Marmot, Me and the ‘Location Paradox’

In a co-authored piece in the early 1990s the phrase location paradox was introduced. It may appear a slightly clumsy phrase, but the point was: (a) to distinguish between ‘insiders’ and ‘outsiders’, and (b) to assert that insiders are listened to insofar as they advocate ineffective policies, while outsiders are hushed or ignored insofar as they advocate effective policies.

This brings me to a long-running tension or difference I have had with Michael Marmot (him down the road from me at UCL). I should first declare my respect for Michael and to clear up some misunderstandings. Michael has enjoyed a stellar career in epidemiology and public health, has made a significant contribution to our understanding of the social determinants of health and, most especially in recent years, has taken on the mantle of a public intellectual (that is, he has entered the public sphere to forward an evidence-based agenda for social change to enhance equity and social justice). This is enormously and unequivocally to his credit.

So where is the tension/difference? The various dialogues we have had over the years boil down to a singular exchange. Michael: ‘But I want to make a difference in the real world Graham!’ Me: ‘But you haven’t and aren’t Michael!’ In a way I am merely rehearsing the sentiments of Vicente Navarro here. Michael’s ‘real world’ is not mine. Michael’s real world is one in which grotesque maldistributions of power, income and related resources can be highlighted and challenged, as they are in both his WHO Commission Report and the Marmot Report, and remedied. In my real world, however, these same maldistributions are the predictable products of the internal contradictions of capitalism, sharper in post-1970s financial capitalism than they were in postwar welfare capitalism, and of the structural anchors of class relations (in the economy) and command relations (of the state).

Michael the insider is recognised and heard only to the extent that he declines to visit my real world, and the price he pays is to be celebrated and quietly and subtly sidelined in all but politicians’ rhetoric. Which governments don’t profess to care about tackling equity and injustice in health? His insider account of the world effectively denies the outsider account of the world that I as a sociologist inhabit.

I would contextualise this tension or difference between us in the following ways:

1 – I fully respect Michael’s epidemiological/public health research and interventions to influence policy;

2 – I see epidemiology, a form of neo-positivism, less as a discipline than as an efficient toolkit for public health interventions: it is oriented, understandably and appropriately, to prediction rather than explanation;

3 – as I have often said, I regard epidemiological data as grist to the sociological mill;

4 – Michael has written that sociologists, like epidemiologists, surely have their own questions to ask; so we have, and these should in my view be more oriented to: (a) the social than to social aggregates of individuals; (b) to explanation than prediction; and (c) to ‘beneath-the-surface’ structures and mechanisms than to ‘on-the-surface’ events.

Back to the insider/outsider dichotomy. Both are important, as are all of professional, policy, critical, public, foresight and action sociologies (see my other blogs). The location paradox can only be overcome if insiders and outsiders alike acknowledge as much.

To repeat myself, I have never contended that all sociologists should commit to any particular form of sociological work. My longstanding view is that our sociological community should, no ‘must’, cover all bases. Professional sociology is fundamental. Policy sociology (often a companion of epidemiology) is important but increasingly attracts resources that constrain it. If we sociologists neglect public and foresight sociology, withdraw resources from critical sociology, and decline overtures for action sociology, we are sunk: we will become the kind of bourgeois apologists for capitalism that Marxist a generation ago warned against.

Michael Marmot affords an evidence base for social change. Richard Wilkinson, another epidemiologist (together with Kate Pickett) that I much admire, predicted a few years back that a 7% (if I recall correctly) redistribution of income would significantly reduce health inequity (and many other ‘social evils’ besides). That’s fine.

The sociological project demands of us that we dip deep beneath the surface to plumb, document, explain and expose health inequalities/inequities to an unsuspecting public, and then some (i.e. debunk myths and actively resist being rubbished and sidelined – to the extent of civil disobedience). Insiders need outsiders every much as outsiders need insiders.

I need Michael and he needs me. I am not comparing our careers! Of course there is asymmetry: he has contributed so much more. But I am contending that (a) (epidemiological/public health) prediction and (sociological – plus biological and psychological) explanation should be seen as complementary, and (b) that at the end of the day it is making a REAL difference that counts. Michael’s real world of events might differ from my real world of generative mechanisms but …

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