lowenberg and Davis

1994); a process, for Foucauldian scholars, which itself spawns new forms of (self) surveillance and control (

cf.

Armstrong 1986). Healthicization, to besure, is another way of conceptualising these issues, but either way, more isclearly at stake here than any plain and simple process of demedicalization.We should not, moreover, lose sight of important similarities

as well asdifferences between biomedicine and holistic health, not least their sharedindividualistic focus (Sharma 1996).

The upshot of the foregoing points is that we should be wary of hastyclaims and broad-brush generalisations about the (de)medicalization of (women’s) sleep, both past and present, based on limited evidence to date.The same goes for appeals to the notion of ‘personalised strategies’ as thenew ‘inner core’ or ‘pivotal axis’ in these debates. At the very least, a morereexive discussion of these issues, and more circumspect conclusions basedupon them, seem called for at this stage in the debate.

Let me muddy the water still further, however. If, as I have suggested, thedegree or extent of medicalization-healthicization regarding sleep is an openquestion, and a complex if not contradictory affair at that, then it is well toremember that lack of attention

to sleep matters is a charge frequentlylevelled against the medical profession, particularly doctors on the front-lineof medical practice. One study, for example, which set out to investigate thepattern of medical student teaching about sleep and its disorders in the UK,found the median total time devoted to these matters in undergraduateteaching as a whole was ve minutes (Stores and Crawford 1998). For





preclinical teaching this rose to a princely sum of 15 minutes, with a at zerorecorded for clinical teaching. As in other countries, these authors con-cluded, ‘undergraduate medical teaching is inadequate as a basis for thedevelopment of competence in diagnosing and treating sleep disorders,which are common and cause difculties in all sections of the population’(1998: 149). This decit, moreover, as other studies have found, is not cor-rected by later postgraduate training – see also Dement, a leading US sleepexpert, who is equally vociferous on this front, charging many doctors with‘ignorance’ when it comes to sleep matters; ‘the worst sleep disorder of themall’ in his view (2000: 9).

In working through the pros and cons of the medicalization-healthiciza-tion of sleep, we also need to think very carefully about the role of themedia. Hislop and Arber, to be sure, touch on this at various points in the

paper, but this raises as many questions as it answers. The media indeed mayplay a variety of roles here which take us far beyond the traditional para-meters of (de)medicalization debates, reconguring their very terms of refer-ence in the process: roles I am currently researching more fully. Kroll-Smith(2003), for example, in a prescient piece, highlights the apparent contrastbetween the density of popular texts

on sleepiness in the US and the absenceof clinical attention

to sleep disorders. The public, he argues, are increasinglyadvised and informed by these ‘extra-local’, ‘textualised’ forms of know-ledge and ‘rhetorical authority’ (

i.e.

authority cast in the rhetoric of medi-

cine

); more porous forms of knowledge, that is to say, which not only occur

outside

the traditional connes or institutional parameters of the doctor-patient relationship, but may indeed bypass

the physician altogether infavour of other types of ‘doctors’ cum sleep specialists or medical researchers,many of whom are PhDs not MDs (Kroll-Smith 2003) – see also Seale(2002) on relations between medicine and the media. Kroll-Smith, in thisrespect, irts with a provocative idea, borrowed from the likes of Beck andBauman, that medicine is becoming something of a ‘zombie institution’(both dead and alive), whereby past panoptical forms of control increasinglyrub shoulders with those of a more post-panoptical nature: a situation inwhich the very terms of the medicalization-healthicization debate take onimportant new (

extra-

medical) dimensions.We should also ask at this point what precisely these ‘extra-local’ or

‘textual’ claims entail as far as proposed remedies for our sleep(iness) areconcerned. One distinct line of thinking here, for example, is less concernedwith increasing the quantity

of our sleep time (to the normative ‘eight hours’)than with improving its quality

through a variety of ‘smart’ or ‘efcient’sleep management strategies, tailored to individual needs, including themerits of napping or micro-sleep: designer sleep for the designer age, onemight say. The possibility remains, moreover, returning to a point raisedin my previous paper (Williams 2002), that future ‘discoveries’ or ‘bio-techbreakthroughs’ will provide the means

or the option

of further reducing, if not eliminating, our need for sleep altogether (

cf

. Melbin 1989): the realm





of science ction one might think, yet these developments are already under-way given breakthroughs in the treatment of narcolepsy which themselveshave helped ‘unlock’ the secrets of sleep. This, to be sure, would not appealto us all, or perhaps more correctly to us all of the time, given that sleep isa valued ‘release’ or legitimate ‘escape’ from the social demands of the con-scious waking world (

cf.

Schwartz 1970). It could nonetheless catch on, forbetter or worse, in an era where yesterday’s impossibilities become today’spossibilities.

If we really wish to sort out what precisely is or isn’t new about thecurrent situation as far as sleep is concerned, however, we should alsolook to the past as well as the present or future. Claims concerning themedicalization/healthicization of sleep today, in other words, need settingin their proper historical context. Certainly, it is possible to point toward

something like the beginnings/precursors of a medicalization of sleep, orcertain aspects of it, in the late 18

th

and early 19

th

centuries, particularlythrough Lavoisier’s contributions to medicine and public health, where pre-cise biological norms regarding the respiratory actions and capacities of sleep-ing bodies were laid down and quite literally incorporated into the spatialdimensions of various buildings (Duveen and Klickstein 1955, Crook 2002).In almost all Victorian public health manuals and lectures, moreover, yound reference to sleep (Crook 2002). The links between sleep, health andhygiene can also be traced at least as far back as the Renaissance through

various published sources and popular texts (Dannenfeldt 2000). The‘problems’ associated with sleep have undoubtedly changed over time, inkeeping with different knowledge bases and ‘remedies’ offered – particu-larly since the advent of so-called ‘sleep science’ in the 1950s/1960s (aswitnessed, for example, through the ‘discovery’ of REM in 1953), and its‘translation’ into the principles and practice of ‘sleep medicine’ (

cf

. Kryger

et al.

2000) – but the fact that important historical precedents/precursorsof this kind can be found suggests the need for further study, if not quali-cations, to our present-day claims about the medicalization-healthicizationof sleep.

It is not simply a question of the medicalization-healthicization of sleepthough, nor of broader processes of commercialisation or commodica-tion, important as they are – commercialisation, in fact, may have outpacedmedicalization to date, although the two may increasingly ride in tandem.

If indeed we are to take Hislop and Arber’s invitation to go ‘beyond’medicalization-healthicization seriously, I wonder in fact whether we should

also

be looking at (possible/potential/prospective?) processes of what, forwant of a better word, one might term ‘sleepicisation’

: processes, that is tosay, which extend far beyond the realm of health to a variety of other socialproblems and issues, both now and in the future. From concerns over poorperformance at school or work, to accidents on the roads and other well-publicised tragedies such as the Exxon Valdez oil spill, the Chernobyl nuclearcatastrophe and the Challenger space shuttle disaster (Coren 1997), sleep (or





sleepiness to be more precise) has increasingly been invoked as a contributoryfactor if not the prime culprit. Drowsy drivers are now increasingly likenedto drunk drivers (Coren 1997), with sleepiness itself in certain circumstancesnow treated as a criminal offence; witness, for example, the Selby rail disaster(

i.e.

a prospective criminalisation

of sleep(iness)).All in all, then, to sum up, the message is clear. Sleep is a fascinating yet

strangely neglected topic of sociological discussion and debate, with manyimportant chapters still to be written (Williams, forthcoming). Hislop andArber’s paper, in this respect, is a timely, welcome and illuminating con-tribution, albeit a theoretically and empirically limited one that does notperhaps take us quite as far ‘beyond medicalization-healthicization’ as atrst appears. Much more, indeed, needs to be done before we can properlyassess the extent of medicalization-healthicization to date, let alone satis-

factorily tackle these other important chapters in sleep’s hitherto (hidden orneglected) story. This, I hasten to add, is as much a comment on or criticismof past sociological neglect as it is of current efforts on this front, Hislopand Arber’s included, with many important challenges, theoretical and meth-odological alike, still ahead in taking these dormant agendas forward.Researching sleep, for example, raises tricky questions about the relationshipbetween the knowing (lived) wide-awake body and the unconsciously know-ing (dormant) body. Construed more positively, however, it is not so mucha case of ‘obstacles’ as ‘opportunities’ for the taking, with a rich variety of

sociological agendas to pursue, in health and beyond. The debate, in short,should continue in a constructive and protable fashion: something to sleepon perhaps . . . ?

Address for correspondence: Simon J. Williams, Department of Sociology,University of Warwick, Coventry, CV4 7ALe-mail: [email protected]

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Beyond Medicalization Healthicization