By EmilyHansen and GaryEasthope . Published by Routledge , UK , 2007 . Paperback, 192 pages with index . ISBN 978 0 415 35685 5 .
Reviewed by John FurlerDepartment of General Practice, University of Melbourne, Victoria
I used to smoke cigarettes, but don’t anymore. More than 20 years ago, working in the United Kingdom in a hospital in the north of England, between patients and lying in the on-call room, I read Lesley Doyal's passionately argued expose of the political underpinnings of health and illness.1 Young and impressionable, I stopped smoking immediately (although like a lot of smokers, it took me several attempts to finally change my lifestyle) as the book crystallised for me just what a politically naïve and complicit act smoking was. Capitalism had me by the throat and I wasn’t going to stand for it. The personal and the political burnt themselves into my psyche in a way that I have never forgotten. I approached this book on lifestyle in medicine with great anticipation, having maintained an intense interest in the link between the micro and the macro in my life as a general practitioner and primary care researcher.
Emily Hansen and Gary Easthope previously collaborated as PhD scholar and supervisor respectively, but have moved on to life as sociological co-authors and academic colleagues. Nevertheless, this book draws primarily on work undertaken in their former roles. The book is largely structured as an exploratory and comparative piece in which notions of lifestyle, drawing on a sociological and a medical framework, are contrasted using both literature and empirical data. There are chapters covering lifestyle as a medical explanatory model, sociological and medical conceptions of lifestyle and assumptions underlying the medical approach to lifestyle. A further two chapters are primarily based on empirical data collected as a part of Hansen's doctoral studies. The field work includes both textual analyses and interviews with and observations of medical practitioners and, interestingly, includes data from consultations with doctors undertaken by Hansen herself. The book concludes with a ‘reflections’ chapter. The book covers enormous ground in its 150 pages. Lifestyle is indeed a pervasive notion and has come to mean many things in many different contexts, making it difficult to set limits to the work. Critiques of biomedicine from a number of traditions are touched upon. The limited evidence linking lifestyle factors and disease is reviewed, as is that between lifestyle interventions at both the structural and individual level and health outcomes. Domains of epidemiology, risk factor epidemiology, risk factor health promotion, social epidemiology, public health and new public health are all invoked and limitations of the way they handle the notion of lifestyle are described.
Hansen and Easthope argue that the notion of lifestyle has become pervasive in all of these medical fields while remaining poorly defined and understood. This leads in practice to rather flexible and diffuse understandings that are framed on the one hand by sociologists, occupying the broad social determinants terrain, and on the other hand by ‘real’ people out there in society (lay people to us). While broadening understanding of disease and illness to include ‘social’ factors (more of that later) has been championed by social scientists, progressives within medical spheres, and the community at times, Hansen and Easthope argue that in practice this broadening has largely served to bolster medical power and dominance and to reproduce powerful notions of individualism. What is good about this book for me is that it reminds me of the difficulty (? impossibility) of living outside of such a dominant discourse. Like the frog nestling quietly in a slowly heating pot of water while the temperature rises to lethal levels around it, medicine as an institution and doctors as individuals ceaselessly and subconsciously adapt to and recreate the broad political and cultural currents around them, not always in a useful and functional way. The flexible and adaptive way in which the notion of lifestyle is used within all these medical camps (particularly by the practitioners spoken to in the field work) is a reflection of the ongoing and deeply politically infused nature of health and illness.
The book also illustrates well the difficulties in terminology in making an extremely complex area of study accessible to a wide range of people. This study of the relationship between notions of ‘social’ and disease and illness is plagued by lack of clarity in the way terms are used, which does not help in making critiques clear. The discussion of lifestyle at times becomes entangled in the way the term ‘social’ is used variously to refer to behaviours such as smoking, interactional processes between individuals and groups, structural groupings in society with different access to resources and power, and finally the broad structural and material conditions of existence.
The book retains strong links with its previous life as a thesis, which occasionally causes some difficulties for the reader. As mentioned, it seems over-inclusive at times and has a tendency to over-reference works in the text (there is an enormously long list of references for a book of this size that may be a valuable resource to some readers). On the other hand, I would have liked more detail on the interview schedules, which would have helped me to put the empirical data in context and lend weight to the conclusions drawn from it.
In the end, I felt I wanted a stronger statement about the political perspective of the authors. This is a politically embedded debate and we need to know from what perspective the authors argue. It meant that the conclusion – that cross-disciplinary research (which gives greater weight to sociological perspectives than is allowed at the moment) is needed to understand this complex area better – was left hanging, with a feeling that more could have been made from this. Nevertheless, the book provides a broad-ranging coverage and overview of this fascinating topic.