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Book Review
Health sociology: An Australian perspective and Health in Australia: Sociological concepts and issues[3rd Edition]
David Gray and Carol Grbich(ed)
ISBN: 1-741032-36-9 / 1-740910-97-4 2006 PB 312 pp / PB 348 pages Frenchs Forest: Pearson Education Australia
Kevin Dew
Wellington School of Medicine and Health Sciences, University of Otago, New Zealand
Writing a textbook on the sociology of health for sociology students and health practitioners requires a delicate balance of competing priorities, and we should not underestimate the difficulty of this task. On the one hand the writing needs to be as accessible as possible to an audience which includes readers unfamiliar with most sociological concepts; and on the other, it must convey the insights and even excitement of the sociological intellectual enterprise. These two texts from David Gray and Carol Grbich tackle this task in slightly different ways. Gray attempts to provide a consistent framework for each chapter, covering sociological approaches to the topic under discussion, and illustrating those approaches with different examples. Grbich's text is an edited collection with 14 authors, so each chapter has a different balance: some largely accessible and descriptive, and others more theoretically driven and challenging.
David Gray's book is targeted at both sociology students and a health care audience interested in sociology. It is organised into three broad sections: introduction; the social experience of health, illness and disability; and the social organisation and production of health. Each chapter starts with a scene-setting description of the topic and then focuses on a few well-worked theoretical examples to illustrate the issues raised, which allows for some continuity between chapters and some depth in the analysis. To illustrate, the sociology of the body is explored through the different perspectives of structuration theory, social constructionism and phenomenology. The book opens with a paradox: increasing levels of 'health' and improved access to services and treatment have been accompanied by decreasing public satisfaction with medicine. This seems to be as good a conundrum as any to set the scene for a sociological orientation to health and illness. Gray positions sociology as a discipline which uses concepts (class, gender etc.) to understand the patterning of health experience, that takes a critical perspective to social arrangements, and has a different understanding of health and illness to biomedicine's. Although he appears comfortable with a range of perspectives, at times Gray falls into a positivist framing, suggesting for example that epidemiological studies uncover the 'true' prevalence of disorders, apparently untouched by Jack Douglas's insights that 'disembodied numbers ... are based on the most subjective of all possible forms of activity' (cited in Downes and Rock 1995:232). That is, prevalence rates are not self-evident and true pictures of reality, but constructed out of styles of reasoning, documentary records, scientific reasoning, lay reasoning and so on.
Gray's book covers a range of topics thoroughly and in an even-handed way: though perhaps lacking in the passion some of us would like to see. Some chapters work better than others in making the links to sociological theory, while some are more descriptive. As with any text of this nature, statements and phrasings will be found that will jar with some readers. For example, Gray claims Parsons produced the first major theoretical contribution to the understanding of health and illness. Even a sociological contribution would have to go back to Durkheim's analyses in Suicide at least. A more significant example occurs in the discussion of suicide in the Aboriginal population where Gray cites the work of Tatz as identifying causes such as 'poor parenting' and 'alcohol and drug use' (p. 176). In other words, proximal causes are noted but structural causes and the historical impact of colonialism are not mentioned in this section. Not that Gray fails to mention these issues elsewhere: a very nuanced discussion occurs later (on p. 281), but the uninformed reader may misread Gray's intention and read the Tatz commentary as justification for blaming the victims.
Although the Grbich text (this is the third edition) is explicitly targeted at health professionals rather than sociology students, this collection tends to place a greater emphasis on the sociological critique of medicine. This perspective is established in the opening paragraph where Grbich refers to the 'deification' of medicine. The rest of the text is divided into three parts headed: social process, social patterns and social relationships. Readers will have their own favourites from the various chapters. I particularly enjoyed the more theoretically articulate chapters such as White's pacy chapter on the social origins of illness. Collyer's chapter on medical technology has been given space for an involved theoretical discussion and could be useful for postgraduate students in the area. And because it is my particular area of interest I enjoyed Easthope's overview of alternative medicine and his analysis of its rising popularity. Most chapters are well organised and informative, although there is great variation in the tone. Julian provides a very powerful description of migrant health, particularly in relation to the plight of refugees. Anderson's discussion of Aboriginal health offers a personal account of his interest in the topic, and also implies (though does not elaborate) a critique of sociological analyses. Clark and McCann's contribution on aging had an occasionally paternalistic tone (e.g. health workers 'should not be embarrassed to discuss the issue' of sexuality with older clients). McWilliam's chapter on examining the body consists mainly of very lightly interpreted transcript material from an interview with one health practitioner and struck me as overly focussed for a text book.
Both books suffer from some quite banal critiques of different theoretical positions at times, and Marxist orientations suffer particularly badly in this regard. For example, Gray critiques Marxist analyses on the basis of the poor health status found in some state socialist societies. I would suggest that critiquing Marxist concepts on the basis of what has happened in state socialist societies in a world dominated by capitalism is poorly directed. Grbich objects to Marxist analyses because consumers have brought about improvements in health. It is difficult to know where to start to rebut such a critique, as it seems so marginal to Marxist analyses. This in itself is not so important, but the quick dismissal of Marxist analyses would lead students to see Marxism as irrelevant and not requiring serious engagement. I find this particularly unfortunate in the area of health, especially when confronting a global environment of increasing health inequalities between rich and poor nations. The Grbich text is partly saved by the inclusion of some authors who do take Marxist critiques seriously.
There is considerable overlap in the content of the two books reviewed here. Both provide glossaries and sets of tutorial questions at the end of each chapter. In the Grbich text, each section has very different tutorial exercises, with some quite standard discussion points and others suggesting role-play. However, there are differences. Gray includes a chapter on the Australian health care system and there is no equivalent in the Grbich text. There is more focus on relations between occupations in the Grbich collection with section three (containing five chapters) focused on this topic. The framing of the topics is different, with Grbich having separate chapters on Aboriginal health, class and health, gender and health; and Gray bringing these together in a chapter on inequalities. It was pleasing to see that Zadoroznyj's chapter on gender and health incorporated a measured discussion of men's health (in contrast to the solution suggested to me in a public health forum discussion of gender and health where men's lower life expectancy could simply be redressed through the use of castration!)
Reflecting on these texts can allow us to consider the state of play of contemporary sociology of health and illness. Both have omissions, some of which are surprising, while some reflect the interests and methodologies of contemporary Australian sociology of health. For example, the discussion of mental health by Hazleton in the Grbich collection makes no mention of Foucault or Scheff. There is little in either book which draws on empirical work influenced by ethnomethodological, actor-network or interactionist perspectives (although Gray does discuss the theory of symbolic inteactionism). We can see an increasing framing of sociology of health in terms of a sociology of the body, and the dominant influence of critical theory, interpretive and postmodernist approaches. Perhaps more clearly demonstrated is the variety of theoretical perspectives available to students when considering the array of topics that come under the rubric of sociology of health and illness.
These two books have dealt with the difficult task of presenting sociological understandings to a wide audience in different ways and overall, quite successfully. It is not an easy assignment getting the right balance of ingredients in sociology textbooks. Gray's text can perhaps be compared to a rich casserole where no particular flavour dominates, and Grbich to a mixed mezze with its variety of distinctive flavours, some sharper than others. Either way, both offer something of a feast of sociological insights.
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