Excessive daytime sleepiness is represented in the popular media as a distinct medical disorder marked by a diminished level of vigilance at socially inappropriate times. Moreover, it is characterised as morally inappropriate signaling the need for personal, if not civil, intervention. Importantly, problem sleepiness is being fashioned and deployed as a legitimate medical disorder by popular media. The idea of EDS and its accompanying symptoms is mediated more by magazines, newspapers, and the Internet than by practising physicians. Excessive daytime sleepiness as a medical disorder, in other words, is emerging in non-medical arenas as ordinary people access the images and grammar of popular media, cast in the rhetoric of medicine, to examine their own sleep behaviours.
Medical sociology in a Panoptical and post-Panoptical society: a case for both-and
In a shot across the bow of modern sociology, Alain Touraine asks us to abandon the word ‘society’ as anything more than a convenient description of a country or a state, as in ‘British’ or ‘American society’ (1998: 119). ‘Society’ is an increasingly meaningless term, he reasons, if it is meant to describe a more or less self-regulating, normative system, characterised by a close fit between social actors and institutions. Touraine is writing about those regions of the world saturated with digital and print media whose economies are increasingly globalised. His counsel, while highly provocative, would seem premature. Routine roles firmly grounded in institutions still exercise considerable jurisdiction over people's lives. But alongside this now familiar version of authority is a second more discursive version. The once-firm presumption that there is a ‘right’ way to be in the world – to work, fashion a family or get sick, for example – softens as people cobble together facts, data, and expert opinions to configure their own versions of work, family and sickness. It is with this protean social milieu in mind that Ulrich Beck encourages us to revisit our conventional ‘units of analysis’ to see what new and unfamiliar sense we might make of them (2000: 25).
Zygmunt Bauman (2000) deploys an idea first advanced by Beck, the ‘zombie institution’, to account for modern systems of social control that are simultaneously dead and alive. A zombie institution is alive in so far as it is embodied in visible social arrangements, but it is also dead (or dying) in so far as its authority to guide, shape and predict human choices diminishes (2000: 6). The emergence of zombie institutions signals ‘the end of the era of mutual engagement … between the supervisors and the supervised’ and the beginning of what he calls a post-Panopticon history (2000: 11). It is a short step between these observations on contemporary history and the idea of rhetorical authority inspired by Dorothy Smith, Arjun Appadurai and others who write about the increasing salience of print and digital texts in the co-ordination of human affairs. Consider medicine, if only briefly, as a zombie institution: the medical gaze will continue, but not in the near-perfect form of a Panoptical society.
To be sure, the institutional authority of medicine remains a potent factor in the day-to-day lives of ordinary people, but illustrated in this inquiry into sleep and sleepiness is an alternative authority expressed in the voices of print and digital media. This second, rhetorical authority, is reaching into the mundane lives of people fashioning what will count as a personal health issue. The idea or culture of medicine will continue to exercise a powerful hold over our lives. But this power is likely to be more discursive and less personified than routinely found in the physician-patient encounter. This new history invites a new look at some of the core concepts in medical sociology. Consider briefly the sociology of diagnosis and the classical distinction between illness and disease.
Contemporary literatures on these two concepts emphasise medicine as a powerful social institution, bounded by tradition, law and mysterious expertise. A Panopticon arrangement, modern medicine names diseases, labels people and prescribes and proscribes patient behaviours. Phil Brown (2000), for example, in a now seminal article, makes a persuasive case for a sociology of diagnosis. Assuming the early modern, Panopticon idea of institutions, he writes, medical diagnosis is ‘based on the dominant biomedical framework … the socialization of medical providers, especially physicians, [and] the professional and institutional practices of the health-care system . . .’ (2000: 78). With a strong voice, Elliot Mishler affirms Brown's Panopticon version of modernity: ‘Diagnosis’, he writes, is the ‘voice of medicine’, in contrast to the ‘voice of the life-world’ (cited in Brown 2000: 82).
The case of excessive daytime sleepiness hints at an evocative idea, to wit, the ‘voice of medicine’ and the ‘voice of the life-world’ are beginning to converse outside the once solid container of institutionalised medicine. ‘[T]he voice of medicine’, it appears, is escaping into a contemporary world of porous institutions increasingly affected and affecting one another in a delightful, if maddening, exchange of digital, video, and print media. In a post-Panopticon history, sociologists are encouraged to re-examine the social locations of medical knowledge, to question the modernist assumption that it is exclusive to hierarchical, systemic arrangements. Medical knowledge, of course, is still found in the institution of medicine and we should not ignore this important area of inquiry, but we should also seek it outside its institutional matrix in less solidified, more casual and contingent venues. A person who self-diagnoses with EDS after taking the Epworth Sleepiness Scale found in a magazine article or on a website does not by herself threaten modern medical authority; but she is exercising, if only momentarily, an alternative authority, one worth investigating.
Open almost any textbook in medical sociology and you will encounter a distinction between illness and disease. In one highly respected text, illness is defined as ‘laypersons’ notions’, that express ‘people's diverse experiences’ (Freund and McGuire 1991: 159–60). Disease, on the other hand, is the province of biomedical knowledge administered by physicians (Freund and McGuire 1991: 204). In a Panopticon world, physicians assign disease languages to bodies, and ordinary people experience their diseases as illnesses. Importantly, even when Freund and McGuire critique the naturalist assumptions of biomedicine by reminding readers that disease, like illness, is also socially constructed, it is physicians who do the constructing and lay people who experience the illness (1991: 204).
Calling attention to the socially constructed make-up of disease is indeed worth the effort. But in addition to this modernist critique, we are invited, at this point in history, to consider how the traditional dichotomy between disease and illness, so central to modern medical sociology, is being reconfigured. Excessive daytime sleepiness is a ‘disease’ fashioned by popular media, and communicated directly to ordinary people outside the institutional encounter between physician and patient. Coached and informed by a persuasive rhetorical authority, ordinary people are claiming to know something valid, that is, medical, about the nature of the body.
From this vantage point, EDS is more than a subjective appraisal of discomfort or suffering – more than an illness in other words – it is also a theory, an explanation, a way of making medical sense of the body. Indeed, an increasing number of ‘diseases’ are fashioned and deployed by popular media in spite of their contested status in institutional medicine. Among the more well known are Gulf War Syndrome, multiple chemical sensitivity, chronic fatigue syndrome and third stage Lyme Disease (for a recent discussion of contested diseases see Brown, Kroll-Smith and Gunter 2000). As we examine the nomenclatures of disease floating about in multiple media, appealing to general and targeted groups alike, we are witness to a rhetorical form of authority discernibly different from Foucault's Panopticon medical gaze (1995: 191). And we are invited to revisit our classic distinction between illness and disease, not to debunk it, but to rethink it.
In sum, submitted here is not an either-or distinction between institutional and rhetorical authority or Panopticon and post-Panopticon moments in time. It is, rather, an invitation to a both-and way of thinking. Consider it a modest call to be adventurous, to look for new and novel social arrangements emerging alongside the familiar ones coded in our common sociological vernacular.