Whose side are we on? Reflections on the FHSI book prize shortlist

Four excellent recent books, all shortlisted for the FHSI Book Prize shortlist, illustrate different approaches to the question of who we write for.

Howard Becker’s 1967 call for sociologists to be on the ‘side of the underdog’ was not advocating partisan research.  Rather, it was a challenge to take seriously ‘hierarchies of credibility’ in our analysis, and acknowledge the fact that we inevitably ‘take sides’.  Whilst some sociologists are upfront about how they do that – stating their positionality, and perhaps advocacy for particular social groups – others strive for impartiality, or evoke the general good of society or knowledge.  Those stances orient towards imagined audiences.  If scholarly books are read largely by academic peers, they also typically invoke other potential readers, with messages crafted for a sympathetic reading by those in positions to change things.  The four on this year’s FHSI shortlist grapple in different ways with the question of whose side we are on, and for whom we orient our analyses.

Anne Kerr and colleagues’ Personalised cancer medicine: Future crafting in the genomic era (Manchester University Press, 2021, open access) is from a large, team project, and positioned as discovery science.  The authors unroll a series of case studies to explore the promissory vision of genomics for patients with ‘foreshortened futures’.  Their accounts treat with dignity and care the experiential accounts of multiple actors – patients, families, researchers, start-up companies and clinicians – whilst never losing sight of the complex institutional contexts that shape those accounts.  As the authors note, contemporary patienthood cannot be explained solely through centring the experiential knowledge of patients, as this is entangled with that of professionals, collectively engaged in crafting futures.  The scale of this study – and the skill with which its multiple authors pull together an engrossing story – makes this truly an ethnography of contemporary genomic medicine in the UK, rather than of cancer survivorship, or of any particular part of the whole, such as the novel adaptive trial.  This is not a text ending with explicit recommendations for policy or practice, or for patients facing decisions about seeking genomic testing.  The imagined reader here is clearly a scholar – interested in the tensions between individualisation and solidarities; between research and care; or between participation and resistance.

A sole authored monograph, focusing on one group, perhaps invites more partisan positioning.  Christina Weis, in her engaging book Surrogacy in Russia: An Ethnography of Reproductive Labour, Stratification and Migration (Emerald Group Publishing, 2021), is upfront about whose side she is on: that of the surrogacy workers she gets to know over several periods of fieldwork.  Their experiences, she notes, are their truth, and this is what centres this text. First, it shapes her conceptualisation of surrogacy – as work, because this is what it is for the women she meets in Russia who do it.  These women often have few other opportunities for income, in a context (at least at the time of Weis’ fieldwork) of a relatively permissive legal framework.  Second, this necessitates acknowledging the difficult emotions in the field – when pregnancies fail, or when the gatekeepers excluding embodied the power they also have over surrogacy workers.  Her stated aims are not to contribute to policy debates around legal frameworks, or the broader societal implications of surrogacy, but rather to improve the wellbeing of women in Russia doing this labour.  This is a book for them, as well as the scholarly field.

Others strive for impartiality, in methods and tone.  Tania M. Jenkins, in Doctors’ Orders:  the making of status hierarchies in an elite profession (Columbia University Press, 2020), notes that she aimed to be as ‘balanced as possible’ in her fieldwork, remaining apolitical during interviews, and seeking to judge her two sites equally. This is a nuanced and compelling account of how hierarchies are reproduced,  taking as its case two residency training programs in the USA, one which recruits almost all USA-trained doctors, and another which takes US-citizens trained in the Caribbean and overseas candidates.  Elites, Jenkins notes, learn to the ‘play the game’ early on, as parents with more wealth prepare their offspring with the financial, social and cultural capital to succeed; these advantages are amplified through biases in selection for training programs, leading to unequal educational experiences and opportunities for career advance. Jenkins shows how this happens through the thousands of small decisions that make up unfair structures, and which ideologically normalise the outcomes of stratification.  As residents of one program learn their sub-par status, and end up in lower-status specialties, their more advantaged counterparts learn that they are future leaders. Jenkins is sophisticated on the ways in which these structural and embedded processes appear as meritocracy and agency, with mythologies of standardised training, and equal opportunities. The thorough and impartial tone lends credibility to this coruscating critique of meritocratic ideology, though the overt claims are somewhat conservative, even functionalist. Jenkins suggests, for instance, that these informal hierarchical structures exist in part because the US has no way of mandating medical workforces towards underserved populations.  Her recommendations are largely oriented at tinkering: tweaking selection processes such that they are less vulnerable to bias, for instance.  Grandstanding denunciations of inequality might resonate with the sociological reader, yet hold little sway with medical educators who can do little about them.

Finally, LaTonya J. Trotter provides a virtuoso demonstration of how a focus on one site – and an unusual one, of a nurse-led facility for older clients – can both shed light on the devastations of unequal societies, and offer at times an almost utopian glimpse of other possibilities.  In More than medicine: Nurse practitioners and the problems they solve for patients, health care organizations, and the state (Cornell University Press, 2020), Trotter shows what holistic care is and can be, and what is missing from the usual medically-dominated provision of care.  This draws on long term, careful, participatory fieldwork, and there is a profound respect for those she has worked alongside and their clients. Yet, like Kerr and colleagues’ book, this is no naïve turn to experience, but a sociologically rich account of the institution, in history and place, as well as the people within it, subtly drawing on a wide canvass – of professional histories, of the structural determinants of ill health, of African-American housing and collective action. Her professionals, managing the complex needs of clients whose health has been eroded by lifetimes (and generations) of disadvantage, are mopping up the failures of social care in the US.  This book achieves the rare feat of offering a devastating critique of a health and social system, which has largely retreated from care, whilst honouring those at the front line, and showing a glimpse of how particular institutions can do things better if there is little immediate hope for the system as a whole.

These books all disturb any easy alignment with the underdog.  Anne Kerr and colleagues point to the contradictions of personalised medicine, in which there are no clear groups of beneficiaries or losers: research has to attend to the micro-politics of who is enrolled in promissory or participatory discourses, who is silenced, and who resists.  Christina Weis and Tania M. Jenkins both powerfully document the operation of gradations of power. There is no clear division of top dogs and underdogs: whether within an elite profession, or within the ethnically-differentiated possibilities of surrogacy work in Russia. Jenkins also notes the multiplicities of power relations in ethical dilemmas she faced when observing poor patient care: was she on the side of research, staying silent to protect her field? Or should she report the incident, and jeopardise the project? And LaTonya Trotter’s ethnography – of a typically underdog profession, for once in the driving seat, and marginalised patients – reminds us that ethnography can produce nuanced, sophisticated accounts that honour the participants, their communities, and scholarly understanding whilst being clearly on the side of social justice.