by Nick Fox
Free Association Press, 1999
Review by Gavin Hougham, M.A., Ph.D. (c) on Jun 30th 2000
Beyond Health: Essays on Control, Resistance and Renewal is Nick Fox's latest book in a long-running project to bring the ideas, insights, and method of postmodernism to the realm of health and illness. I say "method" but use the term with some caution because the postmodern program is so methodologically catholic, and so is suspicious of the Enlightenment elevation of scientific reductionist method as the path towards truth. Fox provides a practiced exemplar of postmodern analysis of health and illness phenomena and this book is a good example of how it is done.
This book defies easy categorization, but Fox defines his project in the current volume as nomadic in spirit, roaming the intellectual landscape (and actual global geography -- Thailand and Australia) in search of ways to apprehend and move beyond what he thinks are the strictures of "modern" views of health and illness grounded in rationality, hierarchy, history, and most of all, biology. He aspires to escape notions of embodiment (the organism as substructure, or as holding or containing the social) so narrowly defined by modern medicine, but also widely held by social sciences born of modernity: economics, sociology, psychology.
Fox's first book, The Social Meaning of Surgery (1992), was a transitional attempt to bring the apparatus of postmodern criticism and theory to the very heart of biomedicine: the surgical operating suite. That report on the uses of power, authority, routine, discourse, movement and structure was followed shortly by Postmodernism, Sociology and Health (1993), a theoretical "critique of sociology's modernism." Beyond Health was supposed to be a sequel to Postmodernism, but Fox avers that it can stand alone as applied post-modern criticism, not mere "navel-gazing."
Fox is senior lecturer in sociology at the University of Sheffield (England), where he teaches and conducts mostly ethnographic and observational research. He describes himself as "principally a social theorist," so readers of Beyond Health should be prepared to wrestle with notoriously difficult ideas in service of his goal to help move the theory and praxis of health and culture -- currently grounded (he might say land-locked) in modern, realist, and so-called essentialist ontologies -- towards an emancipatory and almost libertarian future of uncertain structure. Yet, this is supposed to be "a practical guide, not a book of theory," so Fox takes the time to develop many examples to illustrate his points. One chapter, for example, discusses how hospital discharge decisions are a multi-voiced struggle between patients, families, and physicians to assert autonomy, authority, and power over what we usually think of as a straightforward issue: one leaves the hospital when one is well. Fox brings us to bedside intimacy with these actors through rich and telling dialogue excerpts from his field notes. But how practical is this?
If the reader is happy with a practical guide written in metaphor, abstraction, and the abstruse challenges of contemporary psychoanalytic and social theory, then this will be a good read. Although Fox is a careful writer, I find him elliptical; his concepts are always fuzzy and conditional. He does define some jargon (e.g., "BwO, the Body-without-Organs") in a short glossary but this hardly helps matters where neologisms are unnecessary to the argument. Maybe that's the modernist in me talking. For Fox and others working in this tradition, "argument" is somewhat anachronistic.
This kind of work is perhaps best thought of as immersion therapy, perceptual poetry, travel diary, nomadic observations, and so on. It is a "witches ride" through topics in medical sociology that all sound familiar to us (power in the surgical theater, time frames and rhythm in the hospital, the caregiver experience, risk management and occupational safety) but as Fox admits, or perhaps laments, in his opening pages, it is hard to get "there" (i.e., to a postmodern understanding of these topics in health and illness) from "here" (modern understandings and framings grounded in observation, surveillance, logic, rationality, causality, argument, and all the other trappings of control). Getting there almost takes a leap of faith or a trip through the looking glass, for reading work of this kind is unlike reading most analytical monographs. Fox gently pushes the reader to see the familiar as unfamiliar.
Some might argue that Fox is repetitive in his foundations, mostly a few seminal pieces by philosophers Gilles Deleuze and Félix Guattari, but this is not a criticism; it is more like a fun homework assignment. Beyond Health motivated me to look at some of this work, and reading through Deleuze's Spinoza: Practical Philosophy proved a key insight into Fox's métier. Fox is clearly an acolyte in the Spinoza/Deleuze school of social criticism, and those familiar with Deleuze's final work, Essays Critical and Clinical, will find Fox's turn at problematizing the concept of health -- and indeed of inventing new concepts ("profound symptomatology") -- very familiar terrain. As the painter goes beyond the present to invent (a painting) with a familiar set of symbols, materials, and vocabulary steeped in the visual, so too does the successful social theorist invent (concepts) that sound familiar, but on inspection go beyond our understandings and framings of existing concepts. Beyond Health is really an exercise in challenging our understandings of health (illness, embodiment, caring) and in suggesting some ways in which we might reconceptualize those understandings in ways that are not grounded in existing (pathological) social structures and culture.
Beyond Health is an interesting journey with a self-described nomad, and for nomads the journey is not merely a means to an end, but the end itself. We discover new vistas and hidden valleys with every step, yet even as the terrain reveals, we imprint and change the landscape with every step. Although some may be frustrated by this almost ecological approach to social analysis, others with more patience may find the exercise therapeutic and informative, dare I say, emancipatory, for that is one of the goals of this kind of work. It seeks in part to free us from dualist framings (health vs. illness), hegemonic viewpoints (the clinical gaze, physician-centered paternalism), and realist constructions (health is biology) of the world in which we both find ourselves part of, and in turn help construct. I wish there was an easier way to get there from here, but readers who embark on Fox's journey will be amply rewarded.Gavin Hougham is a medical sociologist with experience in public health, gerontology, geriatrics, medical ethics, health services research, and cross-cultural (Japanese) research. He is currently Project Director in General Internal Medicine at the University of Chicago Medical Center, where he directs grant-funded socio-medical research. He has published on research ethics, informed consent, physician assisted suicide, and has recently taught Advanced Seminar in Data Analysis, Social Science Research Methods, Survey of Social Science, Medical Sociology, Sociology of Health Organizations, Sociology of Health and Social Behavior.
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