Tromso lies within the arctic circle but was bathed in sunshine as a group of local and overseas experts on eHealth – plus Annette and I – met to pool our resources. It was to be one day on the university campus in Tromso discussing a study of the role of video conferencing in the provision of crisis intervention in psychiatry, followed by two days aboard coastal ferries pondering ongoing research and its dissemination and prospects for other funded projects.
I had agreed with old friend Aksel Tjora to give a talk on ‘eHealth and Social Theory’ in the first day at sea. Nobody was more aware of my limited qualifications to do so than I was. As well as the Tromso contingent and representation from Trondheim and Oslo, Sue Ziebland, Cathy Pope, Susan Halford and Alex Broom (the last from New Zealand via Australia and Brixton) were in attendance. Outsider ignorance, I told myself, must be sold as an asset. This blog is the gist of what I had to say. I noted by reminding myself out loud that eHealth covers a wide range of information and communication technologies (ICTs). These include: electronic health records, telemedicine, health informatics, health knowledge management (Medscape), virtual healthcare teams, mHealth (mobiles), medical research using ‘grids’ and healthcare information systems. The arena is large and well occupied.
I then revisited my six ideal types of sociological engagement, of practitioners and of theory. This reads as follows. 1: professional sociology is conducted by scholars whose theory is cumulative; 2: policy sociology is done by reformers whose theory is utilitarian; 3: critical sociology the product of radicals who do meta-theory; 4: public sociology is the province of democrats whose theory is communicative; 5: action sociology is the domain of activists whose theory is strategic; and 6: foresight sociology is conducted by visionaries whose theory might be described as speculative. The point in revisiting this triadic typology beyond Burawoy was to emphasize sociology’s heterogeneity of reach and aspiration and to suggest that this is an onus on us to cover bases 1-6 ‘as a community’ if not as individuals.
From then on in I took my brief to be to the positing of ‘issue clusters’ that might usefully by addressed by those interested in the interface between sociology and eHealth and to which social theory might be expected to have a significant input. I did this under the rubrics of micro-, meso- and macro-theory. I can only give a flavour here.
There are questions to be asked about differentiation and demarcation in virtual versus actual (face-to-face) interaction. Many ICTs come under the umbrella of eHealth and are characterized by the mediation of information storage and transmission by technologies. The virtual abbreviates, codes and sometimes re-inscribes the actual. Indeed, the virtual can trump, supercede and, as Baudrillard might express it, be more ‘real’ than the actual.
People vary in their tolerance of and adaptation to ICTs. Often it affords novel privatized forms of sociability. eHealth can involve dealings with ‘familiar strangers’, doctors or patients who are present but absent. Moreover ICTs’ meditative functions rewrite the rules that govern actual interaction in multiple and subtle ways. This rewriting might have positive or negative effects on concordance depending on the context. Thus health professionals and patients alike might – as it were, of necessity – ‘buy into’ telemedicine or video conferencing in the vast uninhabited hinterland around Tromso, but not in South London. We do not yet know if ICTs occasion new patterns of what Gareth Williams a generation ago called ‘narrative reconstruction’, namely, ways in which people-cum-patients refashion their identities in changed circumstances.
eHealth technologies are an important vehicle for Foucault’s ‘technologies of the self’. They may epitomize a new ‘power/knowledge’ disciplinary; but they also offer effective modes of transmission of an ideology of personal responsibility. Initiatives in mHealth, now extending to health-monitoring apps on mobiles, pave the way for a pervasive policing of the responsible self. This is fertile ground for Mertonian middle-range theory.
The promise of the ‘technological fix’ is no less ubiquitous. As is perhaps most apparent in the realm of climate change (a much better and more scientific term than global warming), the optimistic sense of rescue attributed to technological innovation has entered the popular stream of consciousness (and as Giddens and others have argued has now become a last resort in relation to climate change). Technology is presumed a force for good, a means to ‘fix’ outstanding problems. So too with eHealth. How then are we to theorize this ‘collective prejudice’ and its unintended consequences? Often, as Aksel Tjora and I have argued, it seems that square pegs are forced into round holes. Certainly re-negotiated social orders are required.
The concept of ‘governmentality’ (‘the conduct of conduct’) invites macro-sociological engagement. Technologies of the self mature into a form of governance. Faith in ICTs embracing eHealth sits at the core of neo-liberal ideology. Rhetorics of ‘choice’ facilitate this ideology, offering up for sale in our consumer society a false but lucrative prospectus to would-be patients. I have argued that this is the logical pay-off for the 0.1% in financial capitalism whose capital buys the power to exploit the middle and working classes. The hard core of the capitalist executive and the political power elite constitute the governing oligarchy and its allies. Foucault is good on power but not on domination: a class/command dynamic underpins the fondness for prescriptions of personal responsibility and for technological fixes. Exposing ideologies remains a pivotal task for sociology.
A macro-perspective contextualizes both micro- and meso-studies of developments in eHealth. This extends to pilot and evaluative research on the delivery of health care via eHealth. Criteria like effectiveness, efficiency, equity, accessibility and satisfaction should be applied within the parameters of a political economy of financial capitalism.
These comments under the headings of micro-, meso- and macro-theory are of course perfunctory. They might have been other than they are and in any case are in need of elaboration. They are illustrative.
In my Tromso talk I ventured two other remarks by way of conclusion. First, a dialectical orientation can be helpful. This would focus on absence rather than presence: it would require us to think in terms of what might have been/be rather than what is (see my four blogs on Roy Bhaskar’s dialectical critical realism). It would hinge on counter-factuality. It bears remembering that technological fixes and eHealth are neither ineluctable nor intrinsically desirable.
Second, I wanted to stress that eHealth can and should be studied and appraised through the lenses of each of the six types of sociology I identified above. It is important that this emerging field is not simply left to professional and policy sociology.
I must reiterate in conclusion that I am a novice in this field.