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The development of medical sociology in Europe
so<, 2,. Mrd Vol 17. No. ?I. pp. 1591-1597, Printed ,n Great Brmm
THE
DEVELOPMENT
0?77-953hiX3 53.00 + 0 IXI Pergamon Prca\ Ltd
1983
OF MEDICAL
SOCIOLOGY
IN EUROPE*
LISBETH M. CLAUS
NIMH University
Postdoctoral Researcher, Department of Family of Missouri-Columbia, TD3-W Medical Center,
and Community Medicine, Columbia. MO 65212, U.S.A
general profile of contemporary European medical soctology is derived from a larger study and based on: (I) in-depth sociohistorical analyses and evaluations of the development of the subdiscipline in five European countries; (2) a survey of the background and activities of European medical sociologists (N 646) in twenty different European countries: and (3) contacts with resource persons and medical sociologists generated by the compilation of a Directory of European medical sociologists. Besides illustrating common features in the origins and developments of European medical sociologies. a number of characteristics of the discipline are highlighted. Special attention is being paid to elements of mstitutionalization and professionalization of the discipline. Finally. reflectrons as to the prospects of medical sociology in Europe and the possibility of creating a ‘European’ medical sociology are offered Abstract--This
Medical sociology as a sociological subdiscipline has known a tremendous growth in the last decades. Since Robert Straus published in 1957 his now famous article “The Nature and Status of Medical Sociology” in the A~rr~rica~r Socio/ogicc~/ Revielt. [I] the discipline has expanded greatly. Much is known about the development of the disctpline in the United States. However, no systematic information was available about the growth and status of medical sociology in Europe. To remedy this situation. a comprehensive study was undertaken on the development of European medical sociology. It should be kept in mind that the term European rncrlic~nl .socio/og~~might in itself be a misnomer. Europe is a conglomeration of different nations with varied social and political systems. nationalistic groups, ethnic traditions and languages. In addition, the origins and development of medical sociology in particular countries were initially often self-contained within national boundaries and languages. Hence, it might be more appropriate to speak about the discipline in terms of Europcm tnedicul sociologies. Despite this diversification. this article presents common denominators in the growth of medical sociology in Europe since World War Il. Besides illustrating common features in the origins and development of European medical sociologies. a number of characteristics of the drscipline will be highlighted. They reflect the specific styles of work being done, and elements of professionalization and institutionalization of the field. Finally. these state of the field evaluations are further supplemented with some reflections as to the prospects of medical sociology in Europe and the possibility of de\ eloping a ‘European’ medical sociology. The generalizations presented in this article are based on data collected in a variety of ways: (1) A SLIT\ey was conducted among medical sociologists working throughout Europe. A total of 646 medical ‘Thr> research \v:ts supported b! a 15-month Postdoctoral Fellovv ship of the Kathoheke Universiteit Leuven (Di\isron for Medical Sociology) and a grant from the Nation‘tl Fund of Scientific Research (N.F.W.O.) in Belftum.
sociologists from 20 different European countries responded to a mail questionnaire and supplied information on their background and activities [2]. (2) A directory of active European medical sociologists was compiled [3] and (3) In-depth sociohistorical (post WW-II) analyses and evaluations of the development of medical sociology were undertaken in five different Europan countries: the United Kingdom, Belgium. Poland, the Federal Republic of Germany and France. These case studies, based on secondary sources and in-depth interviews with medical sociologists. documented the origins and development of medical sociology in a particular country and evaluated the subdisciplines in the broader national context of society, paying particular attention to the state of of sociology and the formal organization of health care [4]. THE ORIGINS
OF MEDICAL
SOCIOLOGIES
IX EUROPE
‘Medical sociology’, or at least what the discipline is considered to be today. is mainly a post World War II development. In that sense, the origins of modern medical sociology lie in the United States since it developed there earlier. However, a scientific discipline does not arise ahistorically but develops in a particular context. It is generally assumed that modem medical sociology was made possible as a result of changing trends in health, medicine and health care. In addition, the growth and maturation of the social sciences provided theoretical frameworks and methodological tools to be applied to the subject matter. The general predisposing climate for the origins of modem medical sociology is then considered to he in the convergence of these trends in medicine and the social sciences, A convergence which took place around the second World War. This study focused upon the development of ‘modem’ medical sociology and, as such, used the post World War II era as a time frame for retrospective analysis. An extrapolation and comparison between the origins and roots of American and European medical sociology is worth mentioning at this
1592
LISBETH M.
point. Although it is generally assumed that medical sociology started after the second World War. it is possible to historically trace what could have been labeled medical sociology prior ‘to that time. In this respect, premedical sociology and its steady progression to medical sociology are contextually totally different on both continents. In Europe, attention to the social aspects of health and disease had been present in disciplines such as social medicine, public health, and anthropology in the late l&h, 19th and early 20th centuries. Social medicine, social hygiene and public health flourished especially in France, Germany and United Kingdom. Theoretical treatises (and often empirical studies) of physicians, anthropologists, philosophers and social activists such as Edwin Chadwick, Rudolf Virchow. Salomon Neumann, Henry E. Sigerist. Viktor von Weizsacker, Alfred Grotjahn, Cabanis, Louis-Rene Villerme and others, could all be labeled premedical sociology. In Europe, premodern medical sociology grew from there through social epidemiology and public policy. In the United States, the roots of modem medical sociology are totally different. Early modem medical sociology was basically theoretical, abstract and nonempirical. The Flexner Report shifted all interests in American medicine to the ‘scientific’ approach. As a result, medical sociology originated from a different angle in the United States than it did in Europe. Samuel Bloom’s observations of the different developments of American versus European medical sociology could be traced back to the different historical roots of the discipline on both continents [5]. Another situational factor which makes the origins of medical sociology different in the United States vs Europe is the impact of the second World War. While in the United States, the second World War is often seen as having been instrumental in originating medical sociology [6], the war had a disabling effect on the origins of the discipline in Europe. The growth of sociology in Europe was interrupted by the first and second World Wars. Especially the second World War caused a major rift in sociology. It took almost one generation to continue and/or rebuild the sociological research traditions after the war. Although it was beyond the scope of this study to trace these historical roots of medical sociology, the historical context of the origin of the discipline should be kept in mind. The origins of modem medical sociology in the different European countries is situated at different time frames. Specific examples from the case study analysis show that the discipline originated in the early fifties in the United Kingdom, in the late fifties in the Federal Republic of Germany, in the early sixties in Poland, in the mid-sixties in Belgium, and in the midto-late sixties in France. Only a few European countries developed medical sociology in the fifties (probably limited to the United Kingdom, the Netherlands and the Federal Republic of Germany). In a large number of countries, medical sociology originated in the sixties. In the majority of European countries, however, medical sociology did only originate in the seventies and sometimes eighties. Evidence from this study further suggests that in almost all European countries one can find at least a few people who pursue research and/or teaching activities in
CLAUS
medical sociology. This does in no way implv that there is an ‘institutionalized’ field of medical sociology in these countries. Rather. there are individuals. often as lonely cavaliers, pursuing medical sociological research and/or teaching activities. Looking at additional factors which gave birth to modem medical sociology in Europe, one needs to mention the role of some individuals. Although it might appear that the individual and coincidental level was far more important than a collective movement in the origin of medical sociology. exemplars do not arise without a historical context. With respect to the role played by individuals, one can identify two types of people: (1) the ones who entered the field. and (2) the ones who promoted the field. THE DEVELOPMENT MEDICAL
OF EUROPEAN
SOCIOLOCIES
A number of interrelated enabling and disabling factors influenced the development of medical sociologies in Europe. Enabling factors were: the govemment’s role in the funding of sociological research, the growth of the universities, the expansion of sociological research, the student revolt movement, recommendations and/or regulations in medical education, and medical sociology’s own professionalization. Among the disabling factors one should mention the rigid university structure, the perception of medical sociology as a critical discipline, the power of rival disciplines, the lack of support of the mother discipline. and the lack of training possibilities. All these factors are interconnected and part of a broader ideological scheme. Enabling factors A major enabling factor has been the role played by governments in funding medical sociological research. During the sixties, a number of European govemments expanded their research funding into the social sciences. This funding interest in social science research was partly based on the rationale that policy decisions should be supported by scientific research evidence. Medical sociological research benefited from research funds because of an additional factor related to the organization of the health care system. In the late forties, most European countries established national health insurance schemes. In the sixties, costs for health care exceeded all previously anticipated budgets. In addition, concerns arose whether the quality of care matched the monetary investments of the national health insurance systems. These issues regarding cost and quality of health care fit a more general debate in the sixties of quantity vs quality of life. This debate was responsible for allocating resources to medical sociological research. A second factor which enabled the development of medical sociologies in Europe was the growth of the universities in the past decades. The democratization of higher education, a larger population group, women entering universities, and in general a broadening of the educational system were factors which were responsible for the growth of the universities and the building of new universities. Although the expansion of the humanities was not an explicit goal it was a by-product of a renewed interest in higher education.
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Development of medical sociology in Europe A third enabling factor was the development and advent of modem sociology itself. The second World War had a dual impact on sociology in Europe. On the one hand it interrupted sociological activities for almost one decade, on the other hand it made the advent of a different ‘modem’ sociology (vs classic European sociology) easier. Post World War II sociology was partly modeled after American sociology. Attention was paid to specialized knowledge areas within sociology and there was a renewed focus on research methodology. Such an emphasis, combined with the growth of the discipline in general, facilitated the development of sociological subdisciplines. A fourth enabling factor in the development of European medical sociologies was the political climate and student movement in the late sixties. In several European countries, the student movement can directly be linked to the expansion of medical sociology. It led to experimentation with behavioral science teaching in medical education [7]. The general political climate of the sixties further enhanced the need for a ‘critique’ of the medical care system. The political climate of the sixties was further responsible for several new recommendations and/or regulations concerning medical education. These recommendations emphasized the need for medical training which was better adapted to the practice of medicine. The behavioral sciences (and in particular medical sociology) were seen as one of the answers to bring medical education closer to medical practice. The introduction of these subject matters in medical school curricula provided a worksetting for many medical sociologists. Finally, the development of European medical sociologies was enhanced by their own emerging professionalization. Although the institutionalization of medical sociological research and teaching activities in Europe was never as important as, for example, in the United States, it still enhanced the growth of the discipline. The training of a new generation of medical sociologists (although only at a limited number of places) and the usefulness and applied nature of European medical sociologists made it possible for the discipline to create for itself a raison d’etre. Disabling factors A number of countervailing forces impeded the development of medical sociologies in Europe. If again. a comparison between the development of medical sociology in Europe vs the United States wsould be made, none of the disabling factors mentioned for Europe seem to have been at play in the United States. A first disabling factor in the development of European medical sociologies is the ‘rigid’ university structure in Europe. Two particular structural barriers for the development of medical sociologies are: (1) the structural position of sociology within the European universities. and (2) the way in which a professional academic career is sustained within European universities. Sociological teaching and research activities in many European universities are not necessarily conducted within autonomous sociology departments. Often. sociology is imbedded within social sciences. social and political sciences. history, law. economic
sciences, etc. This structural position makes the development of a sociological subdiscipline more difficult. It is not surprising. therefore. that in many European universities medical sociology established itself within medical schools. The second barrier for the development of medical sociology (or for that matter any other discipline) in European universities is the rigid way in which professional academic careers are made (or broken) in a guild-like university structure. Although the ‘patron-dauphin’ system as described by Renee Fox [8] should probably not be generalized to all European universities, its impact on academic research cannot be neglected. Promising researchers who are not sponsored or generated through the university system. may very well no1 remain committed to the field. A second disabling factor in the development of European medical sociologies is the perception by others of being a critical discipline. Medical sociology’s sometime association with neo-Marxism. the student revolt, critical analyses of health care. and its strong involvement in the political aspects of medicine have given the discipline a critical and radical lable. Although among European medical sociologists one finds the whole spectrum of people (from politically conservative to the radical left), the discipline is often perceived by the medical profession as left wing. This label impedes the development of medical sociologies, especially in countries where the discipline is still highly underdeveloped. A third disabling factor in the development of European medical sociologies is the power of rival disciciplines. Medical sociology’s establishment of an autonomous (but in Europe extremely broad) professional domain often reached and/or crossed the boundaries of longer established rival disciplines. Social medicine, public health, medical demography and geography are well established disciplines in Europe. These disciplines have much stronger alliances with the medical (academic) profession than medical sociology does. A final disabling factor in the development of European medical sociologies has been the lack of support from the mother discipline. European medical sociologies did not develop within (theoretical) sociology. In addition, the discipline often became institutionalized in medical rather than sociological settings. Medical sociology was for long not recognized as a valid subarea of sociological research attention. In general, established scholars in sociology showed little support for medical sociology, while often supporting other sociological subdisciplines (labor, organizations, family, law, religion, etc.). In this sense, they monopolized resources which could have been shared with medical sociologists.
CHARACTERISTICS MEDICAL
OF EUROPEAN
SOCIOLOGIES
European medical sociologies are discussed in terms of a number of paradigmatic, institutionalization and professionalization features. Three major and interrelated characteristics of European medical sociologies are : (1) The boundaries of the discipline are ill-defined and broad: (2) European medical sociologies have an
LISBETH M. CLAUS
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applied character: and (3) European logies are ‘policy’ analysis oriented.
medical
socio-
(3) The hounduries of European medical sociologies In general. there is little concern about what constitutes the discipline of medical sociology in Europe. This was most clearly expressed by Magdalena Sokolowska when she stated that “In fact. we do not worry that something does not ‘really belong’ to medical sociology” [9] The broad scope of the discipline of medical sociology could partly be a result of the eclectic background of European medical sociologists. However, that eclecticism is probably rooted in a European tradition of liberal arts education. Social science training in Europe today has often a broad and multidisciplinary humanistic character. Sociology training is, in many universities, imbedded in larger departments (law, philosophy, social and political sciences, etc.). The broad scope of medical sociology was especially well illustrated in the range of research topics and interests expressed by European medical sociologists in the survey. (2) The upplied sociologies
character
of
Europeun
medical
European medical sociologies have basically an ‘applied’ character. The pursuit of sociological knowledge as such is subordinate to the application of that knowledge in the health sphere. The definition of ‘applied’ is, however, not uniform in the different European countries. As a general rule, one can say that medical sociological research in Europe is not aimed at knowledge for the sake of the enhancement of sociological theory in the first place. The usefulness of that knowledge is at least as much a priority as the refinement of sociological models and paradigms. This should not leave the impression that European medical sociologies are a-theoretical. However, the pursuit of esoteric knowledge is not the sole rationale for medical sociological research. ‘Applied’, as mentioned before, does not necessarily mean the same in all European countries. In some countries, the emphasis is on providing descriptive and evaluative research as tools for decision-makers in health care. In other countries, it means a more utilitarian and interventionist approach in shaping government policy and social welfare. In still other countries, it means defining health priorities and implementing health policy and planning. The applied character of European medical sociologies is probably related to a number of factors such as a European social welfare tradition, the governments’ role in the funding of sociological research and the relationship between sociology and policy-making research. (3) The policy-muking .voc~io/ogics
character of‘ Europcun medical
An extension of the applied nature of European medical sociologies is its focus on policy-making. How far medical sociological research has been able to be part of the policy-making progress is harder to evaluate. True, government sponsored medical sociological research projects always contain recommendations for policy makers. in how far these recommendations are incorporated in policy decisions cannot be ascertained from this study.
The institutionalization of medical sociolop> m Europe is not far advanced. There are. of course. the well established centers. which at one time had large numbers of research sociologists on staB. In the it was not unusual for these centers seventies. (Aberdeen. Leuven, Warsaw) to have a concentration of a dozen medical sociologists at one time. Outside of these centers, medical sociologists are main& concentrated in medical schools. There are fen chairs of medical sociolog,y in sociology departments. .4n extreme example IS the Federal Republic of German) where all twelve medical sociology units are located within medical schools. In these European countries where medical sociology is well developed it is. in general. not institutionalized within the mother disclpline ‘sociology’. Rather. medical schools and other applied settings are the places from which medical sociologists work. This institutional framework partl! accounts for the lack of medical sociology teaching program for sociology students. The situation of medical sociology in these countries where the discipline numbers only a few active sociologists is of particular interest. The lack of establishment of the discipline in one of these countries was evaluated by a respondent to the survey as follows: “(. .) Medical sociology is still considered a hqbrld category which must find a scientific recognition both from medical researchers and from social scientists. The soc~ologists who have engaged in medical sociology studies ha\e found actual dificulty m getting access to resources. \uch as the exammation of medical archives m the hospitals. and difficulty of access to funds under the label ‘medical
sociology’ [lo]‘. Not uncommon in these countries is a confusion division of roles between sociologists and medicine researchers. Profi3sionalization
in the social
feutures
From the survey on the activities of European medical sociologists, it became apparent that European medical sociology has a rather low professionalization profile. The eclectic background of its members. a neglect of the transmission of a body of knowledge. and the rather loose boundaries of the discipline of medical sociology are partly responsible for this. The lack of professionalization of medical sociology, is further ,impeded by the absence of formal tratnmg programs in most European countries. University level teaching of medical sociology for graduate soctology sociology students is limited to a few centers in Europe. People who desire to become medical sociologists in Europe often have to go abroad for training (in a different language). Finally, although there are a number of regional textbooks. books translated from English, and other research publications intended for medical sociologists, there are only a limited number of publications in some European countries. This problem is compounded by the lack of publication markets for certain languages. Therefore, European medical sociologists often have to rely upon textbooks and studies in another language which show little relevance to their particular society. Medical sociology is still a very youn! discipline in Europe. Therefore, instead of speaking of ‘generatlons‘ of medical sociologists in the true sense of the word.
Development
of medical
it seems more appropriate for European medical sociologists to speak of different groups or types. The following model of grouping European medical sociologists is presented as an ideal type. It needs to be adapted to the particular European country and its state of development of medical sociology. Only in countries where the discipline is firmly established can one potentially find all of the groups discussed hereafter. Although this model is basically structurally defined. individual particularities (such as personalities, career commitments and opportunities) can be accounted for here. European medical sociologists are divided into five different groups: (1) the ambassadors; (2) the professionals; (3) the researchers; (4) the activists: and (5) the transients. (1 ) The trndw.watior.s Only a limited number of people would fit this category of ‘ambassadors’. They are to be found among the first individuals who entered the field of medical sociology in a particular country. They attempted to institutionalize the field in their country and gave it professional status and visibility. Often. to that purpose, they built schools which were to become bastions of medical sociological research (and sometimes of teaching). These ambassadors did not necessarily build sociological schools, in the sense of promoting a particular sociological theory. In general. these pioneers had relatively few publications. Most did. however, initially write a medical sociology textbook in their language-textbooks which synthesized the existing literature in the field (mainly American medical sociology), and were supplemented with a morphological analysis of health care in their own country. The importance of their role is to be measured in terms of synthesizing the field, attracting funding sources for the discipline, and in general, making medical sociology a visible and viable discipline in their country and abroad. Ambassadors are ‘process’ rather than ‘product’ type people. It should be reemphasized that without the commitments of these ambassadors. many medical sociologists would have found it necessary to leave the field because of lack of resources.
(2) The pro f~~ssionals The second group of medical sociologists in Europe are people who were more interested in particular concepts and theories and the testing of those ideas, rather than attempting to develop or institutionalize the field of medical sociology. The ‘professionals’ have occupied a place in medical sociology in Europe because of the particular topic they studied. because of the particular style of sociological work they represented. or for both of these reasons. They are people who are more interested in the pursuit of knowledge and its application than in the promotion of the field a5 such. These ‘professionals’ have usually a heavy publication record. Both groups. ‘ambassadors’ and ‘professionals’ are institutionally almost in identical positions. Careerwise. they, now occupy the established chairs and tenured positions in the universities. These two groups of medical sociologists have complemented each other in many ways. they are the two sides of the same coin. While the ambassadors were able to attract funds and
sociolog)
I595
in Europe
give recognition for the discipline. the professionals managed to produce the professional research material and credibility needed for the institutionalization of the field. In many countries these two groups often simultaneously entered the field. One group fits more the model of the managerial cadre, the other of the professional cadre.
(3 ) The researchc~rs The researchers usually entered the field later than the ambassadors or professionals. They often were attracted by one of these groups on research tasks or were generationally students of them. The researchers deserve this name because of the varied research experience they were able to acquire. They are. however, often not responsible for attracting funds or defining the research priorities. They are a very young group of people (in their thirties) in academically insecure positions. They have probably a sufficient professional commitment to remain in the field if opportunities were created. However, the university structure and lack of academically secure future might make them abandon the career of medical sociologist. Especiahy in the light of the fact that the first and second group, in most countries, can be expected to remain in the field for about two decades. (4) The activists This group of medical sociologists is, generationwise. from the same cohort as the researchers. The difference is that they went into applied, non-academic work settings. They are a relatively small, but growing, group of people who work in a variety of voluntary health agencies, sick funds, hospitals, local and municipal health authorities, self-help programs, etc. They are involved in small scale action-research, and/or health education and promotion activities. In some countries they act as clinical sociologists being involved in actual patient care. There is a large gap between these activists and the academic sociologists. The activists have, in general, a much smaller base of professional support and interaction than the academically-based sociologists. (5) The transients This ‘group of people enters and leaves the medical sociological scene depending upon the labor market. They are attracted when contract research is available. In general, they have little ambition to remain medical sociologists, or have in fact little opportunity to do so even if they wanted. PROSPECTS
FOR
EUROPEAN
MEDICAL
SOCIOLOGIES
What awaits European medical sociologies in the eighties? The answer to this question will depend upon the particular country under consideration. In some countries where there are already a large number of active medical sociologists, an employment saturation condition is in sight. In other European countries. (where the discipline is not greatly developed) medical sociology can be expected to grow if the necessary incentives are provided. One fact is clear, however. If governments (which are the major sponsors of medical sociological research) are going to restrict their
LISBETH
I596
funding, medical sociological research in Europe will suffer greatly. A potential restriction in government funding would have to be compensated by other funding sources.. If this were not possible, a lot of medical sociologists might be (or have already been) forced to leave the field (especially the ‘transients’ and the ‘researchers’). European medical sociologies, in contrast with for example Amercan medical sociology. have a number of extra potentialities. Some of the paradigmatic features of European medical sociologies greatly compensate for the lack of institutionalization and professionalization of the discipline. The lack of stringent boundaries of medical sociology, its applied and policy-making emphasis, and the eclectic background of its medical sociologists make it probably more flexible and adaptable to changing times and constraints. Despite the potential for flexibility of the discipline in Europe, one has to keep in mind that restrictions are likely to be imposed on the growth of the discipline in the future. Such restrictions will necessitate a number of strategies. These will include, among others, a search for alternative funding sources, a certain amount of rationalization of medical sociological research activities, continued interest in practical relevant research issues, and planned professionalization interventions rather than haphazardous ones. TOWARDS
A
EUROPEAN
MEDICAL
SOCIOLOGY?
The last question to be addressed in this study dealt with the possibility of developing a European medical sociology. It became clear from this research that one could hardly speak of a European medical sociology but that it is more appropriate to speak of European medical sociologies. Can a European medical sociology be developed despite the social and cultural diversity of the different European countries? Although there are noticeable trends towards Europeanization, many more factors play in favor of particular medical sociologies than against. Notwithstanding the importance and richness of such national expression, the importance of harmonization of particular European medical sociologies will be pursued. There have been, in recent years, noticeable trends toward the harmonization of European medical sociologies. In many European countries, medical sociologists are grouping themselves in formal association and informal professional groups. Several countries now have medical sociology groups (United Kingdom. Federal Republic of Germany, Switzerland. Austria. Scandinavian countries, Poland, Italy). These national associations are giving more visibility to the discipline and are facilitating contacts among medical sociologists, Among the pioneers of European medical sociologists, there is a great deal of formal and informal professional contact. Three bastions of medical sociology research (Aberdeen, Warsaw and Leuven) are connected by bilateral agreements calling for exchange of faculty and researchers. International and supra-national organizations such as the World Health Organization (WHO) and the European Economic Community (EEC) are more and more counting on the expertise of European medical sociologists as consultants and advisors. In 1980. the WHO,
M. CLAUS
Regional Office for Europe. invited five leading European medical sociologists. to discuss the contribution of sociologists to the WHO Regional Office’s program development [I I]. The World Health Organization. Regional Office for Europe, in that respect has shown considerable interest and support in the task of bringing European medical sociologists in closer touch with one another and to identify experts in the area. Despite these trends, several factors are at play which inhibit the development of European medical sociology. There is among European medical sociologists a great amount of ethnocentrism, which precludes genuine professional communication and contact. It became clear from this research that. as a general rule, medical sociologists mainly work within their ‘language’. thereby denying valuable research work being done by neighboring sociologists. It seemed more common to look at Anglo-Saxon publications than at, often more pertinent, work in another language. This, despite the fact that these medical sociologists had often a working knowledge of the language in a neighboring country. Linguistic and cultural barriers have often as a result a duplication of research activity without the benefit of crossfertilization of the research results. In addition, a focus on local and regional rather than national samples make cross-cultural comparisons even more difficult. Comparative European research in the area of medical sociology is further limited through the lack of standardized and coordinated research methods. What is needed to facilitate the development of a European medical sociology? Linguistic and cultural barriers among European medical sociologists and the absence of a formally organized professional network have prevented a great deal of professional contacts and potential research collaboration in the field. One of the practical aims of this study has been to bring European medical sociologists closer together by providing systematized knowledge about the field and its active components (medical sociologists). However. further steps need to be taken with regard to the professionalization of the discipline. At this writing the foundations are being built for a ‘European Society of Medical Sociology’. The development of a European medical sociology in the future seems inevitable. Although the harmonization of the different European medical sociologies is a worthwhile aim. the interplay of different political, social and cultural factors on the development of the sociological discipline foremost contributes to the richness of the field. Medical sociology is ‘alive and well’ in Europe.
REFERENCES
Straw R. The nature and status of medical sociology. Am. social. Rev. 22. 200. 1957. Claus L. M. The Growth of‘ (I So~iologicct/ Disc,ipline. on the Drvrlopmenr
of
Mrdicctl
Sociology
in Europpr.
Vol. 1 : The General Study. Katholieke Universiteit Leuven, Sociological Research Institute. Leuven. 1982. Claus L. M. (Ed.) Europeun Medicul Sociologists: .A Diwcrory Illnrssctnd
of People Active in the Swiolog~ of‘ Hdth. Hdth Cure. Katholieke Universiteit Leuven.
Sociological Research Institute. Leuven. 198 I. L. M. The Growth of (I .Soc~io/o,~ic~ttl Disc~ipline
Claus
Development
of medical
on the Development qf Medical Sociology, in Europe, Vol. 2: Case Studies. Katholieke Universiteit Leuven. Sociological Research Institute, Leuven, 1982. 5. Bloom S. W. The profession of medical sociologist and the implications for training programs. In Teaching Medical Sociology by Nuvens Y. and ._. (Edited Vansteenkiste J.), p. 37. Mariinus Nijhoff, Social Science Division. Leiden, 1978. 6. Day R. A. Toward the Development of a Sociology of Sociology : The Case of Medical Sociology. University of Missouri-Columbia, Unpublished Ph.D. Dissertation, 1981. 7. Claus L. M. Medische Opleiding in Verandering: De
sociology
in Europe
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Plaats van de Gedragswetenschappen in het Medisch Curriculum. Katholieke Universiteit Leuven, Unpublished Master’s Thesis, 1973. chateau. Science 136, .8. Fox R. Medical scientist ina 476. 1962. M. Health and Sociefy, Selecled Research 9. Sokolowska and Bibliography. Polish Academy of Science, Institute of Philosophy, Warszawa, 1978. IO. Personal letter from Italian respondent. December 1980. I I. World Health Organization. Contribufion 10 Sociolog) Programme Developmmi in the Regionul Oj’iw j&r Europe, WHO Regional Office for Europe. Copenhagen. 1981.
THE
DEVELOPMENT
0?77-953hiX3 53.00 + 0 IXI Pergamon Prca\ Ltd
1983
OF MEDICAL
SOCIOLOGY
IN EUROPE*
LISBETH M. CLAUS
NIMH University
Postdoctoral Researcher, Department of Family of Missouri-Columbia, TD3-W Medical Center,
and Community Medicine, Columbia. MO 65212, U.S.A
general profile of contemporary European medical soctology is derived from a larger study and based on: (I) in-depth sociohistorical analyses and evaluations of the development of the subdiscipline in five European countries; (2) a survey of the background and activities of European medical sociologists (N 646) in twenty different European countries: and (3) contacts with resource persons and medical sociologists generated by the compilation of a Directory of European medical sociologists. Besides illustrating common features in the origins and developments of European medical sociologies. a number of characteristics of the discipline are highlighted. Special attention is being paid to elements of mstitutionalization and professionalization of the discipline. Finally. reflectrons as to the prospects of medical sociology in Europe and the possibility of creating a ‘European’ medical sociology are offered Abstract--This
Medical sociology as a sociological subdiscipline has known a tremendous growth in the last decades. Since Robert Straus published in 1957 his now famous article “The Nature and Status of Medical Sociology” in the A~rr~rica~r Socio/ogicc~/ Revielt. [I] the discipline has expanded greatly. Much is known about the development of the disctpline in the United States. However, no systematic information was available about the growth and status of medical sociology in Europe. To remedy this situation. a comprehensive study was undertaken on the development of European medical sociology. It should be kept in mind that the term European rncrlic~nl .socio/og~~might in itself be a misnomer. Europe is a conglomeration of different nations with varied social and political systems. nationalistic groups, ethnic traditions and languages. In addition, the origins and development of medical sociology in particular countries were initially often self-contained within national boundaries and languages. Hence, it might be more appropriate to speak about the discipline in terms of Europcm tnedicul sociologies. Despite this diversification. this article presents common denominators in the growth of medical sociology in Europe since World War Il. Besides illustrating common features in the origins and development of European medical sociologies. a number of characteristics of the drscipline will be highlighted. They reflect the specific styles of work being done, and elements of professionalization and institutionalization of the field. Finally. these state of the field evaluations are further supplemented with some reflections as to the prospects of medical sociology in Europe and the possibility of de\ eloping a ‘European’ medical sociology. The generalizations presented in this article are based on data collected in a variety of ways: (1) A SLIT\ey was conducted among medical sociologists working throughout Europe. A total of 646 medical ‘Thr> research \v:ts supported b! a 15-month Postdoctoral Fellovv ship of the Kathoheke Universiteit Leuven (Di\isron for Medical Sociology) and a grant from the Nation‘tl Fund of Scientific Research (N.F.W.O.) in Belftum.
sociologists from 20 different European countries responded to a mail questionnaire and supplied information on their background and activities [2]. (2) A directory of active European medical sociologists was compiled [3] and (3) In-depth sociohistorical (post WW-II) analyses and evaluations of the development of medical sociology were undertaken in five different Europan countries: the United Kingdom, Belgium. Poland, the Federal Republic of Germany and France. These case studies, based on secondary sources and in-depth interviews with medical sociologists. documented the origins and development of medical sociology in a particular country and evaluated the subdisciplines in the broader national context of society, paying particular attention to the state of of sociology and the formal organization of health care [4]. THE ORIGINS
OF MEDICAL
SOCIOLOGIES
IX EUROPE
‘Medical sociology’, or at least what the discipline is considered to be today. is mainly a post World War II development. In that sense, the origins of modern medical sociology lie in the United States since it developed there earlier. However, a scientific discipline does not arise ahistorically but develops in a particular context. It is generally assumed that modem medical sociology was made possible as a result of changing trends in health, medicine and health care. In addition, the growth and maturation of the social sciences provided theoretical frameworks and methodological tools to be applied to the subject matter. The general predisposing climate for the origins of modem medical sociology is then considered to he in the convergence of these trends in medicine and the social sciences, A convergence which took place around the second World War. This study focused upon the development of ‘modem’ medical sociology and, as such, used the post World War II era as a time frame for retrospective analysis. An extrapolation and comparison between the origins and roots of American and European medical sociology is worth mentioning at this
1592
LISBETH M.
point. Although it is generally assumed that medical sociology started after the second World War. it is possible to historically trace what could have been labeled medical sociology prior ‘to that time. In this respect, premedical sociology and its steady progression to medical sociology are contextually totally different on both continents. In Europe, attention to the social aspects of health and disease had been present in disciplines such as social medicine, public health, and anthropology in the late l&h, 19th and early 20th centuries. Social medicine, social hygiene and public health flourished especially in France, Germany and United Kingdom. Theoretical treatises (and often empirical studies) of physicians, anthropologists, philosophers and social activists such as Edwin Chadwick, Rudolf Virchow. Salomon Neumann, Henry E. Sigerist. Viktor von Weizsacker, Alfred Grotjahn, Cabanis, Louis-Rene Villerme and others, could all be labeled premedical sociology. In Europe, premodern medical sociology grew from there through social epidemiology and public policy. In the United States, the roots of modem medical sociology are totally different. Early modem medical sociology was basically theoretical, abstract and nonempirical. The Flexner Report shifted all interests in American medicine to the ‘scientific’ approach. As a result, medical sociology originated from a different angle in the United States than it did in Europe. Samuel Bloom’s observations of the different developments of American versus European medical sociology could be traced back to the different historical roots of the discipline on both continents [5]. Another situational factor which makes the origins of medical sociology different in the United States vs Europe is the impact of the second World War. While in the United States, the second World War is often seen as having been instrumental in originating medical sociology [6], the war had a disabling effect on the origins of the discipline in Europe. The growth of sociology in Europe was interrupted by the first and second World Wars. Especially the second World War caused a major rift in sociology. It took almost one generation to continue and/or rebuild the sociological research traditions after the war. Although it was beyond the scope of this study to trace these historical roots of medical sociology, the historical context of the origin of the discipline should be kept in mind. The origins of modem medical sociology in the different European countries is situated at different time frames. Specific examples from the case study analysis show that the discipline originated in the early fifties in the United Kingdom, in the late fifties in the Federal Republic of Germany, in the early sixties in Poland, in the mid-sixties in Belgium, and in the midto-late sixties in France. Only a few European countries developed medical sociology in the fifties (probably limited to the United Kingdom, the Netherlands and the Federal Republic of Germany). In a large number of countries, medical sociology originated in the sixties. In the majority of European countries, however, medical sociology did only originate in the seventies and sometimes eighties. Evidence from this study further suggests that in almost all European countries one can find at least a few people who pursue research and/or teaching activities in
CLAUS
medical sociology. This does in no way implv that there is an ‘institutionalized’ field of medical sociology in these countries. Rather. there are individuals. often as lonely cavaliers, pursuing medical sociological research and/or teaching activities. Looking at additional factors which gave birth to modem medical sociology in Europe, one needs to mention the role of some individuals. Although it might appear that the individual and coincidental level was far more important than a collective movement in the origin of medical sociology. exemplars do not arise without a historical context. With respect to the role played by individuals, one can identify two types of people: (1) the ones who entered the field. and (2) the ones who promoted the field. THE DEVELOPMENT MEDICAL
OF EUROPEAN
SOCIOLOCIES
A number of interrelated enabling and disabling factors influenced the development of medical sociologies in Europe. Enabling factors were: the govemment’s role in the funding of sociological research, the growth of the universities, the expansion of sociological research, the student revolt movement, recommendations and/or regulations in medical education, and medical sociology’s own professionalization. Among the disabling factors one should mention the rigid university structure, the perception of medical sociology as a critical discipline, the power of rival disciplines, the lack of support of the mother discipline. and the lack of training possibilities. All these factors are interconnected and part of a broader ideological scheme. Enabling factors A major enabling factor has been the role played by governments in funding medical sociological research. During the sixties, a number of European govemments expanded their research funding into the social sciences. This funding interest in social science research was partly based on the rationale that policy decisions should be supported by scientific research evidence. Medical sociological research benefited from research funds because of an additional factor related to the organization of the health care system. In the late forties, most European countries established national health insurance schemes. In the sixties, costs for health care exceeded all previously anticipated budgets. In addition, concerns arose whether the quality of care matched the monetary investments of the national health insurance systems. These issues regarding cost and quality of health care fit a more general debate in the sixties of quantity vs quality of life. This debate was responsible for allocating resources to medical sociological research. A second factor which enabled the development of medical sociologies in Europe was the growth of the universities in the past decades. The democratization of higher education, a larger population group, women entering universities, and in general a broadening of the educational system were factors which were responsible for the growth of the universities and the building of new universities. Although the expansion of the humanities was not an explicit goal it was a by-product of a renewed interest in higher education.
I593
Development of medical sociology in Europe A third enabling factor was the development and advent of modem sociology itself. The second World War had a dual impact on sociology in Europe. On the one hand it interrupted sociological activities for almost one decade, on the other hand it made the advent of a different ‘modem’ sociology (vs classic European sociology) easier. Post World War II sociology was partly modeled after American sociology. Attention was paid to specialized knowledge areas within sociology and there was a renewed focus on research methodology. Such an emphasis, combined with the growth of the discipline in general, facilitated the development of sociological subdisciplines. A fourth enabling factor in the development of European medical sociologies was the political climate and student movement in the late sixties. In several European countries, the student movement can directly be linked to the expansion of medical sociology. It led to experimentation with behavioral science teaching in medical education [7]. The general political climate of the sixties further enhanced the need for a ‘critique’ of the medical care system. The political climate of the sixties was further responsible for several new recommendations and/or regulations concerning medical education. These recommendations emphasized the need for medical training which was better adapted to the practice of medicine. The behavioral sciences (and in particular medical sociology) were seen as one of the answers to bring medical education closer to medical practice. The introduction of these subject matters in medical school curricula provided a worksetting for many medical sociologists. Finally, the development of European medical sociologies was enhanced by their own emerging professionalization. Although the institutionalization of medical sociological research and teaching activities in Europe was never as important as, for example, in the United States, it still enhanced the growth of the discipline. The training of a new generation of medical sociologists (although only at a limited number of places) and the usefulness and applied nature of European medical sociologists made it possible for the discipline to create for itself a raison d’etre. Disabling factors A number of countervailing forces impeded the development of medical sociologies in Europe. If again. a comparison between the development of medical sociology in Europe vs the United States wsould be made, none of the disabling factors mentioned for Europe seem to have been at play in the United States. A first disabling factor in the development of European medical sociologies is the ‘rigid’ university structure in Europe. Two particular structural barriers for the development of medical sociologies are: (1) the structural position of sociology within the European universities. and (2) the way in which a professional academic career is sustained within European universities. Sociological teaching and research activities in many European universities are not necessarily conducted within autonomous sociology departments. Often. sociology is imbedded within social sciences. social and political sciences. history, law. economic
sciences, etc. This structural position makes the development of a sociological subdiscipline more difficult. It is not surprising. therefore. that in many European universities medical sociology established itself within medical schools. The second barrier for the development of medical sociology (or for that matter any other discipline) in European universities is the rigid way in which professional academic careers are made (or broken) in a guild-like university structure. Although the ‘patron-dauphin’ system as described by Renee Fox [8] should probably not be generalized to all European universities, its impact on academic research cannot be neglected. Promising researchers who are not sponsored or generated through the university system. may very well no1 remain committed to the field. A second disabling factor in the development of European medical sociologies is the perception by others of being a critical discipline. Medical sociology’s sometime association with neo-Marxism. the student revolt, critical analyses of health care. and its strong involvement in the political aspects of medicine have given the discipline a critical and radical lable. Although among European medical sociologists one finds the whole spectrum of people (from politically conservative to the radical left), the discipline is often perceived by the medical profession as left wing. This label impedes the development of medical sociologies, especially in countries where the discipline is still highly underdeveloped. A third disabling factor in the development of European medical sociologies is the power of rival disciciplines. Medical sociology’s establishment of an autonomous (but in Europe extremely broad) professional domain often reached and/or crossed the boundaries of longer established rival disciplines. Social medicine, public health, medical demography and geography are well established disciplines in Europe. These disciplines have much stronger alliances with the medical (academic) profession than medical sociology does. A final disabling factor in the development of European medical sociologies has been the lack of support from the mother discipline. European medical sociologies did not develop within (theoretical) sociology. In addition, the discipline often became institutionalized in medical rather than sociological settings. Medical sociology was for long not recognized as a valid subarea of sociological research attention. In general, established scholars in sociology showed little support for medical sociology, while often supporting other sociological subdisciplines (labor, organizations, family, law, religion, etc.). In this sense, they monopolized resources which could have been shared with medical sociologists.
CHARACTERISTICS MEDICAL
OF EUROPEAN
SOCIOLOGIES
European medical sociologies are discussed in terms of a number of paradigmatic, institutionalization and professionalization features. Three major and interrelated characteristics of European medical sociologies are : (1) The boundaries of the discipline are ill-defined and broad: (2) European medical sociologies have an
LISBETH M. CLAUS
1594
applied character: and (3) European logies are ‘policy’ analysis oriented.
medical
socio-
(3) The hounduries of European medical sociologies In general. there is little concern about what constitutes the discipline of medical sociology in Europe. This was most clearly expressed by Magdalena Sokolowska when she stated that “In fact. we do not worry that something does not ‘really belong’ to medical sociology” [9] The broad scope of the discipline of medical sociology could partly be a result of the eclectic background of European medical sociologists. However, that eclecticism is probably rooted in a European tradition of liberal arts education. Social science training in Europe today has often a broad and multidisciplinary humanistic character. Sociology training is, in many universities, imbedded in larger departments (law, philosophy, social and political sciences, etc.). The broad scope of medical sociology was especially well illustrated in the range of research topics and interests expressed by European medical sociologists in the survey. (2) The upplied sociologies
character
of
Europeun
medical
European medical sociologies have basically an ‘applied’ character. The pursuit of sociological knowledge as such is subordinate to the application of that knowledge in the health sphere. The definition of ‘applied’ is, however, not uniform in the different European countries. As a general rule, one can say that medical sociological research in Europe is not aimed at knowledge for the sake of the enhancement of sociological theory in the first place. The usefulness of that knowledge is at least as much a priority as the refinement of sociological models and paradigms. This should not leave the impression that European medical sociologies are a-theoretical. However, the pursuit of esoteric knowledge is not the sole rationale for medical sociological research. ‘Applied’, as mentioned before, does not necessarily mean the same in all European countries. In some countries, the emphasis is on providing descriptive and evaluative research as tools for decision-makers in health care. In other countries, it means a more utilitarian and interventionist approach in shaping government policy and social welfare. In still other countries, it means defining health priorities and implementing health policy and planning. The applied character of European medical sociologies is probably related to a number of factors such as a European social welfare tradition, the governments’ role in the funding of sociological research and the relationship between sociology and policy-making research. (3) The policy-muking .voc~io/ogics
character of‘ Europcun medical
An extension of the applied nature of European medical sociologies is its focus on policy-making. How far medical sociological research has been able to be part of the policy-making progress is harder to evaluate. True, government sponsored medical sociological research projects always contain recommendations for policy makers. in how far these recommendations are incorporated in policy decisions cannot be ascertained from this study.
The institutionalization of medical sociolop> m Europe is not far advanced. There are. of course. the well established centers. which at one time had large numbers of research sociologists on staB. In the it was not unusual for these centers seventies. (Aberdeen. Leuven, Warsaw) to have a concentration of a dozen medical sociologists at one time. Outside of these centers, medical sociologists are main& concentrated in medical schools. There are fen chairs of medical sociolog,y in sociology departments. .4n extreme example IS the Federal Republic of German) where all twelve medical sociology units are located within medical schools. In these European countries where medical sociology is well developed it is. in general. not institutionalized within the mother disclpline ‘sociology’. Rather. medical schools and other applied settings are the places from which medical sociologists work. This institutional framework partl! accounts for the lack of medical sociology teaching program for sociology students. The situation of medical sociology in these countries where the discipline numbers only a few active sociologists is of particular interest. The lack of establishment of the discipline in one of these countries was evaluated by a respondent to the survey as follows: “(. .) Medical sociology is still considered a hqbrld category which must find a scientific recognition both from medical researchers and from social scientists. The soc~ologists who have engaged in medical sociology studies ha\e found actual dificulty m getting access to resources. \uch as the exammation of medical archives m the hospitals. and difficulty of access to funds under the label ‘medical
sociology’ [lo]‘. Not uncommon in these countries is a confusion division of roles between sociologists and medicine researchers. Profi3sionalization
in the social
feutures
From the survey on the activities of European medical sociologists, it became apparent that European medical sociology has a rather low professionalization profile. The eclectic background of its members. a neglect of the transmission of a body of knowledge. and the rather loose boundaries of the discipline of medical sociology are partly responsible for this. The lack of professionalization of medical sociology, is further ,impeded by the absence of formal tratnmg programs in most European countries. University level teaching of medical sociology for graduate soctology sociology students is limited to a few centers in Europe. People who desire to become medical sociologists in Europe often have to go abroad for training (in a different language). Finally, although there are a number of regional textbooks. books translated from English, and other research publications intended for medical sociologists, there are only a limited number of publications in some European countries. This problem is compounded by the lack of publication markets for certain languages. Therefore, European medical sociologists often have to rely upon textbooks and studies in another language which show little relevance to their particular society. Medical sociology is still a very youn! discipline in Europe. Therefore, instead of speaking of ‘generatlons‘ of medical sociologists in the true sense of the word.
Development
of medical
it seems more appropriate for European medical sociologists to speak of different groups or types. The following model of grouping European medical sociologists is presented as an ideal type. It needs to be adapted to the particular European country and its state of development of medical sociology. Only in countries where the discipline is firmly established can one potentially find all of the groups discussed hereafter. Although this model is basically structurally defined. individual particularities (such as personalities, career commitments and opportunities) can be accounted for here. European medical sociologists are divided into five different groups: (1) the ambassadors; (2) the professionals; (3) the researchers; (4) the activists: and (5) the transients. (1 ) The trndw.watior.s Only a limited number of people would fit this category of ‘ambassadors’. They are to be found among the first individuals who entered the field of medical sociology in a particular country. They attempted to institutionalize the field in their country and gave it professional status and visibility. Often. to that purpose, they built schools which were to become bastions of medical sociological research (and sometimes of teaching). These ambassadors did not necessarily build sociological schools, in the sense of promoting a particular sociological theory. In general. these pioneers had relatively few publications. Most did. however, initially write a medical sociology textbook in their language-textbooks which synthesized the existing literature in the field (mainly American medical sociology), and were supplemented with a morphological analysis of health care in their own country. The importance of their role is to be measured in terms of synthesizing the field, attracting funding sources for the discipline, and in general, making medical sociology a visible and viable discipline in their country and abroad. Ambassadors are ‘process’ rather than ‘product’ type people. It should be reemphasized that without the commitments of these ambassadors. many medical sociologists would have found it necessary to leave the field because of lack of resources.
(2) The pro f~~ssionals The second group of medical sociologists in Europe are people who were more interested in particular concepts and theories and the testing of those ideas, rather than attempting to develop or institutionalize the field of medical sociology. The ‘professionals’ have occupied a place in medical sociology in Europe because of the particular topic they studied. because of the particular style of sociological work they represented. or for both of these reasons. They are people who are more interested in the pursuit of knowledge and its application than in the promotion of the field a5 such. These ‘professionals’ have usually a heavy publication record. Both groups. ‘ambassadors’ and ‘professionals’ are institutionally almost in identical positions. Careerwise. they, now occupy the established chairs and tenured positions in the universities. These two groups of medical sociologists have complemented each other in many ways. they are the two sides of the same coin. While the ambassadors were able to attract funds and
sociolog)
I595
in Europe
give recognition for the discipline. the professionals managed to produce the professional research material and credibility needed for the institutionalization of the field. In many countries these two groups often simultaneously entered the field. One group fits more the model of the managerial cadre, the other of the professional cadre.
(3 ) The researchc~rs The researchers usually entered the field later than the ambassadors or professionals. They often were attracted by one of these groups on research tasks or were generationally students of them. The researchers deserve this name because of the varied research experience they were able to acquire. They are. however, often not responsible for attracting funds or defining the research priorities. They are a very young group of people (in their thirties) in academically insecure positions. They have probably a sufficient professional commitment to remain in the field if opportunities were created. However, the university structure and lack of academically secure future might make them abandon the career of medical sociologist. Especiahy in the light of the fact that the first and second group, in most countries, can be expected to remain in the field for about two decades. (4) The activists This group of medical sociologists is, generationwise. from the same cohort as the researchers. The difference is that they went into applied, non-academic work settings. They are a relatively small, but growing, group of people who work in a variety of voluntary health agencies, sick funds, hospitals, local and municipal health authorities, self-help programs, etc. They are involved in small scale action-research, and/or health education and promotion activities. In some countries they act as clinical sociologists being involved in actual patient care. There is a large gap between these activists and the academic sociologists. The activists have, in general, a much smaller base of professional support and interaction than the academically-based sociologists. (5) The transients This ‘group of people enters and leaves the medical sociological scene depending upon the labor market. They are attracted when contract research is available. In general, they have little ambition to remain medical sociologists, or have in fact little opportunity to do so even if they wanted. PROSPECTS
FOR
EUROPEAN
MEDICAL
SOCIOLOGIES
What awaits European medical sociologies in the eighties? The answer to this question will depend upon the particular country under consideration. In some countries where there are already a large number of active medical sociologists, an employment saturation condition is in sight. In other European countries. (where the discipline is not greatly developed) medical sociology can be expected to grow if the necessary incentives are provided. One fact is clear, however. If governments (which are the major sponsors of medical sociological research) are going to restrict their
LISBETH
I596
funding, medical sociological research in Europe will suffer greatly. A potential restriction in government funding would have to be compensated by other funding sources.. If this were not possible, a lot of medical sociologists might be (or have already been) forced to leave the field (especially the ‘transients’ and the ‘researchers’). European medical sociologies, in contrast with for example Amercan medical sociology. have a number of extra potentialities. Some of the paradigmatic features of European medical sociologies greatly compensate for the lack of institutionalization and professionalization of the discipline. The lack of stringent boundaries of medical sociology, its applied and policy-making emphasis, and the eclectic background of its medical sociologists make it probably more flexible and adaptable to changing times and constraints. Despite the potential for flexibility of the discipline in Europe, one has to keep in mind that restrictions are likely to be imposed on the growth of the discipline in the future. Such restrictions will necessitate a number of strategies. These will include, among others, a search for alternative funding sources, a certain amount of rationalization of medical sociological research activities, continued interest in practical relevant research issues, and planned professionalization interventions rather than haphazardous ones. TOWARDS
A
EUROPEAN
MEDICAL
SOCIOLOGY?
The last question to be addressed in this study dealt with the possibility of developing a European medical sociology. It became clear from this research that one could hardly speak of a European medical sociology but that it is more appropriate to speak of European medical sociologies. Can a European medical sociology be developed despite the social and cultural diversity of the different European countries? Although there are noticeable trends towards Europeanization, many more factors play in favor of particular medical sociologies than against. Notwithstanding the importance and richness of such national expression, the importance of harmonization of particular European medical sociologies will be pursued. There have been, in recent years, noticeable trends toward the harmonization of European medical sociologies. In many European countries, medical sociologists are grouping themselves in formal association and informal professional groups. Several countries now have medical sociology groups (United Kingdom. Federal Republic of Germany, Switzerland. Austria. Scandinavian countries, Poland, Italy). These national associations are giving more visibility to the discipline and are facilitating contacts among medical sociologists, Among the pioneers of European medical sociologists, there is a great deal of formal and informal professional contact. Three bastions of medical sociology research (Aberdeen, Warsaw and Leuven) are connected by bilateral agreements calling for exchange of faculty and researchers. International and supra-national organizations such as the World Health Organization (WHO) and the European Economic Community (EEC) are more and more counting on the expertise of European medical sociologists as consultants and advisors. In 1980. the WHO,
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Regional Office for Europe. invited five leading European medical sociologists. to discuss the contribution of sociologists to the WHO Regional Office’s program development [I I]. The World Health Organization. Regional Office for Europe, in that respect has shown considerable interest and support in the task of bringing European medical sociologists in closer touch with one another and to identify experts in the area. Despite these trends, several factors are at play which inhibit the development of European medical sociology. There is among European medical sociologists a great amount of ethnocentrism, which precludes genuine professional communication and contact. It became clear from this research that. as a general rule, medical sociologists mainly work within their ‘language’. thereby denying valuable research work being done by neighboring sociologists. It seemed more common to look at Anglo-Saxon publications than at, often more pertinent, work in another language. This, despite the fact that these medical sociologists had often a working knowledge of the language in a neighboring country. Linguistic and cultural barriers have often as a result a duplication of research activity without the benefit of crossfertilization of the research results. In addition, a focus on local and regional rather than national samples make cross-cultural comparisons even more difficult. Comparative European research in the area of medical sociology is further limited through the lack of standardized and coordinated research methods. What is needed to facilitate the development of a European medical sociology? Linguistic and cultural barriers among European medical sociologists and the absence of a formally organized professional network have prevented a great deal of professional contacts and potential research collaboration in the field. One of the practical aims of this study has been to bring European medical sociologists closer together by providing systematized knowledge about the field and its active components (medical sociologists). However. further steps need to be taken with regard to the professionalization of the discipline. At this writing the foundations are being built for a ‘European Society of Medical Sociology’. The development of a European medical sociology in the future seems inevitable. Although the harmonization of the different European medical sociologies is a worthwhile aim. the interplay of different political, social and cultural factors on the development of the sociological discipline foremost contributes to the richness of the field. Medical sociology is ‘alive and well’ in Europe.
REFERENCES
Straw R. The nature and status of medical sociology. Am. social. Rev. 22. 200. 1957. Claus L. M. The Growth of‘ (I So~iologicct/ Disc,ipline. on the Drvrlopmenr
of
Mrdicctl
Sociology
in Europpr.
Vol. 1 : The General Study. Katholieke Universiteit Leuven, Sociological Research Institute. Leuven. 1982. Claus L. M. (Ed.) Europeun Medicul Sociologists: .A Diwcrory Illnrssctnd
of People Active in the Swiolog~ of‘ Hdth. Hdth Cure. Katholieke Universiteit Leuven.
Sociological Research Institute. Leuven. 198 I. L. M. The Growth of (I .Soc~io/o,~ic~ttl Disc~ipline
Claus
Development
of medical
on the Development qf Medical Sociology, in Europe, Vol. 2: Case Studies. Katholieke Universiteit Leuven. Sociological Research Institute, Leuven, 1982. 5. Bloom S. W. The profession of medical sociologist and the implications for training programs. In Teaching Medical Sociology by Nuvens Y. and ._. (Edited Vansteenkiste J.), p. 37. Mariinus Nijhoff, Social Science Division. Leiden, 1978. 6. Day R. A. Toward the Development of a Sociology of Sociology : The Case of Medical Sociology. University of Missouri-Columbia, Unpublished Ph.D. Dissertation, 1981. 7. Claus L. M. Medische Opleiding in Verandering: De
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Plaats van de Gedragswetenschappen in het Medisch Curriculum. Katholieke Universiteit Leuven, Unpublished Master’s Thesis, 1973. chateau. Science 136, .8. Fox R. Medical scientist ina 476. 1962. M. Health and Sociefy, Selecled Research 9. Sokolowska and Bibliography. Polish Academy of Science, Institute of Philosophy, Warszawa, 1978. IO. Personal letter from Italian respondent. December 1980. I I. World Health Organization. Contribufion 10 Sociolog) Programme Developmmi in the Regionul Oj’iw j&r Europe, WHO Regional Office for Europe. Copenhagen. 1981.