Abstract
This article elaborates how C. Wright Mills’ “sociological imagination” invites us to “commit sociology.” We argue critical thinking is the foundation of a liberal arts education, and its purpose is to have students recognize that the social world is constantly being constructed and reconstructed—how exactly depends upon the power dynamics embedded in the social, economic, and political institutions of any given time and place. Yet it is very challenging to achieve an awareness of the larger social processes in which our everyday actions are embedded or to recognize the role our everyday practices have in the maintenance or erosion of existing social injustices and inequalities. Moreover, political leaders feel threatened when their agendas, policies, and actions are questioned by the masses. Committing sociology—ipso facto being a successful liberal arts graduate engaged in public debates—threatens political leaders because it calls them to account for their ideologies and the impacts of their policies: a “crime” indeed.
Personal Reflective Statements
Dr. Susan Machum teaches sociology at a liberal arts college that focuses on instilling critical thinking and social justice in its students. As an undergraduate student herself at St. Thomas she was introduced to Mills’ The Sociological Imagination in her introductory sociology course. Initially it felt like gobbledygook so well indoctrinated in neoliberal individualism was her consciousness. However, over time, the task and promise of sociology took hold because her awareness of social inequality and the unfair opportunity structures and outcomes of social programs and policies were also her lived experiences. Her lifelong agenda has been to uncover and address layers of social injustices in order to promote better outcomes for marginalized groups, especially those living in rural communities where she has her roots.
Dr. Michael Clow is Professor of Sociology, but his graduate training was as a political economist in Political Science. How to teach introductory sociology was a challenge he faced early in his career, and Mills’ text, The Sociological Imagination, was recommended to him. Convinced of the need to present an overview of the discipline and the origins of its many conflicting ideological traditions, he has sought the means to bring Mills’ insight into the meta-method of sociology into the mainstream of sociological education.
Introduction
In the Spring 2013, the Prime Minister of Canada, Stephen Harper, made headlines by attacking the Liberal Party Leader, Justin Trudeau, for his insistence on the need to study the underlying causes of domestic terrorism rather than focusing solely on terrorist acts themselves. In a news story Fitzpatrick (2013( reports that at a press conference, Harper publicly admonished Trudeau and reporters for asking too many questions and insisted “… this is not a time to commit sociology”. The Prime Minister’s remark frames the act of asking probing questions—a key dimension of what it means to be a sociologist—as a threatening, almost criminal, activity. In this article, we explore the nature of the “crime” Harper charged Trudeau with, namely, what it means to “commit sociology.” We do so to better teach our students how to think sociologically, and secondarily to examine why a conservative Prime Minister would be so opposed to it.
We begin with a brief discussion of C. Wright Mills’ thoughts on what it means to think sociologically (1959). In the second section, we outline the meta-analytic framework Mills claimed all the great classical sociological theorists, regardless of their ideological hue, had utilized to undertake sociological research (Mills 1959:6-7). Here we offer our simplification of his research questions. In the third section, we illustrate Mills’ method by comparing features of the Canadian and British health care systems. This comparative case study demonstrates how Mills’ questions can produce a sociological understanding of a public issue. In our conclusion, we reflect on why sociology, not just radical sociology, generates the ire of a neoliberal ideologue like Stephen Harper.
Thinking Critically: The Task of the Sociological Imagination
Unlike history, political science, economics, and psychology, sociology is not well known in the public sphere. It is therefore challenging to define the discipline, its subject matter and its characteristic mode of thought for an undergraduate audience. After all, unlike political science and economics, we study just about everything people do. We don’t confine ourselves to the present but study the past and speculate on the future. And we don’t conform to popular assumptions that individual personality, human nature or “the market” direct our activities and set the shape of society. What we study and how we do so are largely unknown to freshmen, and a continuing struggle for undergraduates to grasp and make their own.
Since the dictionary definition that sociology is the “science of society” is too nebulous to capture what sociologists do, as professors we rely on the notion that sociologists study the various ways humans have organized their affairs. Humans are a social species, we explain, which means more than we live together, in close proximity to others. For humans, being social means that we have to work together, across many forums, in an organized fashion, to accomplish the goals and tasks at hand. History shows there have been many ways to organize our affairs. The agenda of sociology then is to study the many ways we have organized ourselves; the consequences of organizing ourselves this way rather than that; and the processes of how we organize and reorganize ourselves to do things.
It is the breadth of our subject matter and our focus on interlocking relationships that leads sociology to have strong connections with other disciplines. How social activities are organized and reorganized is essentially a political process and sociology is thus related to political science and its interest in political conflict and cooperation, and the operation of political institutions. Given the present emerges from past actions and political processes, historians are, as Berger (1963) noted, close companions along our professional journey. In a similar vein, sociologists interested in work and economic outcomes discover overlapping interests with economists when we study production, distribution, and consumption processes, even if our assumptions are not so rigidly tied to market models, that is, to exchange relationships. And like social psychologists, we are concerned with how people make sense of their social situations and act in groups. Recognizing all social scientists seek to make sense of the same social world, sociologists have things to learn from, and to teach, fellow scholars of society.
Few texts have the staying power and are as broadly referenced by sociologists as C. Wright Mills, The Sociological Imagination (1959). Part of the book’s ongoing pedagogical attraction is Mills’ promise that the acquisition of a sociological imagination will allow us to overcome the range of dualisms—micro and macro, individual and society, biography and history, self and world—with which we struggle. It is important to recognize Mills did not for a moment believe sociologists were the only social scientists capable of seeing this relationship between individual experiences and the characteristics of the time and place within which they occurred. He argued sociology was but one discipline that aimed to link and comprehend multiple layers of social life and their evolution through time and space (1959:18-19). All those who possess a sociological imagination are able “to grasp history and biography and the relations between the two” (1959:6). They are able to visualize and document the multilayered, complicated and constantly changing character of human life and society; and to understand and connect those layers into a holistic analysis.
Throughout The Sociological Imagination, Mills powerfully refutes the methodological individualism that leads us to attribute our personal troubles and successes to ourselves, when both are inexplicable without knowledge of the social contexts and the ways they create or constrict individual action and opportunity. Mills uses powerful examples to show that what Marx called the “false consciousness” of individualism can best be understood as the lack of a sociological imagination. Many sociologists admire Mills because his framework helps us in this era of neoliberalism to address the emphasis on individualism and the myth of the self-made man. He eloquently insists we must recognize that our lives are embedded in a large web of social situations and processes. In this Mills was like another more contemporary popularizer of the sociological imagination, journalist Malcolm Gladwell, who in Outliers (2008) makes clear individual successes and failures are strongly influenced by the time, place, and the organization of activities in which we are located.
Unfortunately, our experience as professors is that much of the rhetorical beauty and eloquence of Mills’ presentation is extremely challenging for students to comprehend, in large part because they have been encouraged to view their own lives as the outcomes of individual accomplishments or failures. Collectively, we routinely practice “commodity fetishism,” in that we tend to see most of the “objects” and “goods” that we interact with as distinct, separate entities disengaged from the series of social activities that brought them into existence and within our reach. According to Czerny, Swift, and Clarke’s Getting Started on Social Analysis (1994:14-15), we can begin to become the “system thinkers” Mills called for us to be by starting to ask questions and seeking answers about the processes our everyday lives and activities are embedded in. For example, Czerny et al. (1994:13) challenge us to ask probing questions about the cup of coffee we are about to drink, to consider: Who grew the coffee? How was it processed? Where did the milk and sugar come from? How did the cup holding this hot liquid arrive in our possession? Who made the machines in which it was brewed, the spoon with which it was stirred? Who served it and what are their working conditions? How are all the activities connected to coffee linked to natural resource–based industries, food systems, labor systems, and so on and so on? Probing the delivery of a simple cup of coffee generates an extensive series of questions. A series of questions which when answered systematically and holistically will lead us on the path to Mills’ sociological imagination.
Although the scale of such analysis can be overwhelming, from our vantage point asking the right questions is a core, but underexplored, element of Mills’ sociological imagination. In the next section, we outline how we focus student attention on the meta-analytic framework embedded in Mills’ opening chapter in order to help them develop an awareness of the myriad connections and relationships among layers of social life.
Mills Method of Inquiry: How to Become a Sociologist
In the introductory chapter of The Sociological Imagination, Mills asserts classical sociologists were concerned with the practical problems of the society in which they lived; and their theoretical legacy, he argued, emerged from their study of those problems, their causes, and their solutions. In his review of the classics, what Mills extracted from their work wasn’t consensus on the nature of modern society but an underlying method of analysis, a meta-method for sociological research that he argued all classical sociologists, regardless of their political stripes, sought to answer (Mills 1959:6). Mills lays out in three paragraphs the kind of questions he observed “classical social analysts, however limited or however broad the features of social relativity they examined” asked (1959:6-7). From our vantage point, these series of questions provide the research agenda Mills believed would produce and refine a sociological imagination.
Despite its insight direct use of Mills’ meta-method tends to be underutilized in sociology. We think this is partly a consequence of the overwhelming detail and scope of each series of questions. Our approach brings Mills’ list of questions (1959:6-7) to students’ attention, and then simplifies and adapts them for teaching purposes. We have found our simplified questions capture the essence of Mills’ research agenda while bringing the research program necessary to develop a sociological imagination into sharper focus for students. In this section, we present both Mills’ paragraphs of questions and our abbreviated versions of them. Mills’ (1959:6) first series of questions call on researchers and students to ask: What is the structure of this particular society as a whole? What are its essential components, and how are they related to one another? How does it differ from other varieties of social order? Within it what is the meaning of any particular feature for its continuance and for its change?
Clearly, this series of questions invites us to study the present arrangements of society. We boil these questions down to “How is society (or a specific activity within it, such as health care) organized? And what are the consequences of organizing it this way?” We would argue that implicit in the nature of “organization” is a question of who or what groups of people are created by this particular form of organizing. One cannot discuss organization without discussing the actor groups whose activities are informed by particular social structures. For example, the organization of health care cannot be understood without reference to the doctors, patients, health authorities, administrative bodies, and the plethora of other health care professionals embedded in it. Mills only identifies actor groups in his third paragraph of questions (1959:7). We would argue actor groups, their roles and activities, need to be included as part of this first series of questions about the present structure of society rather than be addressed separately.
Mills’ (1959:6-7) second paragraph of questions is even denser than the first. Here, he questions: Where does this society stand in human history? What are the mechanics by which it is changing? What is its place within and its meaning for the development of humanity as a whole? How does any particular feature we are examining affect, and how is it affected by, the historical period in which it moves? And this period—what are its essential features? How does it differ from other periods? What are its characteristic ways of history-making?
This string of questions asks us above all to document the past activities and events from which the present emerged. We abbreviate them to: “How did this way of organizing society (or an activity within it such as the health care system) emerge?” Again implicit in our simplified version will be the issue of who participated in the construction of the existing order?
For the most part, Mills’ (1959:7) third series of questions is largely focused on who and what kind of people emerge from the organization and struggles within society (or around a particular dimension of its activities): What varieties of men and women now prevail in this society and in this period? And what varieties are coming to prevail? In what ways are they selected and formed, liberated and repressed, made sensitive and blunted? What kinds of “human nature” are revealed in the conduct and character we observe in this society in this period? And what is the meaning for human nature of each and every feature of the society we are examining?
These questions warrant a detailed examination of how society influences the social psychology of its members, and thus speak to the whole interpretative tradition within sociology. They also bring up explicitly the questions of who currently prevails in contemporary society and who is coming to prevail in the future that is emerging? Answering these questions implicitly addresses “who prevailed” in the construction of the society unfolding before us. In our simplification of Mills’ questions, we have chosen to avoid the social–psychological concerns Mills raises in favor of the more structural features of his thought. Undoubtedly, this is reflective of our own bias and intellectual limitations but it does allow us as sociological researchers to investigate ongoing social processes rather than becoming preoccupied with personal troubles. Of course, this is not to say there is no relationship between the two. However, students are all too inclined to micro-gaze upon the details of their personal experience. Our teaching goal is to have students understand the larger social milieu within which their lives unfold and this requires more attention be paid to actor groups’ interests rather than individual experiences.
We have found Mills’ lists of questions to be a valuable but complex package that when abridged can greatly assist students undertake research. It is noteworthy that Mills’ starting point for sociological analysis is with present arrangements, then the past. As sociologists we seek to understand the contemporary but it can only be achieved by recognizing past processes and actions, which when combined, can greatly improve our chances of predicting the future. Our working reformulation of Mills’ questions can be summarized as follows: How is society (or a specific activity within it, such as health care) organized? What are the consequences of organizing it this way? Who prevails, or whose interests prevail, within this organization of our affairs? How did this way of organizing society (or an activity within it, such as the health care system) emerge? Who prevailed, or whose interests prevailed, in its construction? Who and what is coming to prevail?
Although we argue that an initial run through the questions should be organized around present, past, and emerging future, we make it clear to students that the study of an activity or public issue quickly requires the analyst to repeatedly examine the relationships between the present, past, and future.
In the context of teaching and undertaking research, it is quickly evident that sociologists provide different answers to these questions. Mills, after all, is famous for critiquing the sociology of his day as either too conservative or too abstract and aridly scientific. Mills was a radical and felt that “good sociology” had to be actively critical of the status quo. In his discussion of public issues (Mills 1959:8-13), Mills made clear he stood foursquare on the side of those who were experiencing the deleterious consequences of social arrangements. He was more concerned with the “losers” under existing institutional arrangements, for the victims of public issues, rather than the privileged. That is a position we would also identify as the basis of good sociology. Nonetheless, Mills clearly knew that his questions didn’t have to be answered with this own moral evaluation of existing arrangements and the power distribution that underlie them. That is implicit in his claim that all the classical sociologists asked these kind of discipline-defining questions, but they certainly did not answer them with a uniform political perspective. He was well aware of the existence of a more conservative sociological imagination than his own, and more radical sociological imaginations too.
This divergence of perspective in the answers offered by different researchers arises not from individual eccentricity, but out of the conditions of our participation as members of society in the social construction of reality (Clow 2008:69-70). Questions of which social arrangements are good, better, or worse inevitably arise. Questions of who wins and who loses from social arrangements, and of how effort, risk and benefit are distributed by particular forms of social organization naturally arise. To study society, its history, and emerging future, it is therefore necessary to engage matters of political and moral judgment and purpose. We should bear this truth in mind as teachers of the next generation of sociologists and as participants in the wider task of liberal arts education. Inevitably, we must provide room for a respectful “ear” to the variety of moral and political judgments our students will bring to bear in their answers to these questions.
Practicing the Method: A Brief Look at Two Health Care Systems
In their landmark study of scientific knowledge, Barnes, Bloor, and Henry (1996:102-3) argue that theory is learned through examining exemplary studies and then trying them out for oneself on objects of study. Only after the form of analysis is well practiced and understood is the student in any given subject matter ready to be a practitioner of their discipline. When teaching students how to be sociologists we thus routinely have them use our version of Mills’ meta-method to analyze social issues. Here, we illustrate our approach by examining the health care systems with which we are personally familiar, those in Canada and the United Kingdom, using our simplified version of Mills’ questions. Health care is a complex topic and our analysis is by no means exhaustive. Interested readers can consult many fine books and articles to elaborate our analysis (e.g., see Armstrong and Armstrong 2008; Barton 2009; Hutchison et al. 2011), but even a brief examination does offer insight into the value of Mills’ questions for gaining an appreciation of how sociologists work.
Given the scope and breadth of any social system, the first thing we need to consider is what limited number of features of the system we will focus our “searchlight” on to delineate how it is organized and with what consequences (Coates 1994:252). In the instance of health care, we focus on who owns health care assets, how health care providers are paid for services rendered, and the way health care providers are organized. As we will see, these three features demonstrate different patterns of organizing health care services across two quite similar nation states in the later half of the 20th century.
Our illustration begins with how health care is organized in Canada. After outlining the major features of the Canadian health care system, we compare it to the British National Health Service (NHS). We then look at the history of how these public health care systems emerged, emphasizing for our students that the particular features of social institutions are malleable and the result of social processes and decisions. Finally, we ask questions about these health care systems emerging futures. Our goal is to emphasis that humans create and recreate the social world through the exercise of political power and will. If we like how something is working we will often fight hard to retain it, only if we don’t like something are we generally motivated to change it.
How Is the Health Care System Organized in Canada? With What Consequences? Who Prevails?
An examination of who owns health care assets reveals only part of the health system is publicly owned in Canada. The public health care system only extends to physician and hospital services—all other health care services are available through private, for-profit providers. Moreover, while health care falls under provincial jurisdiction, two tiers of government, federal and provincial-territorial, are involved in the financing of public health care assets.
To qualify for federal funding, each Canadian province and territory must ensure their health care system meets the five federal guidelines established in the Canada Health Care Act (Czerny et al. 1994:21). Specifically, each provincial health care system must ensure that in regard to physician and hospital services: All residents are covered; coverage moves between provinces; coverage is comprehensive and not overly restrictive in terms of medical treatment services in hospitals and by physicians; services are accessible in reasonably good time; and finally, the health service is a nonprofit, publicly administered one (Minister of Justice 2012). If these five conditions are met, the federal government financially supports the provincial and territorial level health care systems’ acquisition and maintenance of assets and delivery of services.
It is this public ownership and administration of key assets—in particular hospitals, community health care clinics and all the diagnostic equipment and means of treatment located within them—that is, at the core of Canada’s Medicare system. Paying for these assets is largely accomplished through general taxation; some provinces do require residents to pay directly into their provincial system through compulsory public insurance programs, while others do not. The costs of some ancillary services related to hospitalization, such as ambulance costs may be covered as part of the “free” public program in some provinces, but not in others. In short, how extra revenue is generated and how health care dollars are spent is in the purview of each provincial government. This accounts for differences in health care delivery from province to province.
What each provincial Medicare system has in common is that hospitals are publicly owned and administered by regional health authorities, usually through a provincially owned corporation that reports to the provincial Minister of Health. These hospital or regional publicly owned health care authorities are the direct employers of all health care providers who work directly for the hospitals. For example, emergency room physicians, nurses, diagnostic and treatment technicians, dieticians, physiotherapists, occupational therapists, administrators, and other extensive support staff in the hospital are paid their salaries from public funds through the health corporation. Many of these health care providers and support staff are unionized government workers who bargain collectively for pay and working conditions with the health authority. However, as a rule, Medicare corporations do not directly employ the majority of physicians. Instead, most physicians own and maintain their own private practice; they act however as exclusive “contractors” for the Medicare system.
To practice medicine in a province, a physician must have a Medicare billing number in that province, and they submit their bills to the provincial heath care authority under a fee-for-service payment structure negotiated between the provincial Medical Association and the health care authority. In short, for physicians, there is a single payee, the provincial government through its health authority. Each provincial Medicare Corporation controls both the number of billing numbers available and owns and administers the medical infrastructure, so they are in charge of allocating physicians access to the hospital facilities needed to test, diagnosis, and treat patients. Consequently ready access to resources such as operating rooms has, at times, been a contentious issue between physicians and Medicare authorities.
Outside of physician- and hospital-related care, most other health care provisioning is available only through the market. As a consequence, Canadians have to pay out-of-pocket or through private health insurance for dentistry, physiotherapy, occupational therapy, psychological therapy, Chinese medicine, acupuncture, massage therapy, herbalism, chiropractor care, homeopathy, and other forms of health care services outside the hospital setting. Likewise, prescribed medications outside the hospital setting must be privately purchased from a for-profit pharmacy. People who want to have their vision, hearing, or teeth examined usually must pay for these services themselves. As a consequence, access to the full slate of health care resources of society is not universal and the uptake of these services is far less equitable than those offered by physicians and hospitals.
A second consequence of the public/private split in health care provisioning in Canada is that private, for-profit insurance companies make a lot of money offering policies to individuals and workplaces to cover the costs of dental work, prescription medications, eye examinations and glasses, massage therapy, and so on. Access to such health benefits through workplace insurance, and the terms of other private insurance programs, are crucial in determining the accessibility of nonpublic-provided health care services by Canadians.
Clearly, the split between publicly funded and privately funded health care services implicitly privileges wealthier socioeconomic groups. It also privileges certain health care providers. Public dollars directly support physicians’ activities and those of the nurses, technicians, and others who support their work in the hospital setting, and not those who work outside the hospital. The provincial government determines the diagnostic treatments that will and will not be covered under their public health care program. Private insurance coverage dictates the treatment a patient will or will not be able to receive or afford under their insurance plan within the private sector. Dentists, optometrists, and all “alternative” health care providers must individually bill patients, collect fees-for-services rendered, and invest in diagnostic and treatment equipment.
There are other important dimensions of social organization within health care that we don’t let students go without knowing. For example, within the health care system itself, there exists a hierarchy of professions. This hierarchy is usually along the lines of the “technical division of labor”—who does what—among health care providers. The fundamental distinction is between professionals and “semiprofessionals.” Professionals govern their own affairs through peer-review accreditation whereas skilled, semiprofessionals work under the direction of the self-governed professionals. Among the professions, physicians are the most financially secure and most prestigious group of actors. They direct a very large army of semiprofessionals including nurses, technicians, and therapists in the hospital system. Even though they also direct a number of semiprofessionals, such as dental hygienists and opticians, self-governing private sector professionals like dentists and optometrists garner less prestige than those who are embedded in the state-funded health care system.
Among the ranks of physicians themselves, another dimension of social hierarchy prevails, with “specialists” perched on top and general practitioners (GPs or “family doctors”) situated at the bottom in terms of prestige, pay, and expertise. In Canada, patient access to specialists is controlled by GPs, who assess and advise the patient directly on treatment or pass them along to a specialist for further diagnosis and the development of a treatment plan which the GP will then monitor as things develop. In this situation, both GPs and specialists have privileged access to publicly owned resources for diagnosis and treatment, as well as the assistance of semiprofessionals employed by the hospital. Most services are provided “free-of-charge” to patients in the doctor’s office and hospital, but should one wish to access these same services (still under the physician’s authority) outside the hospital setting—for example, physiotherapy services—they must be purchased directly for cash or through one’s private or workplace insurance. Poor people and many “middle-class” people cannot afford the costs of these private health care providers.
Beyond the split between the public sector and the private sector division of health care services, the Canadian approach to health care is premised on a particular understanding of the human body. That is, how the human body, the human person, is cared for is itself socially organized. In the Canadian approach to health care, the human body is imagined and treated as a series of separate and “distinct” pieces under the care of medical specialties, that is, cardiologists care for the heart, podiatrists for the feet, otolaryngologists for ears, nose, and throat, and the list goes on. The upshot is that for the most part people are treated as a collection of body parts, rather than holistically. Furthermore, the treatment of certain “body parts” is subject to rival groups of nonphysician professionals—for example, ophthalmologists have medical degrees (they have all the basic training of other medical doctors) and are thus classified as physicians who have specialized in eye and vision care. On the other hand, even though they have years of training and hold a Doctor of Optometry degree, optometrists are not classified as medical doctors. Optometrists are trained to examine, diagnose, treat, and manage eye and vision disorders but they cannot perform surgery or prescribe medications like ophthalmologists can. The treatment of mental health—brains and minds—is similarly divided between the medical specialty of psychiatry and the “nonmedically trained” psychologists. And teeth are treated quite separately again, indeed they sit entirely outside the purview of medicine and are treated by a separate group of professionals: dentists. In Canada, “medicine” and hospitalization have been separated from the provision of drugs, dental, vision, and mental health without any logical reason rooted in biology.
As a consequence, rather than perceiving the body holistically and treating a “whole person,” the care and treatment of each body part is done on a piece-by-piece basis. The technical division of labor and fee-for-service payment structures support this approach. In discussions around dental care, recent studies have noted “the lack of dental care is a ‘gaping hole’ in Canadian Medicare and causes many health problems for patients” (Picard 2014:A6). Given dental problems impact cardiovascular, nutritional, and mental health, they should not be treated or understood in isolation from the rest of the body, especially as dental problems are most likely to impact the most socially and economically disadvantaged groups (Canadian Academy of Health Sciences 2014; Duncan and Bonner 2014; Quiñonez 2013). The same story holds true for mental health and vision care. Not being able to see, hear (hearing aids are not covered by most provincial Medicare programs), or eat properly impacts both physical and mental health and can acerbate relatively benign and low-cost problems and turn them into acute, high-cost, care needs.
A final point to be made here is that “health care” in Canada is in effect “illness care” or what Czerny et al. (1994:19-31) refer to as an “illness cure” system. The entire health care system is organized to diagnosis and treat illness rather than maintain good health and prevent illness. An illness prevention system would spend health care dollars very differently—it would focus on ensuring minimum standards for good health were met. Citizens would have access to sufficient and nutritious food, adequate housing, free gym memberships, and clothing suitable for the various phases of the climate. We could very reasonably expand the list to include an environment clear of pollution and safe workplaces. In short, a health care system focused on avoiding illness and promoting health (rather than haphazardly restoring health to those who fall ill) would address the social determinants of health including employment, working conditions, income, education, the state of physical environments, and social networks to name a few (Mikkonen and Raphael 2010).
Who then prevails in the current Canadian health care system? At the most basic level it is the patients of physicians and hospitals—eventually all Canadians at one time or another—who benefit the most from the public provision of physician and hospital services. Physicians and the semiprofessionals who work inside hospitals are also major beneficiaries of the current organization. Canadian citizens and permanent residents do not need to pay out-of-pocket for general medical care, as is the case when medical treatment is provided by for-profit businesses. That is not to say physician and hospital care are free in Canada; they are paid for from income tax and sales taxes, and in some provinces by mandatory insurance contributions to the provincial health authority—a tax by another name. But one pays the costs of health care bit-by-bit over many years, and so ill health is for most Canadians a health crisis, not a financial one. Financial troubles can emerge if you can’t pay for your out-of-hospital prescription medications—so the system does have weaknesses. Nevertheless, Canadians overwhelming support public health care because it is in their own material interests to do so.
Despite its value to patients, the existing public system is experiencing financial constraint because governments have not been inclined to meet the rising costs of universal access to physicians and hospital services. On one hand, we have Medicare programs that provide acute and ambulatory care; but, on the other hand, accessing these services in a reasonable time frame can be challenging. At present, many provincial systems do not have enough GPs to meet population needs, and hospitals are chronically under-resourced (and perhaps not optimally utilizing available resources). Increased “wait times” as a consequence of health care cuts are a major public issue, resulting in a triage system where access is based on doctors’ assessment of the urgency of need.
The other, less obvious winners in the public system are physicians and other publicly funded health care workers. Physicians are always promptly paid for their services when they are on the public schedule of provincial Medicare, no costly and unsettling need to chase after patients; and fees are set by collective bargaining with the provincial government. It is not an accident that the organized body of physicians—the national and provincial medical associations—is a pillar of the political support for Medicare. Ditto for nurses, technician, and support staff in the hospitals. The opposition to public health care does not lie within the system, but from business and neoliberal ideologues outside it.
The public system has its share of winners and losers. First and foremost among the losers are patients who cannot afford to pay for medications and out-of-hospital services by professionals and semiprofessionals. However, limitations of the public scheme also create opportunities for insurance companies to turn the fear of illness treatment into an occasion for profit. The fact that for-profit multinational corporations supply medications as well as diagnostic and treatment equipment rather than state funded enterprises makes these businesses and their investor’s big winners. Whether the private providers of dental and other health services are winners or losers from the public–private dimension of the health care scheme depends on uncertain guesses about how their incomes would potentially be affected by their inclusion within the public system. Since Canadian physicians initially opposed Medicare, there is much room for debate on this point.
How Does the Organization of the British Health Care System Compare to the Canadian Model?
The British model for health care is a far more thoroughly public model than the Canadian. As in Canada, the government through the NHS owns hospitals and the norm is public administration of these publicly owned assets. Medical practices are, however, also NHS property—physicians all work for the NHS. And by contrast with the Canadian model of health care, the British is characterized by a wider scope of services included under the public scheme—notably, out-of-hospital medications and dental care. But there is more room for the government to contract-out the provision of services to the public system by private corporations in Britain than in Canada.
One of the least obvious, but important, differences between Canada’s Medicare system and the United Kingdom’s NHS is that in Britain GPs and family doctors are paid on a per-patient rather than a per-visit or fee-per-service basis. It is thus in the best interest of the GP and his “surgery” (the British term for doctor’s office) to spend as much time as necessary with the patient on their initial visit in order to diagnosis and treat ailments in a holistic, rather than piecemeal, way. Since more visits do not garner larger salaries, the physician’s goal is to ensure patients stay well. We attribute a British tendency toward greater recognition of the relationships between mental and physical well-being to this feature of health care organization. The broad scope of services under the NHS also contributes to a greater British tendency to address the connections and relationships between the human body’s multiple systems including the circulatory, digestive, endocrine, immune, lymphatic, muscular, nervous, and reproductive system.
Seeing the human body as a working whole, and organizing payment to treat the whole person rather ailing parts probably also results in a much wider range of health care treatments and services being made available to patients without direct payment by the patient. Dental and vision care are part of the NHS, and many prescription drugs are available for only the cost of a dispensing fee paid to the for-profit drug store (dispensing chemist). As a consequence of the broader scope of public health provision in the United Kingdom than in Canada, medical practices are much more team oriented—psychologists work with cancer specialists, midwives with gynecologists, and obstetricians, for example. Even many “alternative” health care providers like homeopaths and massage therapists, who are marginalized from mainstream health care in Canada, are part of health care teams, as are social workers outside the hospital setting.
British GPs work primarily in their surgeries, emergency departments, primary care units, minor injury units, walk-in centers, and clinics. All these sites of practice are NHS-owned. As well, British GPs are much more likely to include home visits as part of their routine strategy for treating patients than Canadian doctors are. And certainly other publicly employed health care practitioners—such as midwives and public health nurses—regularly make home visits to follow through and carry out treatment plans. All of these services are considered standard health care services available to all regardless of their socioeconomic background in the United Kingdom. Barton (2009:4) thus describes the British health care system as universal and comprehensive compared to the Canadian welfare-oriented system.
The consequences of organizing health care differently in the United Kingdom and Canada are not trivial. Overall, the NHS provides its citizens with greater free access to the widest range of illness cure services. Of course, as in Canada, the problem of access in the NHS is wait times for treatment, given the capacity limitations of the system. Whether a physician is available to see you when you need them, whether there are enough surgeons, nurses, and operating rooms available is a matter of details in the division of labor, and whether the system is receiving the financial resources it needs to meet the demands upon it. The problems of wait times and shortage of doctors and health care providers in Britain, like in the Canadian public health care system, is a function of the unwillingness of governments to provide adequate funds to meet the needs of the population. One serious source of the difficulty in the provision of adequate funds for the public health care system in both countries is that governing parties—the Conservatives and “New Labor” in Britain, the Conservatives and Liberals in Canada—are ideologically opposed to public enterprise and desirous of making all endeavors sources of profit for investors and employers (Naiman 2012). It is those working in the public system and the public itself that are the brake on neoliberal politicians and their supporters in business. No government in Canada or Britain would likely survive a frontal assault on their public health care system. Instead, they contribute to the “crisis in health care” by restricting funds and—particularly in Britain—by employing private health care providers to outsource the provision of services under the NHS.
How Did These Ways of Organizing Health Care Emerge? Who Prevailed, or Whose Interests Prevailed in their Construction?
The emergence of these forms of health care organization, we remind our students, is a matter of political history. Space limitations in this article allow us to only provide a brief outline of the major dynamics of that history.
In the 1940s, both Canada and Britain had free-enterprise health care systems, with health services available either as a commodity for profit or from charity hospitals at the latter’s discretion. How did the NHS ever emerge in the late-1940s as a public service system in a capitalist society as deeply unequal as Britain? The answer is that in the wake of World War II (WWII) the population had had more than enough of free enterprise health care because most could not afford to access it even when acutely ill. As part of the campaign to garner support for the war effort the coalition government promised the British population a better postwar future. Post-WWII the population expected policies and programs that would reduce poverty and increase living standards. The coalition government broke up with the General Election of 1945. So it was hardly surprising when the Conservatives, who under Prime Minister Winston Churchill and with the support of Business and the medical establishment, lost the 1945 election as a result of their vociferous opposition to the creation of a NHS. Instead the Labor Party, who above all represented the trade union movement, campaigned and swept to power on a platform promoting the nationalization of major industries, a new Welfare State and a new national health care system for all.
As near bankrupt as Britain was in the wake of WWII, the Labor Party puts a substantial portion of its national budget into the construction of a NHS capable of meeting the British population’s health needs. Interestingly, the medical establishment’s opposition to the NHS did not last long. Doctors found they remained in charge of their medical practices under the NHS, their incomes and their patient numbers increased, the infrastructure of health care expanded steadily, and the standard of national health care soared. Physicians quickly recognized their interests in the new public system. The interests of the British population won out in the fight for a public system and physicians discovered so had they. Their fears about becoming civil servants rather than remaining businessmen evaporated.
Two decades later, the Canadian health care system also emerged as part of the establishment of a Welfare State. At that time, the union movement was strong and it was calling for a more profound safety net than the two main conservative national political parties were interested in developing. The impetus for Medicare’s creation was the decision by the Saskatchewan wing of Canada’s social democratic party, the then Cooperative Commonwealth Federation (CCF), to fight the 1960 provincial election on the issue of establishing a public system for physician and hospital services. To the surprise of the provincial medical establishment and business interests, Tommy Douglas’s CCF won the election. When the health care legislation went into effect in Saskatchewan in 1962, doctors supported by the local business elite went on strike. However, with the help of British doctors who were flown in to staff the hospitals, Premier Tommy Douglas successfully thwarted efforts to stop this new approach to health care delivery. Saskatchewan’s successful example quickly gained national momentum.
At the federal level, by the mid-1960s, the Liberal Party was strongly outflanked on the health care issue by the national social democratic party (by now renamed the New Democratic Party [NDP]). In a minority government situation, the Liberals were forced to finally do something to fulfill a federal Liberal election platform promise on universal health care that dated back to 1919! To keep their hold on national power, the Liberals established a 50:50 national-provincial health care funding formula for any qualifying provincial public system in 1966. No provincial government could now survive refusal to the widespread public demand for a provincial public health care program, and provincial Medicare schemes swept the country (Armstrong and Armstrong 2008, 2010; Chappell 2008; Czerny et al. 1994).
The key dynamic for students to recognize is that all health care systems have political histories. They emerge and change through political processes, debates, and struggles. Within each of these systems the patients prevailed. Although patients gained more services in Britain than Canada, in both instances the inequitable access to health care was reduced. In each case, organized labor and social democratic political parties spearheaded the fight for public health care. Physicians were also winners, in spite of themselves, because they gained access to expensive resources and they only had to bill one agency for their services. All public sector health care employees gained from this reorganization of health care. It was private enterprise that lost the most, to the extent that their opportunity to exploit illness for their own profit was restricted and the benefits of public provision of services was recognized and taken up among ordinary British and Canadian citizens.
The Emerging Future: Who and What Is Coming to Prevail?
The immediate future of health care in Canada and Britain remains a political struggle between those in support of public health care versus those opposed to it. The larger political context of this struggle is that political life in both countries is embedded in a neoliberal agenda aimed at reducing government spending, cutting taxes for the wealthy, abolishing government regulations that impede corporate agendas, attacking labor and eliminating social programs in favor of greater reliance on charities and individual resources (Naiman 2012:196-99). This ideological framework is empowering neoliberal governments in Canada and Britain to impose tax cuts, and attempts to reduce public spending in all social service sectors, including health care. Reduced revenue streams are coinciding with rising health care costs due to aging and longer living populations and increasing incidence of health problems such as obesity and diabetes rooted in high-profit food products and unhealthy lifestyles.
Opponents of public health care have various motivations. Some simply feel that governments cannot afford to provide the funds to meet steadily increasing costs; these people often talk of rationing heath care or charging “user fees” to patients. The belief is strong among some “moderate” conservative politicians that the solution to long wait-lists and rising public health care costs is a two-tier system (private medical care for the well off and public care for the poor). Other opponents of the public system are more transparently ideologically motivated calling for the privatization of public health care—the turning over of public assets and the ownership of hospitals to private corporations. Wealthy opponents of public health care are often more interested in the tax cuts privatizing the public system could facilitate than their own personal health costs. Investors and the business community are motivated primarily by the profits they would accrue by taking over the assets of the public system. A privatized health care system would reap them massive new investment opportunities in an era of a rapidly aging population.
Proponents of the public health care system also have various motives. The left sees public health care as a cornerstone of their efforts to resist rising inequality. Those concerned with their own health are motivated by the awareness that public ownership is their ticket to affordable health care. As personal examples, author Machum had two children without paying personal costs; author Clow had 17 days in hospital and the implantation of a state-of-the-art pacemaker/defibrillator after cardiac arrests for the cost of the ambulance to the emergency room (which was later paid for by private workplace health insurance). In the United Kingdom, doctors and unionized health care workers and the labor movement strongly support the maintenance of the NHS. Similarly in Canada, a coalition of the Canadian Medical Association, the labor movement, and health care worker unions strongly support retaining our provincially owned and operated Medicare system. Proponents of public health care argue that a two-tier approach would gut the public system and raise total health care costs, to the benefit only of the new private owners of health care assets. Collectively, we currently benefit from a public health care system where no profit is added to the cost of services; and the costs of health care are shared over the whole population over our lifetimes. This approach is consistently found to be cheaper than for-profit systems (Wikipedia n.d.).
But being in favor of public health care does not mean that you are opposed to ongoing changes within the system. For example, pressure is mounting, from the nursing community in particular, to reorganize primary care around community health clinics that would feature teams of health care workers (including GPs) who would assess the patient, refer them to hospitals and specialists, and oversee their subsequent treatment rather than around the current practice of organizing care from the GP’s office. In this proposed solution to doctor shortages (precipitated 20 years ago by a significant reduction in the number of places at government supported university medical schools), specially trained “nurse practitioners” would assume many of the current duties of GPs. Needless to say, GPs have tended to resist this solution since it would see another—lower cost—primary caregiver operating on what has traditionally been their turf.
How Is the Battle Over Health Care Likely to Turn Out? Who Is Likely to Prevail?
Predicting the future is at best a matter of educated guesswork. However, as sociologists our awareness of the present and our understanding of historical processes allow us to contemplate the future. Certainly, the forces behind the opposition to public health care are very strong. Indeed, if one considers how successful the corporate campaigns to sell off nationalized industries and reduce other parts of the welfare state in both Britain and Canada have been, what is surprising is that Medicare and the NHS even exist at all in the second decade of the 21st century. But there are reasons for the continuing strength of public health care. Although limitations on government funding have constricted the scale of public medical services, the legislative requirement in Canada that health care be publicly administered has severely limited efforts to privatize parts of the public system or to “contract out” elements of the public service to private contractors. This has been much less the case in Britain. There the extent of contracting out has been much greater, and the financial crunch on the NHS has further pushed health care managers to search for new sources of revenue. For instance to create new revenue streams, they have sought to increase both the number of “private patients” from outside the United Kingdom and the number of British citizens willing to pay for “cosmetic services” not otherwise available under the NHS.
Whatever reorganization of public health care transpires in each country, both British and Canadian populations are deeply and fiercely attached to their publicly funded systems. So far, neoliberal politicians in the United Kingdom like Thatcher, Blair, and Cameron, and their counterparts in Canada, have been able to batter away only at the edges of each system, knowing a frontal assault would likely result in public unrest and a massive electoral defeat in the following election. The reason public health care remains the one relatively intact element of the welfare state is the fact that public health care is the universal “welfare” measure everyone in society shares, and knows they share. Beyond the members of the “one-percent” there has been no basis on which opponents of the system have been able to engineer a division between “us” and the “undeserving” in terms of access to universal medical care.
Conclusion
Throughout this article we have argued that Mills’ formidable list of questions reflects a meta-method that when regularly pursued will develop one’s capacity to think like a sociologist. From our perspective, Mills’ meta-method effectively captures the essential sociological insight that the world works as it does because of how people’s lives and activities are organized; and that the organization of human life is a product of social struggle, not human nature. In the first section of this article, we argued Mills’ is calling on us as sociologists to see the underlying social order, its creation and its consequences, as well as the processes by which the social world changes. Mills argued that the classical sociologists had shared this same research agenda and by virtue of seeking answers to a similar series of questions they had established a distinctive sociological method of inquiry, the “sociological imagination.” He knew these questions had been answered in radically different ways and the answers represented different vantage points on how the world worked and how it ought to work, but he remained convinced our mission as sociologists was to help people improve their lot and the conditions for others. To do so required us to move beyond the immediate circumstances of our own lives and to see the relationship between our own biographies and the historical period in which we live. For Mills (and for us), seeking answers to the questions outlined is the means to establish and practice one’s own sociological imagination.
But our teaching experience is that contemporary undergraduates have only very limited success at understanding Mills’ presentation of the sociological imagination in “The Promise.” A colleague at St. Thomas asked freshmen year after year to explain what the sociological imagination was after they had read The Promise and, on their own, the majority just didn’t “get it.” Their answers clearly showed that even with the powerful examples Mills used, students had failed to distill for themselves an understanding of sociology’s approach to explaining the world. Even the centrality of answering the questions as outlined by Mills eluded them.
Our response was to take a somewhat different approach with Mills. Although we had students read Mills’ text, and even read it out loud with them in class, our focus was to clarify the means by which students might obtain their own sociological imagination—that is, by shortening, simplifying, and reorganizing Mills’ list of questions and then repeatedly using them in class to illustrate what those questions illuminate about a variety of social problems. In the second section of this article, we presented our simplified list of questions; by briefly outlining how the health care systems in Canada and Britain work and the history of their emergence in the third section, we illustrated how the questions allow us to explore the effects of different forms of social organizing.
In our experience, this adaption of Mills’ questions is one of the most valuable tools in our “how to become a sociologist” toolkit. Whereas initially students find Mills’ “promise” to be opaque, the experience of using the simplified list of questions to probe real world issues makes the dimensions of the sociological imagination more concrete. With practice students develop familiarity with the idea that how the world works depends on how it’s organized, and that political struggle is what organizes and reorganizes the world. And even a little bit of such personal experience, then, makes a second reading of Mills’ own presentation more comprehensible. After all, sociology professors “get” Mills because their experience as sociologists allows them to understand what Mills is saying; students also need the same sort of experience to understand Mills.
Using our approach is not unproblematic, of course. Students are initially resistant to the time sequence of our adaption of Mills’ questions—present, past, and future. Because the mantra of “past, present, future” is so ingrained in students’ thinking processes, they resist starting their analysis with how things are presently organized. Mills’ first series of questions allow us to emphasize for our students that sociologists seek to understand how the world is unfolding, what people’s life chances are and what the opportunity structure is. We emphasize again and again that most forms of organizing benefit one group while disadvantaging others. Our job as sociologists is to figure out who prevails, to consider who would mobilize to change the existing order and to recognize who would resist structural transformation. Examination of the past, and speculation on the future, are intended to aid the primary concern with the emerging present.
And quite honestly, our students struggle to comprehend that their own life experiences are a result of both how the social world is organized and their location within it. Our students are much more likely to want to attribute their personal successes to neoliberal ideals of inherent talent and hard work than structural processes or the opportunity structure embedded in the historical moment in which they live. Initially, our students understand those less fortunate than themselves to be responsible for their own poverty, ill health, obesity, or lack of educational success. They often argue people experiencing personal troubles need to exert more self-control, work harder, and be less lazy, and so on to succeed. The whole thrust of the questions we are asking them to answer goes deeply against the grain of their thinking. Often they just don’t want to think sociologically as it conflicts with the very core of the training they have been exposed to up to this point. We feel our emphasis on Mills’ questions—and our emphasis on social structures—helps many of our students gradually recognize there are larger social forces within which their day-to-day decisions and actions occur. Recognizing the present emerged from past decisions and actions, and the future will unfold based on how we act within the present can give students a sense of empowerment. They realize the social world they take for granted and perceive as “natural” was actually built and it can be sustained or transformed based on our collective actions.
It is only from the repetitive effort to answer these questions concerning different social problems that students come to these realizations. The first time we use the questions to guide an analysis students find them strange and unfamiliar. After all, few come to sociology with a sociological imagination. Like getting on a bicycle for the first time, students find their initial attempts at critical analysis to be wobbly. They are uncomfortable because they do not yet have the hang of being a sociologist. But over time, with more and more practice asking and answering these questions their analytic skills improve and they gain confidence to undertake such research on their own.
Predictably, the kinds of answers our students give, the kind of sociological imagination they develop, are not all the same. With enough persistence students embrace the questions, but not all students are comfortable with the divergent positions that inevitably materialize among class members. Our students seem uncomfortable with ideological disagreement. Yet, at the same time, thanks to the diversity within the discipline, students are usually able to find positions with which they can relate as we move on to study different ideological traditions. It is often many years after they graduate that students realize the value of what they have learned through practicing and implementing Mills’ meta-method. It is at this point that some of our students have returned to thank us for providing them with an analytic framework that they have been able to successfully use throughout their life course to analyze the real-world issues they have confronted. In the meantime, if the conversations that ensue in our classes from seeking answers to Mills’ questions are disputatious, we are probably doing our jobs.
Such a reflection on the ideological diversity of sociology brings us once again to the mystery of why Prime Minister Stephen Harper identified “committing sociology” as something to be suppressed. After all, Justin Trudeau, leader of the Liberal Party of Canada, is not a man of the left. But even Trudeau’s flavor of sociological thinking seeks to understand and contextualize individual action in relation to the larger socioeconomic, political, and cultural milieu within which it is situated. For Harper, Trudeau’s query was tantamount to a crime because it displaced public attention from the only “acceptable” explanation for homegrown terrorism: “bad and evil individuals.” Trudeau was suggesting we reflect on what in Canadian society and politics would give homegrown terrorists grievances with the Canadian polity and a belief only violence could supply a remedy. And Harper, the neoliberal ideologue, would have none of it.
Neoliberalism argues that markets and individuals are the only variables to explain human behavior—we might here recall Margaret Thatcher’s pronouncement 30 years ago that “… there is no such thing as society” (Clarke 2005:51). The sociological imagination insists otherwise—it recognizes there are other institutions than markets, that markets themselves are socially constructed through the exercise of political power, that the distribution of effort and reward is not a simple function of individual merit, and that human behavior only makes sense in its societal context. Although neoliberalism insists “There is no alternative” (Clarke 2005) to their program and their preferred future, sociologists assert the contrary that the world can be changed to produce different patterns of effort and reward. Things could be, can be, different. Our examination of the health care system illustrates this point. What emerges at any given time is a consequence of the decisions and actions taken by particular actor groups with particular interests. In a world where the common sense explanation is found in terms of human nature, self-governing markets, and personal values, sociology makes visible what is invisible in public discourse.
Whenever we challenge the dominant thinking of our age we open ourselves to attack from the defenders of power and orthodoxy. We should not, of course, let the Stephen Harpers of the world deter us. It’s threatening to the status quo to uncover the structural origins of society’s winners and losers, the political process by which the existing social order was made and is maintained, and the alternatives ways of ordering our affairs. Sociology’s relations with the dominant ideology and its champions are inevitably fraught by our questioning of how the status quo emerged and is sustained. We hardly live in the best of all possible worlds. Inequality is increasing. Political institutions are more and more beholden to the 1 percent. The rising crises of climate change point to the deepening contradiction between the capitalism and the environment. Harper’s attitude is simply indicative that neoliberals just do not want to hear from environmentalists, climate scientists, advocates for the poor, or sociologists. In this context, the development of a popular sociological imagination is more important than ever. As keepers of the sociological flame, it is our responsibility to teach our students how to think like sociologists.
Footnotes
Acknowledgment
Dr. Machum’s research program is undertaken, in part, thanks to funding from the Canada Research Chairs program.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Machum’s research program received funding support from Canada Research Chairs program.