In Defense of Class Wars in Population Health: The New Landscape of Social Class With Bourdieu,Neo-Marxists,and the Kohn/Schooler/Wright Integrative Models

There Is No Alternative in Health Equity: Should We Challenge the 40-Year Reign of the Social Gradient in Health?

Despite its recognized positive impact on social inequalities research, as a respected field of study within public health and other disciplines, the social gradient has some notable scientific shortcomings that are not frequently addressed within the multitude of studies using it. ⁴ Specifically, both occupation and income lack explanatory depth since they are not conceived as indicators of a construct integrated with a theory. The empiricist/positivist nature of the gradient actually makes it very vulnerable to refutation. All it takes is one refutation to reject the hypothesis.^5–7 Hence, we already know that the gradient is not a “law” of universal generality in its currently accepted form. Another vulnerability comes from the existence of very few social stratification measures – occupation, income, and education – used to test the social gradient in health. Besides, none of these measures are actually social since they are treated as attributes of the person, without being theorized in terms of social relations. ^{8 , 9}

Why We Should Welcome Class Wars

Alternatives to the gradient approach have emerged slowly in social epidemiology. The construct and importance of class, as ownership of the means of production and as collective agent, was advanced by Vicente Navarro in the 1970s and 1980s through a range of contexts, including health policy, international health, and health services.^10–12 In the 1990s, following the work of both Navarro and sociologist E. O. Wright, a small number of social epidemiologists started using class indicators that capture the construct of social class in relation to ownership of the means of production (i.e., technology) and domination at the point of production (i.e., workplace). ¹³ A relatively small set of Neo-Marxian, mostly cross-sectional studies falsified the social gradient with minimal impact on the larger field of social epidemiology. ¹⁴ Although the first version of Social Epidemiology – considered the textbook of the discipline – cited some Neo-Marxian studies, ¹⁴ the second edition did not mention any of those studies. ¹⁵ The landscape of the field of social inequalities in health reveals a ubiquitous social gradient in health that remains unchallenged, possibly influenced by publication bias, given that authors who did not find the social gradient in their studies were less likely to submit or publish their work. Strangely enough for an established multidisciplinary field of study, the social inequalities in health field has access to hundreds of scales of stress and mental health, ¹⁶ while it appears that there are only three possible measures of social stratification: income, occupation, and education.

The Emergence of New Class Indicators Based on Bourdieu, Marx, and Weber

Within the last decade, Mike Savage, the researcher of the Great British Class (GBC) survey and the New Social Classes map of the United Kingdom, famously said, in a Nature article, that there should be an end to the “wars” between Weberian, Marxian, Bourdieusian, and other social class proponents, who should adopt his own new consensus instead. ¹⁷

The Neo-Marxian and Classic Marxist Alternatives

In addition to Savage’s social class framework, inspired by different forms of capital (financial and social), under the direct influence of Bourdieu, new or rediscovered approaches to social class conceptualization have appeared in recent years. First, the classic Marxist approach sees exploitation as the key mechanism producing economic and health inequalities between classes, as defined by production relations: for example, productive capitalist, financial capitalist, and productive worker. ⁹ A second approach is that of Erik O. Wright, who used a Neo-Marxian theoretical lens, with precedents in the work of Nikos Poulantzas. ¹⁸ In addition to exploitation, Wright included domination – defined as control over the labor process – as a mechanism generating inequalities between classes. Depending on the level of control exercised by individuals on company organization and policy, he identified three categories: manager, supervisor, and worker. ¹⁹ This line of work represents a departure from a classification of classes based exclusively on relations of production (capitalist, worker, self-employed) and, within production, to a measure of the mechanisms that sustain those relations, such as exploitation and domination. In addition, these Marxist ^{8 , 12} and Neo-Marxist relational approaches ¹⁹ expose a major shortcoming of the social gradient approach, namely that occupation, education, and income indicators are conceptualized as individual attributes devoid of social relations.

Savage’s new class division, ¹⁷ focused on property and education and similar to classifications proposed by his Weberian predecessors, including Rose, ²⁰ creates a rank of classes that might be intuitive – elite, technical middle class, affluent workers, traditional working class, precariat – but, nonetheless, neglects social relations and their underlying mechanisms that produce economic and health inequities. This classification also conflates relations of production and domination with culture. The resulting groupings are, thus, unable to distinguish economic from cultural or political relations, given that they are a mix of all of these relations. Moreover, as Bradley astutely pointed out, the indicators of social capital used in the GBC survey lead to a devaluing of working class culture ²¹ and the results of the GBC lead to groupings that might be better understood as class fractions, including the so-called precariat, which is part of the working class. ²²

The Re-Emergence of the Marxian/Weberian Integration

The Marxian/Weberian integration corresponds to a synthesis of the two approaches, as proposed by Wright, ²² shortly after his tenure as president of the American Sociological Association (ASA). Similarly, president Melvin Kohn, one of Wright’s predecessors at the helm of the ASA, also proposed a Weberian Marxian integration, ²³ leading one to believe that being president of the ASA certainly leads to compromises such as accepting that Marx and Weber are either compatible or complementary. Nonetheless, Marx goes one step further than Weber, due to his focus on explanatory mechanisms, namely social mechanisms of domination and exploitation. The idea that property relations and stratification can be incorporated within a single empirical model of class and (mental) health was proposed by Kohn and Schooler in the late 1970s and early 1980s. ²³ Likewise, other authors believe that Marx, at least in his third volume of Capital, considered class as both relational and stratified, an idea also implicit in Wright’s dimensional class indicator. ^{5 , 8 , 9}

There Is More to Social Class Than the Simple Gradient of Occupation, Income, and Education

Despite Mike Savage’s claim that his social class framework should be universally accepted, ¹⁷ a diversity of models and indicators in class analysis is long overdue in the social inequalities in health field. More models and indicators are necessary to understand how social inequalities affecting health occur. Social class mechanisms of domination – via psychosocial exposures such as loss of autonomy – are predictive of poor mental health ^{24 , 25} and depressive symptoms. ²⁵ However, hundreds of studies of occupation, education, and income ranks ²⁶ do not provide a single such mechanism, only an association, begging for one.

It might be that the social gradient is a fast and relatively easy way to gauge a country’s health inequalities. Nonetheless, beyond describing and monitoring trends in social inequalities in health, class analysis (Bourdieuian, Marxian, Weberian) provides a far more complex and explanatory insight into ways in which social inequalities are formed, the way they affect health, and what needs to be done to reverse them.