Address for correspondence: Steve Kroll-Smith, Department of Sociology, University of North Carolina at Greensboro, Greensboro, NC 27402, USA e-mail: email@example.com
Abstract Problem sleepiness is emerging as a medical problem in the US and Britain. Though an increasingly salient complaint, clinical medicine is only peripherally involved in the diagnosis and treatment of sleep troubles. Paramount in shaping public perceptions and experiences of sleep are the popular media. The apparent chasm between self-reported sleep troubles and the routine medical gaze is the point of departure for this inquiry. Aided by the idea of rhetorical authority, a case is made for the conspicuous influence of newspapers, magazines and the Internet in shaping a persuasive cultural directive to become conscious of soporific states and their possible deleterious consequences. Attending to this cultural directive, a growing number of people are self-diagnosing with a novel sleep disorder, excessive daytime sleepiness. The increasing significance of popular culture in the creation of medical troubles summons an alternative version of medical sociology. A limited case for this claim is made by revisiting two key ideas in this field: naming diseases and the classic distinction between illness and disease.
The National Sleep Foundation (NSF) recently disclosed that 69 per cent of Americans report experiencing sleep problems, though only four per cent have sought advice or treatment from a doctor or healthcare provider. Nearly 100 million Americans complain of insomnia symptoms, but only six per cent are diagnosed with insomnia by doctors, and only half of those receive treatment for the disorder. Moreover, 40 per cent of adult Americans experience intense sleepiness at least once during the course of the day. Slightly more than half of the US adult population report driving while drowsy; one in five (19%) admit to dozing off behind the wheel (NSF 2001)1.
Importantly, nearly 80 per cent of adults surveyed by the NSF think their sleep troubles are not serious enough to report to doctors, or think there is little their doctors can do for them (NSF 2001). Fewer than 14 per cent of medical interns in the US question patients about their sleep patterns (Haponik, Frye and Richards 1996). In a study of 222 patients’ charts in one Veterans’ Administration clinic, no sleep disorder symptoms were recorded, though 47 per cent of the patients reported sleep-related problems during doctor consultations (Meissner et al. 1998). Problems with sleep and sleepiness, it appears, are occurring with considerable frequency outside institutionalised encounters between patients and doctors.
The apparent chasm between self-reported sleep troubles and the routine medical gaze is a point of departure for this inquiry. Practicing physicians rarely identify and name people's sleep troubles or co-ordinate their behaviours in response to them. Clinical medicine, for all practical purposes, is currently not part of what Dorothy Smith would call the ‘relations of ruling’ (1993: 6–8 and passim) in shaping and controlling the contemporary problem with sleep. This observation begs the question, what indeed are the patterns of discipline and regulation that direct thinking, control emotion, and govern conduct around the somatic goal of good or sufficient sleep? This question, in turn, invites consideration of how a sociology of medicine might look in an historical era marked by the decreasing salience of the medical gaze, an era Bauman refers to, with a hint of hyperbole, as ‘post-Panoptical’ (2000: 11).
The evidence will suggest that popular media are key resources in shaping public perceptions of sleepiness without the direct intervention of clinical medicine. The evidence itself is an amalgam of theorising and data that builds a plausible case for a public increasingly advised and informed by extra-local, textualised forms of knowledge. Two closely related levels of analysis are implied in this inquiry. At one level is a substantive discussion of the popular representation of sleepiness as a peculiarly modern somatic trouble. At the other is a modest theoretical deliberation on a contemporary social order increasingly reliant on ‘textually mediated forms of ruling’ (Smith 1993: 212). The discussion begins with a succinct deliberation on texts, readers, and relations of ruling followed by a word on methods. A lengthy discussion examines several popular media and their varied messages on the problem of sleep and sleepiness. A final section recalls Alain Touraine's (1998) appeal to sociologists to amend their idea of society and concede the historical rift between social actors and social systems. To close, I introduce and modestly critique his entreaty, link it to related work, and suggest the relevance of this new literature to a broader, possibly more interesting, sociology of medicine, one that assumes the increasing salience of popular media. Inspired by this contemporary history, two key ideas in medical sociology are revisited: naming diseases and the classic distinction between illness and disease.
Texts, readers and relations of ruling: a strategy for reading popular media
Substantial work exists on how individuals use stories or narratives to make sense of their illnesses and fashion a corresponding identity (a short list includes Ezzy 2000, Kroll-Smith and Floyd 1997, and Frank 1995). Missing from this work, however, is a consideration of how popular media fashion these stories. Recent work from an eclectic group of social and cultural theorists is converging on a new way of talking about media, personal stories and the government of the person that beckons inquiry into key quarters of medical sociology.
Representatives of several intellectual traditions converged in the past 15 years on a single, evocative idea: the institutional arrangements organising and regulating people's lives are increasingly mediated by ways of knowing inscribed in texts (Rorty 1989, Appadurai 1996, Smith 1993). Texts, or what Rorty (1989) might call vocabularies, are words and images conveyed in digital, electronic and print media that inform and shape the ‘quotidian mental work of ordinary people’ in global societies (Appadurai 1996: 5). Giddens (1991) sees this mental work as a cardinal feature of a late modern world. Here, lay people are continually accessing expert ways of knowing, tinkering with them sufficiently to answer a question or make sense of their misery, and fashioning stories that reflect a correspondence between situated biography and abstract, disembodied texts (1991: 138). Tellingly, he illustrates this lay appropriation of expert knowledge by describing in some detail a person suffering from chronic back pain who searches popular media for therapies, medications and theories of back troubles. ‘Many non-technical books about the back’, Giddens observes, ‘are available on the popular market’ (1999: 140). Apropos Giddens, Fairclough observes, ‘The media are full of expert advice’ (2001: 3), or, perhaps more realistically, messages embedded in the rhetorics of expertise.
Faced with decisions, questions and dilemmas, people are increasingly apt to turn to magazines, books, newspapers, newsletters, and the Internet to acquire new perspectives, facts, explanations and prescriptions for acting. Personal reasoning and sense-making are increasingly tied to clusters of words and images that are ‘detached from local contexts’ and ‘occur simultaneously in a multiplicity of socially and temporally disjointed settings’ (Smith 1993: 211). Texts, in short, are public fragments of social consciousness that work (albeit loosely) in concert, encouraging people to reason, know and fashion their worlds in particular ways.
Dorothy Smith concludes her study of texts and relations of ruling with the following summation: ‘Advanced … societies are pervasively organized by textually mediated forms of ruling’ (1993: 211). Giddens (1991) suggests a theoretical angle on this novel state of affairs. If expert knowledge, from making a nuclear bomb to theorising spinal disorders, is procurable by virtually anyone living in ‘conditions of high modernity’, authority is unavoidably democratised: ‘(forms) of traditional authority become only “authorities” among others, part of an indefinite pluralism of expertise’ (1991: 195). Institutional authority with its hierarchical procedures of observation, categorisation and judgment is increasingly complemented, and at times challenged, by at least one new species of authority; one that no longer occurs in an institutional, territorially fixed encounter between, for example, elected officials and citizens, teachers and students or doctors and patients.
This new species of authority is exercised (at least in part) through a congeries of often weakly related popular media. It is an extra-territorial authority, existing more in time than in space. For want of a better term, we call this novel form of authority rhetorical and search for its existence in the remarkably varied media on the contemporary problem of sleepiness.
The salience of popular media in personal knowledge of health and disease
There are more than good theoretical reasons to examine the role of popular media in shaping people's interpretations and behaviours around the issues of health and disease. The US National Cancer Institute (NCI), for example, recently announced, ‘health news has become a part of everyday life’ (NCI 2001: 1). The American Council on Science and Health (ACSH) concluded its survey of magazine use from 1990 through to 1992 among people interested in nutrition and dieting with this observation: ‘Magazines are the principal source of diet and nutrition information in the American home’ (Woznicki and Case 1994: 6). The ACSH also reports that most American women learn about hormone replacement therapy from the media (Lukachko 1999). Similarly, most people who suffer from arthritis use popular media to learn about its pathology and possible treatment regimens (Pisetsky 1995). A paper in the Journal of the American Medical Association (JAMA) acknowledges the porous boundaries between medical research and popular media, noting the growing significance of the ‘lay press’ in transmitting medical knowledge to the public (Phillips et al. 1991: 1180).
The Internet, not surprisingly, is now a primary source of popular knowledge about health and disease (Cotten 2001). A recent study estimates that more than 60 million US residents search for health and disease information yearly on the World Wide Web (Fox and Rainie 2000). Moreover, and of some importance, 70 per cent report using the knowledge they acquire from the Internet to change personal habits and learn about diseases and treatments (Fox and Rainie 2000). The prevalence of web-based information in shaping personal awareness of health and disease prompted a key article in JAMA on the quality of health-related information on the Internet and education levels appropriate for accessing it (Gretchen et al. 2001).
In short, it appears likely that popular media are a salient source of knowledge about health and disease among non-experts in an historical era increasingly organised around the authority of texts. Coalescing into a pattern of rhetorical authority, popular media inform and shape people's thinking about themselves, their bodies, and their wellbeing. Recalling the apparent disconnect between clinical medicine and the growing number of Americans who self-identify as suffering from some type of sleep trouble, magazines, newspapers, radio, and the WWW are even more likely sources of personal knowledge in the identification and management of sleepiness.
A word on methods
Data for this paper are taken from print and electronic media and represent the plurality of messages and texts that inform and advise people on the problems of sleepiness in contemporary American society. The Reader's Guide to Periodical Literature was used to track and identify popular print coverage of sleep and sleepiness. The first time-period examined is 1982, the year ‘excessive daytime sleepiness’ is first mentioned in non-technical media. While the occasional article and story on problem sleepiness follows throughout the 1980s, it is not until 1990 that sleepiness emerges in popular media as a public and personal health concern, and continues unabated today.
Literature from The Guide was subdivided according to whether or not it was targeted at a singular audience or intended for a more general audience. The magazine Working Woman, for example, targets a particular demographic group, while Newsweek aims at a far broader, more general public.Drawing a distinction between targeted and general audiences is an opportunity to comment on both the more sweeping, inclusive messages shaping sleepiness as a medical problem and the more specific messages written to appeal to discrete life-styles or life-stages. Circulation rates for periodicals are noted throughout the discussion. In addition to The Reader's Guide, the New York Times and the Washington Post, the papers of record in the US, were surveyed from 1980 to 2000. Like their counterparts, the popular magazines, before 1990 these signal papers reported only occasionally on the medical and social risks of sleepiness. From 1990, however, each paper printed a steady stream of news about drowsiness and chronic sleep problems.
Finally, sleep and sleepiness begin to appear on the Internet with predictable frequency in 1997 with the posting of the National Sleep Foundation website. Prior to this time, Internet messages on sleep and sleepiness were limited primarily to postings by researchers. Three popular search engines were examined for their sites on sleep: Ask Jeeves, Dogpile and Yahoo. Sampling from the WWW falls far short of a textbook exercise in a reliable selection strategy. Moreover, and as with print media, we do not know who, in fact, is accessing a website. What we do know is that this new medium is increasingly important in informing and shaping lay knowledge about health, illness, and treatments (see below). A total of 32 sites were examined for their various messages to general visitors. These sites appear on all three search engines.
Redescribing sleepiness: a new language game emerges
To redescribe a thing is to create new and opposing adjectives, adverbs and, occasionally, nouns that coalesce into a qualitatively different picture of it. Redescription becomes sociologically interesting when it changes the way people routinely see, think and behave towards themselves, others and the world. To redescribe buildings as sick, for example, as in sick-building syndrome, is a recent illustration of redescription (Bain et al. 1999). Sleepiness too is currently being redescribed. We can glimpse this change by juxtaposing the popular, common grammar of sleepy as an endearing bucolic and peaceful somatic state with the nascent grammar of sleepiness as an object of scientific and medical investigation.
The common vocabulary of sleepiness, the one most of us know and use, portrays it as a benign, wholesome, and welcomed somatic state. We routinely encounter this vocabulary in verse. Robert Frost brings a day of picking apples to a close. Tired, he is ‘done with apple-picking now. Essence of winter sleep is on the night, the scent of apples; I am drowsing off’ (2001: 76). Shakespeare also knew the poetic in sleepy. It was ‘The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course’ (Muir 1996: 189). Complementing literature and verse is the more popular genre of fairytales and contemporary children's books. Recall, for example, the lovable character Sleepy, one of seven dwarfs in Snow White, a fairytale originating in the 17th century.
A discernable change, however, is now occurring in the way sleepy and sleepiness are described in popular media. Alongside the time-honoured description of this somatic state as innocent and unaffected is an increasing chorus of voices redescribing it as a treacherous, perilous condition. These contemporary redescriptions are not apt to replace the historical meanings of these terms, but they will likely secure a place alongside them, creating a new language game for making sense of these temporal rhythms of the body.
A prelude: the print period from 1982 to 1983
The earliest examples of this emergent vocabulary in the US occur in 1982. Arguably, the point of departure for the redescription of sleep and sleepiness is the February 1982 issue of JAMA. The study found that 51 per cent of 3,900 patients surveyed reported suffering from ‘excessive daytime sleepiness’ (Coleman et al. 1982: 997). At the end of February, the popular magazine Science News (1983 circulation 173,156) ran a one-page story on the JAMA article entitled ‘A nation of sleepyheads’ (Weld 1983). Its lead paragraph is instructive:
If you only listened to television commercials, you might think Americans’ number one sleep problem was difficulty in falling asleep at night. But that isn’t true, a study reported by … the Journal of the American Medical Association reveals. The major difficulty is excessive daytime sleepiness, not insomnia (1983: 138).
The article continues, alerting readers to the study's major conclusion: ‘Fifty-one percent of the patients surveyed experienced excessive daytime sleepiness’ (1983: 138).
The language here is important for what it conveys about how popularising is accomplished. The figures cited in the JAMA article refer to people who present to doctors with sleep troubles. The title of the ScienceNews article, however, is ‘A nation of sleepy heads’, suggesting sleepiness is a pandemic problem, not something the JAMA article necessarily intended to convey. Nevertheless, by the mid-1990s, as we see below, national surveys of non-patients reveal a remarkable number of people reporting sleep troubles, particularly problems with sleepiness.
In August of 1982, six months after ‘Sleep-wake disorders based on polysomnographic diagnosis: a national comparative study’ appeared in the JAMA, Psychology Today (1983 circulation 85,000) published ‘The drowsy crowd’ further popularising and extending Coleman et al.'s research. The authors (Browman et al. 1982) acknowledged their debt to the JAMA article by introducing an alternative grammar that transforms sleepiness from benign repose to ‘hypersomnia,’‘excessive sleepiness,’ and ‘excessive daytime sleepiness’. This latter term is also referred to as ‘Pickwickian syndrome’, named after Dickens's character Joe who slept a good deal of each day at the most inappropriate times (Browman et al. 1982: 35). Drawing from the article in JAMA and their own clinical work, the authors note that excessive sleepiness as a medical problem is more prevalent than insomnia. Indeed, ‘We estimate that perhaps as much as 15 percent of the adult population suffers from excessive sleepiness’ (1982: 36), a condition that is ‘not only disabling but dangerous’ (1982: 35).
In October of 1982, eight months after the appearance of the JAMA study and two months after the article in Psychology Today, Business Week (1982 circulation 776,565) carried its first article on sleep problems (11 October). The article ‘Dealing with troubled sleep’ (Cochet 1982) uses short vignettes of business owners, Chief Executive Officers (CEOs) and managers who suffer from a host of sleep troubles. Featured in this article is the problem of ‘daytime sleepiness’. The majority of people who complain of sleep troubles report that their most significant problem is ‘excessive daytime sleepiness’ (Cochet 1982: 132).
In 1983, the US News and World Report (1983 circulation 2,050,000) ran a six-column story on sleep (Steinberg 1983) reminding readers that ‘daytime sleepiness’ might result in ‘loss of attention, frequent lapses in performance, (and) accidents . . .’ (1983: 68). Forbes magazine (1983 circulation 70,000) linked daytime sleepiness to car accidents in 1983, noting that sleepy executives might suffer from ‘Pickwickian syndrome’ (Love 1986: 156). The Washington Post ran its first article (Rovner 1984) on sleepiness in March of 1984, alerting adults to a faulty notion that should be put to rest, to wit, they require less sleep than children. Sleepiness, the article notes, is a growing ‘health problem’ in the US (30 March 1984). In short, popular print media were redescribing sleepiness, creating an alternative understanding of this cyclic somatic condition.
We might expect a substantial increase in the coverage on problem sleepiness immediately following the clutch of articles appearing in 1982 and 1983; the facts are otherwise. From 1984 through to 1990, only 12 articles listed in The Reader's Guide examine this particular issue, though sleep as a human interest topic, or the subject of verse or story, occasionally appear. The Washington Post did not print another article on sleepiness until 1990. The New York Times ran its first series of articles (totaling five) on problem sleepiness in 1990. Typical of these articles is the assessment that chronic sleepiness leads to ‘gravely impaired judgment and an increase in accidents’ (Wise 1990: 15 May Section C: 1). Why some health issues incubate longer than others before (if ever) achieving national attention is a question worth exploring, but we must leave it unanswered at this time and continue. The issue at hand is the marked increase in national coverage of problem sleepiness beginning in 1990.
The print period: 1990 to 2001
The Nation's Business (1989 circulation 850,000)ran a short, but telling piece in February 1990 on problem sleepiness (Schaefer 1990). Subtitled ‘Managing insomnia’, readers were alerted to the deterioration of ‘problem-solving and decision-making abilities’ that accompany acute daytime sleepiness (1990: 132). Fortune (1989 circulation 755,000) followed with a lengthy discussion of ‘The executive insomniac’ (Kiechel 1990). ‘[I]n any given year upwards of 50 million Americans have trouble sleeping’. Moreover, ‘go-getter Type A personalities suffer sleeplessness in disproportionate numbers’ (1990: 183).
Arguably, the most important vehicle for launching sleepiness into popular culture is a December 1990 cover story in Time, a magazine that circulated to 4,500,000 people in 1989. ‘Drowsy America’ (Toufexos and Dolan 1990) announced in unsparing terms the contemporary problems with sleepiness. It is ‘as threatening as a heart attack … Drowsiness [is] a leading cause of traffic fatalities and industrial accidents … Inadequate sleep [is] a major factor in human error’. Moreover, ‘[w]eariness corrodes civility and erases humor’. And finally – and, appropriately, considering this list of troubles—Dr. Charles Pollak, head of the sleep disorder center at Cornell University considers ‘sleepiness one of the least recognized sources of disability in our society’ (Toufexos and Dolan 1990: 79–81). ‘Millions of Americans are chronically sleep deprived’, the article continues. A quote from Dr. William Dement, director of Stanford University's sleep center explains: ‘Most Americans no longer know what it feels like to be fully alert. … They go through the day in a sort of twilight zone’ (1990: 80).
Time concludes its cover story on sleepiness with a strong normative message:
What is needed most of all … is a fundamental change in Americans’ thinking about the necessity of sleep. A difficult task, yes. But not impossible … Wake up, America—by getting more sleep (Toufexos and Dolan 1990: 81).
In all, 11 articles on daytime sleepiness were posted in The Reader's Guide in 1990 (see Figure 1). From 1990 through to 2000 the problem of sleepiness resounds through popular literatures. The Guide posts 224 citations on the many aspects of problem sleepiness during this 11-year period. A bar graph nicely illustrates the marked increase in coverage of this issue from 1990 to 2000.
In addition, from 1990 to 2000 the Washington Post published 46 articles on sleep disorders, the risks of drowsy drivers, and sleepiness and workplace performance. Seventeen of these articles discuss hypersomnia or excessive daytime sleepiness as a growing public health problem. The New York Times did not ignore sleep disorders and problem sleepiness after 1990, publishing 39 stories on these and related topics between 1990 and 2000. TheTimes, it is worth noting,devoted more space to editorials about the dangers of somnolent people than the Post.
Importantly, during this period the textual message that ‘excessive sleepiness is a public health problem’ is circulated in both general reader and targeted reader periodicals. The likelihood that problem sleepiness is effectively communicated as a public and personal health issue is increased to the extent that coverage occurs in both types of publications.
Interpreting general and targeted coverage
Imagine general reader coverage as a bass line of a music score and targeted reader coverage as the melody. Booming in a deep voice, for example, is the USA Today Magazine (1993 circulation 249,000) announcing its headline ‘The great American sleep debt’ (Williams 1993) to anyone in the general population. Or, US News and World Report (1993 circulation 4,500,000)declaring ‘Americans asleep at the wheel’ (Steinberg 1993) to its mass audience. In that same year a more subtle voice lilting above the boom of the general periodical targeted specific populations with similar messages. Tailored to its specific audiences, Working Woman (1993 circulation 560,000) profiled a woman suffering with excessive sleepiness in ‘Diary of a mad insomniac’ (Heller 1993) and Men's Health (1993 circulation 1,200,000) urged men to take sleep hygiene seriously in ‘Choose to snooze’ (Lafavore 1993).
This working relationship between the booming message to the general reader and the more tailored message to a select reader runs throughout this 10-year period. In 1994, for example, The New York Times Magazine (1994 circulation 1,700,000) published a feature piece entitled ‘America's falling asleep’ (Brody 1994). A sleep expert concludes on a dramatic note: ‘There is more sleepiness in more people more of the time than ever before, and the consequences of human error have never been more serious’ (1994: 65). Also in 1994, The Ladies Home Journal (1994 circulation 5,000,000) published a biographical sketch of ‘The exhausted woman’ (Hickey 1994), echoing the general message of the NY Times Magazine as it applies to the lives of career women. ‘Women’, it notes, ‘are increasingly disabled by chronic sleepiness’ (1994: 86).
The complementary voices of general and targeted texts (Figure 2) are working together to make excessive sleepiness a fragment of social consciousness with a modicum of authority over people's lives. Moreover, they help account for the noticeable gap between self-diagnosis with a sleep problem and physician-diagnosis and treatment.
The rhetorical authority of magazines and newspapers in the prosaic mental work of ordinary people is increasingly salient, due in part to the often contingent, fortuitous character of once solid institutional centres of control. The ‘problem of excessive daytime sleepiness’, it would appear, is emerging in print media as a personal and public health issue in spite of its general disregard by clinical medicine. But print media are only a part of the bibliography of textual authority on sleepiness. The World Wide Web is competing with if not surpassing, newspapers and magazines in organising conduct around the problem of sleep.
The web period and excessive daytime sleepiness: 1997–2002
In 1993, fewer than three per cent of American households were accessing the World Wide Web (WWW). By 2000, 42 per cent of American households were connected to the Web (US Census Bureau 2001). And the Web, it is safe to say, is awash with healthcare information. Cotten records estimates of health websites ranging from ‘10,000 … to close to 20,000’ (2001: 321). The considerable range in this estimate stems, in part, from the absence of anything like a Reader's Guide for the Internet. The sheer volume and protean character of the WWW precludes any reasonable attempt to catalogue its contents. Although a reliable and functional bibliography of web-based health and illness information is not possible at this time, a growing number of lay people are nevertheless accessing it for their personal use. Presaging this discussion, Cotten sites a recent article suggesting that Internet health and illness information is likely to challenge physicians’ control of the distribution and interpretation of medical knowledge (2001: 325).
Sleepiness is a frequent topic in at least one major news site: Cable Network News Interactive or CNN Interactive (CNNI) (http:www.cnn.com/HEALTH). From 1997 to 2000, CNNI and CNBC together posted at least 31 stories on problem sleepiness. As early as 1995, CNNI was posting occasional headlines like ‘Sleep problems are costly, dangerous’ (23 October) and reminding readers that ‘sleepy people are accidents waiting to happen’. Between 1995 and 1996, CNNI posted five articles on sleepiness. By 1997, however, sleepiness appeared with considerable regularity on the CNNI site with at least one account a month appearing on the ‘Health Story Page’ with titles like ‘Lack of sleep America's top health problem, doctors say’ (17 March). While it is difficult to pinpoint the exact number of websites dedicated to sleep problems, three popular search engines (Google, Ask Jeeves and Dogpile) found a total of 32 addresses (there are probably more) dedicated to sleepiness and its associated problems. Importantly, these sites provide continuous conduits between current research on sleep and sleepiness and the Internet public. The British Sleep Society, for example, seeks to improve public health by promoting education and research into sleep and its disorders (http://www.sleeping.org.uk). The Sleep Well, a website developed by the Stanford University Sleep Research Center, encourages visitors to search medical journals on-line for timely information on sleep problems (http:// www.stanford.edu/dement). ‘Sandman’, a digital librarian, ‘is trying to consolidate all the information available by [sleep] disorder to make it easier to find the information you are looking for’ (http://www.sleepnet.com).
But the Internet is doing more than consolidating information on problem sleepiness and reinforcing and complementing the authority of printed texts. It is also emphasising a particular way of making sense of daytime sleepiness. No longer just an unwelcome somatic state, daytime sleepiness is being transformed into a distinct medical disorder.
Excessive daytime sleepiness: from symptom to disorder
Type the word ‘sleepy’ or ‘sleepiness’ into any search engine and a majority of the ‘hits’ will portray this somatic state as some variation of ‘Excessive Daytime Sleepiness’. The National Sleep Foundation, for example, defines ‘Excessive Daytime Sleepiness [EDS][as] a condition in which an individual feels very drowsy during the day and has an overwhelming urge to fall asleep . . .’ (http://www.sleepfoundation.org). The Yahoo health web page defines EDS as a ‘significant sleep disorder and is different from fatigue’ (http://www.health.yahoo.com/). MeritCare Health System reminds visitors to its site that ‘excessive daytime sleepiness … can have serious consequences such as auto accidents … poor school performance … work-related accidents’ and more (www.//meritcare.com). The British Sleep Foundation Home Page reminds its viewers: ‘Drivers falling asleep at the wheel cause about 20% of major road accidents in Britain and these accidents result in a higher rate of death and serious injury as sleeping drivers don’t brake or swerve. These are avoidable deaths’ (http://www.britishsleepfoundation.org.uk).
It is reasonable to assume that the legitimacy of rhetorical authority is likely to increase by amplifying the moral valence of its textual lessons. Cephalon Pharmaceuticals devotes an entire site to EDS, defining it as ‘feeling drowsy and tired and having to sleep during the day … People with EDS frequently doze, nap, or fall asleep in situations where they need to be or want to be fully awake and alert’ (http://www.daytimesleep.org). Finally, EDS has made its way to at least one Internet bibliographic resource. Thinkquest defines it as a ‘disorder whereby the victim experiences drowsiness during the day and has an overwhelming urge to fall asleep. . . .’ (http://.library.thinkquest.org).
Clinically, excessive sleepiness is typically identified as a possible sign or symptom of narcolepsy or obstructive sleep apnoea, two sleep disorders with long histories. Someone with conspicuous daytime sleepiness might be examined to determine the presence of one or the other of these disorders (Mahowald 2001). The Internet, in collaboration with print media, however, is redescribing excessive daytime sleepiness as a separate, discrete pathology, cleaving it from narcolepsy and sleep apnoea and encouraging people to view it as a singular problem. Examine the several definitions of EDS offered above; not one of them refers to it as a symptom. It is discussed, rather, as a discrete medical issue. The National Sleep Foundation (NSF), for example, promotes excessive daytime sleepiness as a distinct pathology in several ways. ‘EDS’ is listed first among its catalogue of sleep disorders posted on its web page, standing alone as a singular pathology. Moreover it is not referred to as a ‘symptom’ of an underlying sleep disorder; it is described, rather, as ‘associated’ with other, more prominent, sleep disorders, particularly narcolepsy, but also sleep apnoea and restless leg syndrome, among others (http://www.sleepfoundation.org).
A telling piece of rhetorical evidence is also apparent in this shift to EDS as a unique pathology, to wit, the emergence of the acronym EDS. Shortcuts to the familiar, acronyms in medical nosology are used to denote diseases or syndromes (TB, AIDS, or CJD), not symptoms. Promoted to an acronym, excessive daytime sleepiness or ‘EDS’ assumes a more singular identity as a bona fide medical disorder. But there is more than a lingual shift at work here.
Dozens of websites on EDS now include a subjective, Likert measure of excessive sleepiness to self-test for EDS. The Daytime Sleepiness Test, also known as the Epworth Sleepiness Scale, is a subjective measure of relative states of sleepiness. Simple to administer and score, it is found on websites and publications of major sleep advocacy and research organisations, as well as pharmaceutical companies marketing sleep-related drugs (see web pages for The Stanford University Sleep Clinic, Cephalon, Inc. and the National Sleep Foundation). Even the cable news CNNI posted The Epworth Sleepiness Scale on its health page (http://www.cnn.com/HEALTH/indepth.health/sleeping. conditions/test). A scalar measure designed to be self-administered might easily assume a somatic reality against which a number becomes a meaningful piece of evidence about the relative presence or absence of a particular disorder. The disorder in question, of course, is excessive daytime sleepiness.
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.
In its ‘2001 “Sleep in America” Poll’, the National Sleep Foundation surveyed the sleep habits and experiences of a representative sample of adults in the US. Among its many suggestive conclusions is the sizable proportion of respondents who report experiencing excessive sleepiness during the day. Indeed, a total of 40 per cent of US adults apparently suffer from mild to severe EDS. Over half of this group (22%) report recurring symptoms of EDS from a ‘few days a week’ to ‘every day’ (NSF 2001: 84). Respondents were also asked to rank their Internet use from ‘Rarely/Never’ to ‘Heavy’. It is worth noting that 42 per cent of adults reporting ‘daytime sleepiness at least a few times a week’ made ‘Light’ to ‘Heavy’ use of the Internet (2001: 29).
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.
With a few exceptions, sociologists have ignored sleep and sleepiness. Little is known about dormant cultures and their various social arrangements. There are hints, however, that dormancy and soporific bodies are emerging as legitimate topics of social and cultural inquiry (Two recent examples are Kroll-Smith 2000 and Williams 2002).