Gender, Ethnicity and Class (and Its Proxies)
There is no doubting the causal impact of gender and race or ethnicity on health and
health care. They are clearly implicated in the production and reproduction of health
inequalities, and they no less clearly antedate the class-based stratification system
of capitalism through all its phases. But, I contend, it is class that is of stand-out
importance for a sociology of health inequalities. Sayer (2015, p. 170) explains why
this is:
“While gender and race inequalities are produced primarily by sexism and racism, class
differences would persist even if the upper and middle classes were nice and respectful
to the working class. The unequal distribution of property and the unequal division
of labor would be largely unaffected. Class prejudice is common, but it's more a ‘response
to' economic inequalities than a cause of them. By contrast, the enduring of sexism
and racism would have a major impact on gender and race relations.”
He continues:
“Neoliberals – New Labor for example – can appear quite progressive about gender,
race, sexuality, disability and condemn those who discriminate against people on these
grounds. Unsurprisingly, the elephant in the room is economic inequalities or class
difference. Though it never admits it, neoliberalism is a political-economic movement
that seeks to legitimize widening economic inequalities and defend rentier interests
above all others. Rentiers can live off others regardless of their gender, race, sexuality
and so on.”
Class has lost a degree of its salience for identity-formation in the individualized,
“liquid” or relativized culture of contemporary financial capitalism, but it has lost
none of its structural force. If it has a reduced impact “subjectively”, it has, I
contend, enhanced its impact “objectively”.
With regard to health inequalities, the measures of class that have been deployed
have been parsimonious proxies for the concepts familiar from classical sociology:
Marx has all but disappeared and Weber has been tailored primarily to the study of
trends in social mobility via Goldthorpe and his colleagues. I draw four conclusions
from this. First, it seems apparent enough that the proxies or class routinely used
to uncover, track and account for health inequalities, namely, the Registrar General's
(RG) Classification of Occupations and the National Statistics Socio-Economic Classification
(NS-SEC), substitute, respectively, occupational prestige and job characteristics
for class as a social structure or relation (Bartley, 2017). The findings from this
considerable array of investigations consistently reveal that the higher the likes
of the prestige/rewards/security/authority/autonomy of people's jobs the better their
chances of sustained good health and longevity. Marmot Review (2010) has even claimed,
more controversially, that there is a discernible “social gradient” such that as employment
grades increase, so too do the people's health prospects.
Second, it can nevertheless be inferred (in critical realist terminology, “retroduced”)
from the findings of studies using these proxies that class as a pivotal and enduring
structure or relation must exist for studies using the RG or NS-SEC classifications
to deliver the findings they have long done and continue to do.
Third, to resort to class proxies like the RG and NS-SEC is to exclude the empirical
consideration of class as a social structure or relation. More specifically—a hugely
significant point in my view—it “absents” any possibility of investigating the putative
causal salience of what has conventionally been seen as the “ruling class”, namely,
that fraction of the top 1% that wields enormous and overriding social and political
power (Scambler and Scambler, 2015). The 1% is swallowed alive and disappears from
view and analysis in the RG and NS-SEC. As Coburn (2009, p. 44) has emphasized, the
authors of extant investigations “seldom go far enough up the causal chain to confront
the class forces and class struggles that are ultimately determinant.” I think this
is an understatement and I shall focus later on the causally pivotal role of those
capital monopolists comprising a tiny fraction of what Clement and Myles (1997) called
the “capitalist executive” in the production and reproduction of health inequalities
(see Scambler, 2018).
Fourth, I fully acknowledge that there are horses for courses. In other words, the
NS-SEC, scrupulously derived from Weberian theory by Goldthorpe, is helpful, apt and
functional for the study of changes in social mobility over time (see the excellent
Budoki and Goldthorpe, 2019). But what it gives to sociology with one hand it takes
away with the other.
The Class/Command Dynamic
I have maintained elsewhere, first, that objective class relations are more not less
potent in post-1970s financial capitalism than in the postwar welfare-state capitalism
that preceded it; and second, that the capitalist executive in general, and the fragment
of hard-core capitalist monopolists—those few major shareholders, rentiers, and CEOs—“players”—in
our newly exacerbated global or transnational capitalist arena—in particular, have
bought more policies from the state's power elite than was possible hitherto. The
historian Landes (1998) has written that those with wealth have always bought those
with power; and I maintain that they get more for their money in financial capitalism
than they did in the postwar era. The rationale for capitalizing—an apt word—on this
newfound purchasing power? The hard-core capital monopolists are, in Habermasian terms,
totally, ineluctably “strategic”: they privilege accumulating capital to their personal
advantage above all else. They are, as I have spelled out elsewhere, “focused autonomous
reflexives” (Scambler, 2012). The bottom line, empirically, is that they have been
able to purchase a greater range of policies favoring their own personal and familial
accumulation of capital than hitherto, hence my reference to a novel class/command
dynamic. This is critical not only for the deepening of wealth, income and—in their
wake—health inequalities, but also for the ongoing dismantling of our NHS. Predictably,
women, the dis-abled, the long-term sick and vulnerable, and those comprising class-disadvantaged
segments of ethnic/racial minorities have suffered most.
This requires some elaboration. The main political plank of neoliberal ideology in
the UK has been “austerity”. This discourse has provided cover for a sustained attack
on working-class interests and well-being that has significantly enriched the capitalist
executive in general and the—now super-rich—capital monopolists in particular. Other
principal beneficiaries include those working for and with the capitalist executive
and the power elite of the state. I have elsewhere defined the UK's “governing oligarchy”
(though some, like Sayer, prefer the term “plutocracy”) as consisting of the hard-core
of the transnational capitalist executive plus the nation-state's power elite (Scambler,
2018).
Working-class health and longevity has been measurably damaged by the strangulation
of those capital or “asset flows” known to be conducive to good health. These can
be summarized as follows:
Biological (or body) assets can be affected by class relations even prior to birth.
Low-income families, for example, are more likely to produce babies of low birthweight;
and low birthweight babies carry an increased risk of chronic disease in childhood,
possibly in part through biological programming;
Psychological assets yield a generalized capacity to cope, extending to what is increasingly
conceptualized as “resilience.” In many ways the “vulnerability factors” that Brown
and Harris (1978) found reduced working-class women's capacity to cope with life-events
salient for clinical depression are class-induced interruptions to the flow of psychological
assets;
Social assets have come to assume pride of place in many accounts of health inequalities
and feature strongly in the work of Marmot and Wilkinson. The terms social assets
or “social capital” refer to aspects of social integration, networks, and support.
The political use to which social capital is sometimes put should not lead to its
neglect;
Cultural assets or “cultural capital” are initially generated through processes of
primary socialization and go on to encompass formal educational opportunities and
attainment. Class-related early arrests to the flow of cultural assets can have long-term
ramifications for employment, income levels, and therefore health;
Spatial assets have been shown to be significant for health by area-based studies.
These have documented that areas of high mortality tend to be areas‘ with high rates
of net out-migration; and it tends to be the better qualified and more affluent who
exercise the option to move;
Symbolic assets, representing the variable distribution of social status or “honor”,
are known to impact on health via people's (sense of) social position, especially
relative to those others who comprise their reference groups;
Material assets refer to “relative deprivation” due to impoverishment and meager standard
of living. The relevance of material assets for health and longevity has long been
stressed, although the mechanisms linking low income with health remain much debated.
The process is as follows: concomitant with the enhanced class-driven character of
government policy are a series of shifts of direction, such as part-time, transitory
and insecure employment, extending to zero hours contracts; deteriorating workers'
rights and conditions; the sidelining of trade unions; the ending of final salary
pension schemes and the increase in the age of retirement; benefit cuts, culminating
in the rolling out of Universal Credit; the defunding of local government services
and, to an extreme degree, social care; NHS cuts and privatization; and so on.
The net effect of this targeted action against the welfare state and the working class,
carried out under the aegis of austerity and a political rather than economic choice,
is to severely reduce the flows of health-related assets for many people. Although
there can be compensation between asset flows—a strong flow of social assets can for
example mitigate the negative effects of a reduction in the flow of material assets
following a job loss—the research suggests that reductions tend to cluster across
flows, and also that reduced flows at critical junctures of the lifecourse, like childhood,
can have severe deleterious and long-term effects. So there is an empirically traceable
causal chain stretching from the boardroom decisions of big bosses and shareholders
through elite career-oriented politicians to the bodies and minds of the most disadvantaged
and vulnerable citizenry.
Is Sociology Being “Tamed?”
I have built on Burawoy's (2005) explication of “four sociologies” by appending a
further two. The resulting six sociologies are outlined here, together with ideal
types of theory and of practitioner:
Professional sociology—scholar—cumulative theory
Policy sociology—reformer—utilitarian theory
Critical sociology—radical—meta-theory
Public sociology—democrat—communicative theory
Foresight sociology b- visionary—speculative theory
Action sociology—activist—strategic theory
It is in my view the responsibility of the community of sociologists as a whole to
ensure that all six bases are covered, not that every sociologist should attempt all
six. I will focus here on the import of foresight and action sociology for any consideration
of health inequalities. Foresight sociology develops speculative theory (i.e., anticipates
“alternative futures,” whether societal or institution-based) and is practiced by
visionaries. Action sociology deploys strategic theory (i.e., is oriented to accomplishing
change) and is conducted by activists. In the most general terms, sociologists as
visionaries might focus on concrete ways in which what are commonly called “social
determinants” of health and disease and of their unequal distributions might be so
amended, rejigged, or subverted as to ensure greater equality of opportunity and outcome.
Sociologists as activists would represent theories and research emanating from the
scholars of professional sociology and the reformists of policy sociology in civil
society and the public sphere of the lifeworld, and go on to engage with and contest
the dirty politics of their neglect and ideological dismissal often conducted through
the medium of right-wing think tanks unwilling to identity their sponsors.
To fail to convert professional, policy and critical sociology—via public sociology—into
foresight and action sociology is to my mind to acquiesce, qua community, in the taming
of the discipline. In my Sociology, Health, and the Fractured Society I illustrate
further ways in which sociology can, and in my view is, being tamed (Scambler, 2018).
I also offer sets of interrogations of population health and health inequalities pertinent
to each of my six sociologies. Toward the end of this short piece I proffer another
quartet of themes I think it interesting and important to pursue.
With regard to sociology's putative taming, how does the availability of funding for
health inequalities research break down by issue and focus?
Precisely how, and how convincingly, does research into “class and health” via proxy
measurements of class like the RG and NS-SEC warrant retroductive (or more rarely
in qualitative research abductive) inference to the “reality” of class as a structure
or relation impacting as a pivotal causal mechanism for sociological explanations
of health inequalities?
Does the extant body of (largely positivistic) research purporting to address the
linkage between class and health—but in fact “absenting” class as a structure/relation—in
effect function as a “protective belt” around financial capitalism's justificatory
neoliberal ideology by absorbing or deflecting attention from what should be sociology's
true and enduring point of departure toward subsidiary concerns?
How, figuration by figuration, or context by context, does class as defined in this
short paper fare as a causal mechanism salient for health inequalities in comparison
with those of gender and ethnicity/race? While I make a case here for class as prepotent
in the figuration/context of a British nation state precariously lodged in a capitalist
world system, its causal power, as intersectionalists rightly insist, is obviously
far from ubiquitous.
I was a fortunate babyboomer with a degree of latitude to negotiate “free time” to
ask personal and inconvenient—that is, genuinely sociological—questions. Equivalent
negotiations have indubitably grown tougher. But: (a) it actually wasn't quite as
easy for us babyboomers as is often somewhat ritualistically assumed, and (b) it remains
crucial that we, the sociological community, as a whole, and as individual members
of that community, hold our nerve and ground (Scambler, 1996).
Author Contributions
The author confirms being the sole contributor of this work and has approved it for
publication.
Conflict of Interest Statement
The author declares that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.