My review article on health inequalities in this issue (Scambler 2012) benefitted early on from the helpful, detailed and occasionally critical comments of two of the anonymous referees approached by the editors of Sociology of Health and Illness; a third referee exercised his or her right to call forth a plague on all my doings. In other words this is a contentious field, and my inevitably selective representation and forthright ‘take’ on it was always likely to irritate as many or more than it appealed to. Better this, I thought, than yet another account nestling in that hinterland of social epidemiology in which many a sociologist now seems to dwell. It is immensely encouraging that Bill Cockerham and David Coburn (a) accepted the editors’ invitation to comment, and (b) are broadly sympathetic with the principal criterion I invoke for a genuinely sociological approach to health inequalities, namely, one rooted in social structures. This is not of course to imply that they are entirely at one with the case I make. I will respond here to the main points they raise, after which I will be a touch harsher on myself than I perceive them to be: it is perhaps a truism that authors are more aware of lacunae or weaknesses in their arguments than are those who comment on them with a mix of rigour and collegial compassion.
It is apparent from Cockerham’s opening paragraph and his prior publications that he is not enamoured of a neo-Marxist orientation to health inequalities: he is more drawn to Weber than to Marx (Cockerham 2007). But he is as concerned as I am over sociology’s apparent disinterest in ‘the effects of social structures on health and longevity’; and Weber, I suggest, tongue in cheek, owed more to Marx than is commonly acknowledged. Cockerham also draws attention to the salience of novel statistical techniques, like hierarchical linear modelling, to which I would enthusiastically add ‘qualitative comparative analysis’, a product of realism via complexity theory recently deployed by Blackman et al. (2011) (Scambler 2011b; see also Byrne 1998, 2002, 2011). In what we require of a sociology of health inequalities we are, I think, like-minded; any differences arise out of the theoretical resources we choose to mine.
Coburn is more open to neo-Marxist perspectives than Cockerham, unsurprisingly so. While he too agrees that ‘there are too few studies of the structural determinants of health and health inequalities’, he goes on to raise at least two issues of significance. First, he bemoans the fact that structural analysis ‘often stays at high levels of abstraction’; and second, he calls for more historical and comparative case studies. I strongly agree with him in both respects, and experience a twinge of discomfort in doing so. In the gap between C. Wright Mills’ (1963) two devils, grand theory and abstracted empiricism, something more than stand-alone, middle-range theory should be on offer. Cockerham and Coburn in their own contributions, and I more modestly in my review article, have so positioned ourselves as to help close this gap. Neither Cockerham nor Coburn directly address the – maybe overly abstract, relatively untested and certainly embryonic – theory contained in my paper; but there are challenges for me between the lines of their texts.
One challenge also confronts Coburn. I think neither he nor I have yet convincingly shown precisely why and how class relations are the causal progenitor, and in the process ‘underwrite’, the endlessly replicated statistical associations between socio-economic classifications (SECs) and health and longevity (Scambler 2010). Moreover in the UK and in many other developed countries, I suggest, Jones (2011) is spot on in his declaration that since the Thatcherite 1980s the class politics of the advantaged has ‘seen off’ the class politics of the disadvantaged: objectively, health inequalities are about class and ‘class struggle’, while subjectively, this no longer appears to be the case. Some sociologists too have erroneously inferred a reduced role for objective class relations from their reduced role in subjective perceptions of self and others, and have as a consequence taken their eye off the ball.
I have espoused ‘meta-reflection’ in medical sociology (Scambler 2010). This requires: (1) breathing space for thinking – times-out for reflecting on the ramifications of the dialectic of ever-accumulating theory and research; and (2) acknowledgement that nothing in sociology is or can be – as it seems to me is implicit in much positivist and epidemiological thinking –‘proven’, just argued convincingly and compellingly, as it were for the time being. Coburn and I think health inequalities have much to do with class politics and class struggle. Cockerham remains unconvinced. For my part I sense a need to buttress the case. My confidence in the assertion of a ‘new’ (post-1970s) ‘class/command dynamic’, the provocatively named ‘GBH’ and in concepts like that of ‘asset flows’, is reasonably high. But a lot more needs to be said on just how claims, hypotheses and concepts like these promise explanatory power for a neo-Marxist sociological theory of health inequalities with a reach beyond the developed nation-state. My own piecemeal contributions on health inequalities will self-evidently require many more deconstructions and reconstructions before they can convince as genuinely transnational.
This is crucially not just a matter of refining theoretical statements and concepts. Cockerham and Coburn both point to the need for a continuing dialectic of theory and research. Cockerham refers to Klinenberg’s (2002)‘sociological autopsy of a Chicago heat wave that killed several mostly elderly people’. It is a study that revealed the full range of macro-, meso- and micro-level factors or mechanisms that rendered older inhabitants ‘more susceptible to isolation and exposure to heat-related mortality’. It is a superbly apt example. Coburn in similar vein emphasises the significance of historical and comparative studies for a sociology of health inequalities. I could not agree more with these comments. What I would add is that time committed to meta-reflection, or the pulling together of already existing stocks of theories, concepts and investigations, has as yet been too parsimonious.
Finally, I echo Coburn’s appreciation of the work of Richard Wilkinson. It has attracted criticism from statisticians, epidemiologists and sociologists like Coburn and myself, and has more recently been caught up in class politics (Wilkinson and Pickett 2009); but it has reinvigorated the field and taken what can only too easily remain abstruse academic haggling into the public sphere of debate and protest.