Sociology of Health & Illness Vol. 26 No. 4 2004 ISSN 01419889, pp.

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Simon
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rejoinder
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Hislop&and
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Sociology
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Beyond medicalization-healthicization?
A rejoinder to Hislop and Arber
Simon J. Williams
Department of Sociology, University of Warwick

Sleep has undoubtedly been a neglected topic of sociological discussion and

debate, both past and present. Further reflection, however, as I have argued
elsewhere (Williams and Bendelow 1998, Williams 2001a, 2003a,b), reveals
the rich sociological significance of sleep at many levels and in many different ways. How, when and where we sleep, let alone what we make of it, are
all, to a large degree, socio-cultural and historical matters. Sleep is crucial
to any given society, acknowledged or not, permeating its institutions and
the capacities of its embodied agents, its spatio-temporal arrangements and
its discursively constructed boundaries, its rituals and its mythologies, its
policies and its practices. The fact that sleep is lived through, moreover,
underlines its sociological significance as a role and event we continually, if
not ritually, prepare for or rehearse, schedule or organise, manage or mismanage, as part and parcel of our normal (waking) everyday lives.
Sleep, to put it more formally or schematically, is irreducible to any one
domain or discourse, arising or emerging through the interplay of biological
and psychological processes, environmental and structural circumstances
(i.e. facilitators and constraints), and socio-cultural forms of elaboration,
conceived in temporally/spatially bounded and embodied terms. Studying
sleep therefore enables us critically to interrogate a series of deep-seated
(sociological) assumptions about the relationship between wakefulness,
consciousness, temporality and sociality, raising important new embodied
themes and issues along the way (Williams forthcoming).
Clearly these sociological issues extend far beyond the province of health
and illness, yet the relevance of sleep to on-going medicalization-healthicization debates opens another potentially rich vein of research (Williams
2002). It is in this context that Hislop and Arbers (2003) paper entitled
Understanding womens sleep: beyond medicalization-healthicization?
arises. The aim, we are told, is to explore my contention that sleep may
provide yet another chapter in the medicalization-healthicization story
(Williams 2002), drawing upon data collected in an empirical study of
womens sleep. The nub of Hislop and Arbers argument, it seems, based on
this small-scale study (from which generalisations should not be drawn), is
the proposition of a so-called alternative model for the management of
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womens sleep which incorporates a core of personalised activity linked

to strategies associated with healthicization and medicalization: a sort
of three-tier model in which medicalized solutions are deemed the most
extreme, if not deviant, when all else fails. Hislop and Arbers study, in this
respect, is timely, welcome and illuminating. It is also, I venture, problematic
or contentious on a number of counts.
What then of these alleged problems? What is contentious about the
study? First and foremost, what we have here is at best a partial and at worst
a misleading portrayal of my own position on these dormant matters. It is
clear, for example, as my previous work attests, that the degree or extent of
medicalization-healthicization concerning sleep remains an open question
rather than a foregone conclusion. It is also clear, as my other writings on
sleep (Williams and Bendelow 1998, Williams 2001a, Williams forthcoming)
and the limits of medicalization suggest (Williams 2003a, 2001b, Williams
and Calnan 1996), that this in no way precludes or denies the writing of
other important chapters on sleep that take us (far) beyond medicalizationhealthicization debates: far from it. Hislop and Arber, in other words, seem
to be constructing something of a straw man here, a caricature in effect
which on closer inspection is more apparent than real.
A second, closely-related set of issues, concerns Hislop and Arbers own
portrayal of/engagement with medicalization debates, both in general terms
and in relation to sleep. Medicalization, it is clear, to the extent that it does
occur, may take place at different levels (e.g. conceptual, institutional, interactional) with or without the (direct) involvement or expressed intent of
doctors, let alone the harbouring of imperialist ambition (Conrad 1992,
Conrad and Schneider 1980, Williams 2001b, Williams 2003a). The upshot
of this, as far as Hislop and Arbers paper is concerned, is, on the one hand,
a certain tension between their own limited empirical focus on lay-professional
perspectives and doctor-patient relations, particularly the medicalization of
sleep through tranquillisers, and, on the other, the broader more general
conclusions they draw (based of these limited level findings) about the
(de)medicalization of sleep. This is a confusion of part for whole, in effect,
which conflates different levels of analysis in the process. The argument, on
this latter count, appears to be that sleep was medicalized in the past (i.e.
from the 1960s onwards) a process referred to as the core of womens
sleep management (Hislop and Arber 2003) at this time but is now (i.e.
over the past 20 years) becoming demedicalized. Even if we buy into this
argument, which is debatable, it needs substantial qualification, given that
we are really only talking about certain types of sleep problem, in this case
(with all due caution) insomnia, rather than sleep per se. Changes at the
level of the doctor-patient relationship, or the GP-patient relationship to be
more precise (medicine, remember, has many branches and specialisms),
cannot simply or unproblematically be equated with demedicalization for
the reasons outlined above. The medicalization of sleep problems, to
repeat, let alone their demedicalization, is a complex, multi-level process that
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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 medicalizationhealthicization 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 methodological 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. Reference to sleep as a natural process, and discussion of the shift toward holistic 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
(womens) 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
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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 concluded, 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 corrected 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-healthicization 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 parameters of (de)medicalization debates, reconfiguring their very terms of reference 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 knowledge and rhetorical authority (i.e. authority cast in the rhetoric of medicine); more porous forms of knowledge, that is to say, which not only occur
outside the traditional confines or institutional parameters of the doctorpatient 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
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of science fiction one might think, yet these developments are already underway 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 conscious waking world (cf. Schwartz 1970). It could nonetheless catch on, for
better or worse, in an era where yesterdays impossibilities become todays
possibilities.
If we really wish to sort out what precisely is or isnt 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 Lavoisiers contributions to medicine and public health, where precise biological norms regarding the respiratory actions and capacities of sleeping 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 particularly 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 qualifications, 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 commodification, 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 Arbers 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 wellpublicised tragedies such as the Exxon Valdez oil spill, the Chernobyl nuclear
catastrophe and the Challenger space shuttle disaster (Coren 1997), sleep (or
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sleepiness to be more precise) has increasingly been invoked as a contributory

factor if not the prime culprit. Drowsy drivers are now increasingly likened
to drunk drivers (Coren 1997), with sleepiness itself in certain circumstances
now treated as a criminal offence; witness, for example, the Selby rail disaster
(i.e. a prospective criminalisation of sleep(iness)).
All in all, then, to sum up, the message is clear. Sleep is a fascinating yet
strangely neglected topic of sociological discussion and debate, with many
important chapters still to be written (Williams, forthcoming). Hislop and
Arbers paper, in this respect, is a timely, welcome and illuminating contribution, albeit a theoretically and empirically limited one that does not
perhaps take us quite as far beyond medicalization-healthicization as at
first appears. Much more, indeed, needs to be done before we can properly
assess the extent of medicalization-healthicization to date, let alone satisfactorily tackle these other important chapters in sleeps hitherto (hidden or
neglected) story. This, I hasten to add, is as much a comment on or criticism
of past sociological neglect as it is of current efforts on this front, Hislop
and Arbers included, with many important challenges, theoretical and methodological alike, still ahead in taking these dormant agendas forward.
Researching sleep, for example, raises tricky questions about the relationship
between the knowing (lived) wide-awake body and the unconsciously knowing (dormant) body. Construed more positively, however, it is not so much
a case of obstacles as opportunities for the taking, with a rich variety of
sociological agendas to pursue, in health and beyond. The debate, in short,
should continue in a constructive and profitable fashion: something to sleep
on perhaps . . . ?
Address for correspondence: Simon J. Williams, Department of Sociology,
University of Warwick, Coventry, CV4 7AL
e-mail: S.J.Williams@Warwick.ac.uk

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