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A rejoinder
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Blackwell
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26
2004
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BlackwellWilliams
ofto Hislop&and
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Beyond medicalization-healthicization?
A rejoinder to Hislop and Arber
Simon J. Williams
Department of Sociology, University of Warwick
requires further detailed sociological investigation before any hard and fast
conclusions can be reached. The jury, in the meantime, is still (in large part)
‘out’ on this count.
These problems are compounded when other key contentions such as
the ‘inner core’ of ‘personalised strategies’ unreflexively enter the debate.
Whilst I have considerable sympathy with what these authors are trying to
do here, particularly in resisting an over-drawn picture of medicalization-
healthicization to date, one is duty-bound to question the analytical status
or merits of any such reference to ‘inner core’, and compelled to ask just how
‘personalised’ these personalised strategies really are? Where indeed do we
draw the line? The unquestioning (i.e. face value) attitude toward what the
women surveyed have to say on these matters is also not without its problems,
particularly where sleep is concerned, raising important theoretical and meth-
odological questions alike, including the knowledgeability of agents and the
sociological status of their accounts, the relationship between the discursive,
the practical and the unconscious, not to mention the relationship between
subjective reports and objective measures of sleep time and quality. Refer-
ence to sleep as a ‘natural’ process, and discussion of the shift toward ‘hol-
istic’ approaches as (further) evidence of demedicalizing trends, is equally
problematic. For some authors, it should be remembered, the shift toward
holistic approaches, particularly those of a doctor-sponsored kind, has more
to do with remedicalization than demedicalization (Lowenberg and Davis
1994); a process, for Foucauldian scholars, which itself spawns new forms of
(self) surveillance and control (cf. Armstrong 1986). Healthicization, to be
sure, is another way of conceptualising these issues, but either way, more is
clearly at stake here than any plain and simple process of demedicalization.
We should not, moreover, lose sight of important similarities as well as
differences between biomedicine and holistic health, not least their shared
individualistic focus (Sharma 1996).
The upshot of the foregoing points is that we should be wary of hasty
claims and broad-brush generalisations about the (de)medicalization of
(women’s) sleep, both past and present, based on limited evidence to date.
The same goes for appeals to the notion of ‘personalised strategies’ as the
new ‘inner core’ or ‘pivotal axis’ in these debates. At the very least, a more
reflexive discussion of these issues, and more circumspect conclusions based
upon them, seem called for at this stage in the debate.
Let me muddy the water still further, however. If, as I have suggested, the
degree or extent of medicalization-healthicization regarding sleep is an open
question, and a complex if not contradictory affair at that, then it is well to
remember that lack of attention to sleep matters is a charge frequently
levelled against the medical profession, particularly doctors on the front-line
of medical practice. One study, for example, which set out to investigate the
pattern of medical student teaching about sleep and its disorders in the UK,
found the median total time devoted to these matters in undergraduate
teaching as a whole was five minutes (Stores and Crawford 1998). For
© Blackwell Publishing Ltd/Editorial Board 2004
456 Simon J. Williams
preclinical teaching this rose to a princely sum of 15 minutes, with a flat zero
recorded for clinical teaching. As in other countries, these authors con-
cluded, ‘undergraduate medical teaching is inadequate as a basis for the
development of competence in diagnosing and treating sleep disorders,
which are common and cause difficulties in all sections of the population’
(1998: 149). This deficit, moreover, as other studies have found, is not cor-
rected by later postgraduate training – see also Dement, a leading US sleep
expert, who is equally vociferous on this front, charging many doctors with
‘ignorance’ when it comes to sleep matters; ‘the worst sleep disorder of them
all’ in his view (2000: 9).
In working through the pros and cons of the medicalization-healthiciza-
tion of sleep, we also need to think very carefully about the role of the
media. Hislop and Arber, to be sure, touch on this at various points in the
paper, but this raises as many questions as it answers. The media indeed may
play a variety of roles here which take us far beyond the traditional para-
meters of (de)medicalization debates, reconfiguring their very terms of refer-
ence in the process: roles I am currently researching more fully. Kroll-Smith
(2003), for example, in a prescient piece, highlights the apparent contrast
between the density of popular texts on sleepiness in the US and the absence
of clinical attention to sleep disorders. The public, he argues, are increasingly
advised and informed by these ‘extra-local’, ‘textualised’ forms of know-
ledge and ‘rhetorical authority’ (i.e. authority cast in the rhetoric of medi-
cine); more porous forms of knowledge, that is to say, which not only occur
outside the traditional confines or institutional parameters of the doctor-
patient relationship, but may indeed bypass the physician altogether in
favour of other types of ‘doctors’ cum sleep specialists or medical researchers,
many of whom are PhDs not MDs (Kroll-Smith 2003) – see also Seale
(2002) on relations between medicine and the media. Kroll-Smith, in this
respect, flirts with a provocative idea, borrowed from the likes of Beck and
Bauman, that medicine is becoming something of a ‘zombie institution’
(both dead and alive), whereby past panoptical forms of control increasingly
rub shoulders with those of a more post-panoptical nature: a situation in
which the very terms of the medicalization-healthicization debate take on
important new (extra-medical) dimensions.
We should also ask at this point what precisely these ‘extra-local’ or
‘textual’ claims entail as far as proposed remedies for our sleep(iness) are
concerned. One distinct line of thinking here, for example, is less concerned
with increasing the quantity of our sleep time (to the normative ‘eight hours’)
than with improving its quality through a variety of ‘smart’ or ‘efficient’
sleep management strategies, tailored to individual needs, including the
merits of napping or micro-sleep: designer sleep for the designer age, one
might say. The possibility remains, moreover, returning to a point raised
in my previous paper (Williams 2002), that future ‘discoveries’ or ‘bio-tech
breakthroughs’ will provide the means or the option of further reducing, if
not eliminating, our need for sleep altogether (cf. Melbin 1989): the realm
© Blackwell Publishing Ltd/Editorial Board 2004
A rejoinder to Hislop and Arber 457
of science fiction one might think, yet these developments are already under-
way given breakthroughs in the treatment of narcolepsy which themselves
have helped ‘unlock’ the secrets of sleep. This, to be sure, would not appeal
to us all, or perhaps more correctly to us all of the time, given that sleep is
a valued ‘release’ or legitimate ‘escape’ from the social demands of the con-
scious waking world (cf. Schwartz 1970). It could nonetheless catch on, for
better or worse, in an era where yesterday’s impossibilities become today’s
possibilities.
If we really wish to sort out what precisely is or isn’t new about the
current situation as far as sleep is concerned, however, we should also
look to the past as well as the present or future. Claims concerning the
medicalization /healthicization of sleep today, in other words, need setting
in their proper historical context. Certainly, it is possible to point toward
something like the beginnings/precursors of a medicalization of sleep, or
certain aspects of it, in the late 18th and early 19th centuries, particularly
through Lavoisier’s contributions to medicine and public health, where pre-
cise biological norms regarding the respiratory actions and capacities of sleep-
ing bodies were laid down and quite literally incorporated into the spatial
dimensions of various buildings (Duveen and Klickstein 1955, Crook 2002).
In almost all Victorian public health manuals and lectures, moreover, you
find reference to sleep (Crook 2002). The links between sleep, health and
hygiene can also be traced at least as far back as the Renaissance through
various published sources and popular texts (Dannenfeldt 2000). The
‘problems’ associated with sleep have undoubtedly changed over time, in
keeping with different knowledge bases and ‘remedies’ offered – particu-
larly since the advent of so-called ‘sleep science’ in the 1950s/1960s (as
witnessed, for example, through the ‘discovery’ of REM in 1953), and its
‘translation’ into the principles and practice of ‘sleep medicine’ (cf. Kryger
et al. 2000) – but the fact that important historical precedents/precursors
of this kind can be found suggests the need for further study, if not quali-
fications, to our present-day claims about the medicalization-healthicization
of sleep.
It is not simply a question of the medicalization-healthicization of sleep
though, nor of broader processes of commercialisation or commodifica-
tion, important as they are – commercialisation, in fact, may have outpaced
medicalization to date, although the two may increasingly ride in tandem.
If indeed we are to take Hislop and Arber’s invitation to go ‘beyond’
medicalization-healthicization seriously, I wonder in fact whether we should
also be looking at (possible/potential/prospective?) processes of what, for
want of a better word, one might term ‘sleepicisation’: processes, that is to
say, which extend far beyond the realm of health to a variety of other social
problems and issues, both now and in the future. From concerns over poor
performance at school or work, to accidents on the roads and other well-
publicised tragedies such as the Exxon Valdez oil spill, the Chernobyl nuclear
catastrophe and the Challenger space shuttle disaster (Coren 1997), sleep (or
© Blackwell Publishing Ltd/Editorial Board 2004
458 Simon J. Williams
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