Making it in medical sociology

Abstract

This article gives an account of some of my experiences of working in the field of Medical Sociology in Ireland. It concentrates in particular on the time period of the Great Recession and Ireland's economic crash and what it was like to be a precarious researcher and lecturer around that time.

Medical sociology

Medical Sociology is the study of medicine, health and illness, using concepts drawn from the social sciences, the sciences, and the humanities. It is one of the most significant areas of sociology and investigates topics that are deeply important to individuals and to the wider society. Why is the health system organised the way that it is? What is it like to live with a chronic illness? What is it like to look after a child who is suffering? What are the micro, macro and meso-level consequences of violence and aggression? Why do people die younger because they have less money? Should people live longer because they have more money? The questions and topics that are investigated by Medical Sociology often seem endless because health often seems endless, until eventually it does not. Despite Medical Sociology's importance as a research field, it is a difficult area in which to survive. Positions are few and often precarious. Competition is fierce. Despite the focus of the field on concepts such as vulnerability and caring, such traits are not always professionally useful or valued. Failure is more common than success, and success when it comes is always temporary. You can spend years working on a project only for a reviewer to reject it out of hand, thereby increasing – perhaps significantly – the chance that you will not find another job. Maybe you will lose your house because of that decision. Avalanches can start from snowballs.

The peripheral

When I was young, maybe around thirteen years of age, I attended a writing course that was led by the poet Gerard Donovan. Gerry told me that as I went through life I would likely be someone who would find themselves at the edge of parties, looking in at what's going on, but also looking out at what's going on beyond. I realise now that what he was seeing in me was someone who had the beginnings of, and maybe, would continue to develop – unless life got in the way of it – a scientific/observer mindset. This sort of mindset, this ability to apply the scientific method, probably determines you to a degree of unhappiness in life but is a useful thing to have if you are a researcher. It is important to direct this mindset at the world, but also to direct it inwards, what Sociologists call reflexivity. It is always important to think that maybe your hypothesis is wrong. Maybe you have bought into your own hype. If someone put a gun to your head, could you guarantee that what you are saying to you is the truth? As Camus said, you need a mind that watches itself as much as it watches others.

Sociologists sometimes use the term standpoint epistemology when they try to understand people who are on the edge of things. Much of my own research and teaching have focussed on trying to make sense of peripherality as a concept and also the experiences of individuals on the periphery. I have worked with people with chronic conditions whose illnesses are invisible to other people. I have worked with serious offenders and people who have engaged in serious violence and whose motives were often invisible both to themselves and, if I am being honest, to me. I have worked with people with developmental disorders and sexually transmitted infections. I have researched liminal forms of torture and violence. My career, the structured structuring structure that allows me to research peripherality has itself been irradiated by peripherality. I have worked as a social scientist in a Dept. of Medicine. I worked as a qualitative researcher in a quantitative unit. I worked as a Sociologist in a Dept. of Public Health, a Public Health researcher in a Sociology dept. There is a weight to being an outsider, what Bourdieu calls the weight of the world. But there is also a weightlessness.

The social determinants of health

I once worked for someone who told me that the key to surviving in university work was to be a rocket and not a firework. One is going in a singular direction. The other is going in many directions at once. The firework will never reach the exosphere, though it might have an interesting time in the troposphere for as long as it can last. The person thought about this for a moment and told me that I was probably a firework. I didn’t really mind. I like fireworks. I remember being a child and watching fireworks with my mother and brother in London, Captain America comics in my backpack, imploding holes of colour in the night sky. Machine images can make sense in making sense of us. Biological images can also make sense, however – after all, nothing much in nature moves in a straight line. I tend to view my research interests as being almost like imaginal discs, the cells that insects use to reconstitute themselves after they have dissolved their previous form. What will emerge from these discs is often unclear, and unknown to the insect before the process begins, but it is not random, and maybe can be said to be destined in some way. In retrospect, the shapes of things make perfect, illusionary sense.

I have interviewed about two hundred people in my career. Sometimes this seems a lot, sometimes not so much. I have sat with people under their dinner table while they were having psychotic breaks. I have sat with elderly parents of children with disabilities while they struggled to figure out what would happen, after the parents were dead and gone, to their children. I interviewed someone with autism who coughed something into their hand while we talked, and then looked at what was in their hand with the same intense, dispassionate interest that I was probably directing towards them. I have gone clubbing with people with chronic conditions. I have interviewed young women who fought to make sense of the realisation that they probably would never become pregnant. I have sat in a room with a young person who, several weeks before we talked, had lain down in the middle of a motorway and waited to be run over by a car. I have interviewed young men who stuck needles into themselves in order to gain weight, and young women who have stuck needles into themselves in order to lose weight. I have talked to cancer caregivers who have prayed to Jesus Christ for help. I have talked to people who have lost parts of their faces.

Teaching first year Medical Sociology usually means teaching about the social determinants of health. The key to this idea is that your socioeconomic position in many ways determines your health status, your life trajectory, and, eventually, maybe, how, when, where and why you will die. It's difficult sometimes to get across the force of this idea when you are in a classroom. When I teach this concept it often feels remote even to me, the intensity of the idea faded by both its obviousness and by repetition. On some days I can teach this topic three to four times in a row to different groups of students, sometimes for up to six hours at a time. But. But I interviewed a young family in the 2010s. I don’t remember what their house was like from the outside, or how I got there. It wasn’t a good area though; it never was. I don’t really remember their voices either, though I do have a faint memory of them liking my accent. I do remember an uneven pattern of black and green that went all along one of the walls by the window. I had never seen black mold growing in a living room before, or at least not to that extent. Both parents were, or at least had been, addicted to heroin. There was something different about the children, which I couldn’t figure out at the time, but which I later realised was probably the signs of foetal alcohol syndrome. Their heads were too small, their faces were too smooth in some way. I was not sure if the parents could read. The house was infected with the spores of fungi and addiction. It seemed to me that those parents loved their children completely and absolutely, and with unconditional acceptance. I didn’t know if that was going to be enough.

Acceleration

I achieved my first secure academic position at around forty years of age. I spent years after my PhD doing contract research work, sometimes working on my own projects, sometimes on other people's. I think that I might have lived in ten different places in that time. Within that period, there was rarely a time when I wasn’t split between two places. When I worked in one city, my partner worked in another. When I worked in one country, my partner worked in another. Sometimes the only jobs that I could find were part-time ones, which meant being split between different locations within the same city, which could sometimes be worse than being split between different cities. Long-distance travelling usually didn’t wear me down (I have always been good at going away in my mind, imagining scenarios and stories set in the worlds of the Dungeons and Dragons), though it could (international travel was worse; “I ain’t goin’ on no plane fool” is my Mr T like attitude towards flying) and I could find myself surprised sometimes when I thought about the extent of it. I once got in a conversation on a long-distance bus with a woman who was travelling for medical treatment. She asked how long I had been getting the bus. I said for about seven years. I think that I once calculated how long I had spent long-distance commuting physically on on the bus during this seven year period and the figure came to about 1680 hours, 70 full twenty-four hour days or 210 working days, which excluded the time that it took to commute to and from the bus station, wait for the bus to show up, and the normal working commute then everyday within the city. In that time I think the bus crashed twice, neither time the bus driver's fault.

Medical sociological research of the type that I do can have a strong travel component to it as you must often go to where people are. I spent a year travelling around interviewing people about their health problems, visiting a lot of fairly deprived council estates, worlds that were remote to me, though, not, perhaps, to the worlds that my parents would have encountered when they were growing up. I travelled all over Dublin to talk to people who had STIs. One Dublin taxi driver asked if I was a police officer (“you ask a lot of questions”). Another asked if I was an actor. As it turns out, that was just a prelude to the taxi driver revealing that he, in fact, was an actor. “What, my researcher friend, do you know about Shakespeare?” I thought about it for a second. “Literally absolutely nothing”. That wasn’t totally true actually. I knew that nothing comes of nothing.

I have also spent months and months doing archival work, not moving, cataloguing and analysing data kept in closets, in store rooms, in warehouses. I found that psychiatrists usually keep very good records. I spent a considerable amount of time studying the archives of services that worked with young people who were referred to them for aggressive or violent behaviours. This work was the whole of my life for a time, though I think that unless you are a police officer, a practitioner, or a specialist researcher, it is probably time limited work. It was absolutely time consuming. I spent days and days scanning and skimming files, some of which could run to 600 pages. Reading the files you could sometimes see social workers trying to work out if information was true, false, exaggerated. Many of these cases were strange. Many were depressing. Sometimes, unexpectedly, they were hopeful. Children are still children and can be idiosyncratic and creative in their response to adversity. They can respond well to care in an environment that protects them from risk, either the risk that they pose to other people or other people to them. Some of the files contained drawings of suns and trees. Sometimes though, these cases were just hopeless. Many of these children, aggressors themselves, seemed to have had little chance in life. Some of them were described as having been violently, physically, abused. Some were emotionally abused, bullied. Some had worse things done to them. What would that do to a young child, for whom happiness is the furthest arc of a swing? At the time, reading, summarising, quantifying this information, I felt interested in it, focussed on it, but distant from it, like you would if you were reading about it in a novel. When I finished cataloguing atrocities I would often go for coffee on my own, knowing less about the surface of the things than I had at the beginning of the day. I still sometimes think not so much about the extreme accounts, but the less dramatic ones, like the reports of a child being told that they were worthless. When I was a child myself I used to collect a role-playing game called Wraith: The Oblivion. The game was about ghosts, spectres haunting, who had to make sense of trauma in their lives. In the game you had to do your best to try to maintain realistic hope in a world where despair was the more powerful force. In Wraith there were holes in the world, passageways to somewhere else, to Nothing really, that were called Nihils. There are holes in this world too.

The Great Recession

I probably came fully into myself as a researcher during the Great Recession. Although I didn’t really appreciate it, in 2008 – maybe at the height of whatever skill and energy that I had – I was about to enter into a very unstable, insecure, stressful decade in my life. If you had told me, I wouldn’t have believed you. I had been fairly successful until that point, and success can kill imagination; perhaps more importantly, I probably wouldn’t have cared. Cormac McCarthy wrote that, in nature, nothing that is wounded goes uphill. But it still goes.

At least 20% of my working time, maybe 30% in some years, was spent over that decade searching for, applying for, interviewing for, being rejected for, jobs, over and over again. At the start it seemed like a game, though I guess the warning signs were there right from the beginning. I tried to talk to someone outside of an interview, making conversation to kill the time, until they looked at me and I realised that they probably hated me. Over time, as the rejections increased and the jobs became advertised with less and less frequency, things became more serious. I sometimes imagined myself as being like an oceanic white tip in the middle of the Pacific; it seemed like there should be resources around, but the truth was that there wasn’t, and that I was in a resource desert. I tried to be as opportunistic a feeder as I could, tried to chase down everything that came along. I spent weeks and weeks preparing for some jobs, practicing the questions over and over again in my mind while I commuted (no DND for me this month). It rarely worked. I had intelligence, I guess, but maybe not much polish. Maybe that's what they saw. I mean, I made mistakes as well. I was never fully sure what I was walking in to. I once prepared a talk about possible internal collaborators, only to realise on the day that all of the people that I was proposing to work with were also applying for the job. My handler for one job told me that the panel was looking for someone who could win a Nobel prize in medicine. That is not a problem, I said. Sometimes people who knew me were surprised to see me at an interview. Don’t you know the jobs are already gone? Sometimes when I gave interview presentations people stared out the window, daydreaming or thinking about what they needed to do next. Feedback when it came could be harsh and, sometimes, at least to my mind, arbitrary. I don’t like that you like this other researcher, one person said. I still can’t remember whether another person said that you are a significant disappointment, or that you were a significant disappointment. I couldn’t control myself that time. I said “listen, I’ve been disappointing people for a long time before you walked into my life”. Once after an interview someone on the interview panel contacted me and asked to talk. Ok I said. I sat down in front of them. You might be wondering why you didn’t get the job. I said nothing, appeared interested. They looked at me as if they wanted me to know that they were about to say something important. You have to know, they said, I just want a friend. Careful. Careful. Well, I said. We all need friends.

Other people I knew could be in bad situations. I remember sitting drinking coffee with an academic on a street in Dublin. Their contract was finishing soon with no chance of renewal. I’m done they said. I can’t do this anymore. They stopped talking for a moment and then said you know I’ve started self-harming. I’m sorry, I said. That's not great. It's ok, they said. It will get better maybe.

I partly got one role, I was told, because I was no one's protégé. Least worst option? I guess I’ll take it. But why was this person giving me this piece of information at this point? You must be careful about taking other people's perspectives on, or accepting their information at face value. Someone I worked for told me that I had bad luck, but that I was lucky at surviving bad luck. I have often been lucky in the people who I have worked for and with, some of whom have acted as mentors to me over the years. I have seen on occasions, though, people with ambiguous motivations try to place themselves, like dark cuckoos, in the role of guides in other people's lives. It is important to be formed within yourself before they approach you, so that you are not lost to them and their plans for you; to have studied and understood, as I did when I was young, the relationship between Galactus and the Silver Surfer. Sometimes a voice in your mind should say to you this person is not your friend.

When you are precarious you are vulnerable to aggression, whether that aggression is intentionally or incidentally directed at you, and whether it is directed by individuals or by systems. System level aggression you can’t do much about and should treat almost like an Act of God. It's nothing personal, it's just business (though you might feel that it's all personal), the effect of economic and organisational instrumental and purposive rational logics. Individual level aggression that is directed towards you is more immediately problematic and should trigger a different calculus. It can sometimes be easier to accept it, to say nothing. However that can encourage continued aggression. At the same time it can be risky to react, which will often be framed as overreaction. So you must be careful, but you must be an imperfect victim.

Auschwitz

I came to be in Auschwitz in the late 2010s when the wildflowers were in bloom. It was very peaceful, very quiet, and I remember the voices of the birds as being very distinct. But then past the flowers, through the quiet, you see the barbed wire, the barracks, the remains of the gas chambers.

I was in Auschwitz to interview Eva Kor, the Holocaust survivor and a survivor of the Mengele experiments. I have taught a course on the Nazi doctors and Nazi medical experimentation for a number of years now. Sometimes I think that I fell into this topic almost by accident, but maybe not. I have always been interested in German history, and have been interested for a long time in Sociology in the ideas of unrestrained objectivity and instrumentalism. I guess more personally, my father knows a lot about WW2. My wife might know more. Browsing in Hodges Figgis bookstore in Dublin, I came across this book, The Nazi Doctors, by Robert Lifton. I picked it up, flicked the pages, put it back, looked at the cover, examined it. If I come across something I kind of like, I can make a very quick decision on it. If I come across something that I really like, I can take much longer to make a decision. I think I spent about a week staring at the book before finally making a decision to buy it. I put the book aside for a while, decided to read it one day while commuting with a three-hour trip ahead of me. The first two-thirds form the most important academic study that I have read. The final third, the theoretical framework section, and the section that students seem to dislike reading the most, is the most profound. Lifton taught me that the world is not always the world that you think it is. He taught me about the idea of malignant normality, about atrocity situations, and that within individuals are multitudes, and that each of these multitudes represents a different orientation towards life and death.

Eva Kor, who died not so long after we talked, was a tiny woman with a significant positive charge about her. I interviewed her in the gatehouse of Auschwitz Birkenau, close to where the Nazis killed her parents, and near the remains of the barracks where Mengele kept the children, including Eva, while he experimented on them. It was an unusual interview for me; for Eva I think that it was a normal interview, if anything can be said to be normal in such a place. There was a full camera crew there. School children and teachers were waiting outside for a chance to talk to her. She herself was accompanied by busloads of people. She surprised me by the strength of what C. Wright Mills would call her ‘Sociological Imagination’, her sense that what happened in that place was partly an outcome of much longer and broader socioeconomic forces. Although Eva was much older than me, and had an authority about her, I also thought that I could see within her the girl that she had been. Mengele is long dead now. He could not have foreseen, when he tortured those children, what they would become, long after he was gone, witnesses to the blindness of his science and his killing.

Evolution

At the beginning of Frank Herbert's novel Dune, Paul Atreidis has to survive a test called the Gom Jabbar. He must place his hand inside a box that causes intense pain. A poisoned needle is put against his neck. If he can keep his hand in the box as the pain progressively worsens, and thereby show that his human control can override his animal instincts, he will demonstrate that he is fully human and will survive the test. If he tries to flee, he will die.

Getting a secure teaching post was like surviving the Gom Jabbar. I kept my hand in the box while a lot of the people who I started with, and who in many cases were smarter than me (maybe they were, maybe they weren’t, I go back and forth depending on my level of arrogance on any particular day), couldn’t, and went on to do other things with their lives. Health psychologists might characterise this trait as resilience, but I wonder sometimes if I am more like Roland in Stephen King's the Dark Tower; do I benefit in some way from a lack of imagination, an inability to imagine other worlds than these? When I first started lecturing I had a conversation in Dublin with a Nurse who told me that you don’t think like the rest of them. I think that she meant Sociologists. I said that I would agree with that, not fully sure what I was agreeing to. There is a distinction within Medical Sociology between what's called the ‘Sociology Of Medicine’ and ‘Sociology In Medicine’ approaches. The second basically refers to applied medical/health services research, the first studies medicine and health as objects that have themselves been socially constructed. I think the Nurse meant that they saw me as having more of an applied perspective. People can see what they want in you. It can sometimes be professionally risky to have such an applied perspective in more conceptually orientated fields like Sociology.

During the Crash I attended a national event for new lecturers. The presenter drew a triangle. This, he said, is a pyramid. He was a showman. He had me. Most of you are at the bottom. You will not reach the top. You should not try to reach the top. You should leave and do something else with your lives. While I appreciated his triangle of death and his efforts to discourage me, I knew all this. What I didn’t fully know is that I would find the job interesting (I knew that I thought that I would find it interesting, but I didn’t know that I would actually find it interesting – as any Medical Sociologist will tell you, your thoughts and behaviours are not necessarily correlated), and I liked the freedom. It turned out that I had (if I can say this – to tell the truth, I probably am arrogant. Though as Stephen King has said, if you’re not arrogant at the start there's not going to be much left of you at the end) an ability for large group teaching, that I could teach about things like infectious disease and professionalisation and social networks and standardisation to hundreds of students (or at least the ones that showed up), make some of them laugh, make some of them think (I think?); make some of them surf their phones, but that comes with the territory. Smaller group teaching I liked a bit less, though I still liked it. I was good I think at giving one on one advice. I liked the students. I think I made some of them less anxious. I don’t believe that there is a purpose to suffering, but I think my own experience of insecurity probably made me a bit more empathetic, though suffering and empathy can also be inversely correlated.

None of this is to say that the job was easy. I’m not quite an introvert, but it can sometimes be exhausting talking for hours a day to hundreds of people. Sometimes, intermittently, I would get migraines. These started in my early thirties, when I began long-distance commuting, and continued on. I’m not sure what exactly started them. Various things can act as triggers, lack of sleep, stress, all associated with the job. There's not much really you can do about those types of things to be honest. Sleep more, I guess. Attend less meetings but, you know, good luck with that. The role-playing game writer Kenneth Hite wrote once that in action movies the reward for action is information, and the reward for information is more action. Sometimes it seems to me that in universities the reward for meetings is more admin, and the reward for admin is more meetings. Once the migraines start they generally don’t stop without sleep and sometimes the trigeminovascular system really does a number on me. When it gets very bad, and sometimes, maybe about once a year, it can get very bad, it's a strange feeling. The pain behind my right eye is crushing, unrelenting. I have seen videos of free-divers go down, really down, into the water where things are really black and pressured. My head can feel like that, while at the same time my body feels like it is floating away in a vacuum. Sometimes afterwards, if the migraine is bad enough my mind feels empty and I feel at peace. Sometimes, if the migraine isn’t as bad, my extraocular muscles are sore, I feel like I have been kicked in the head and my mind feels bruised. Sometimes I think that I have lived too long.

Pressure comes in various forms. I have always felt the weight of the job in a more general sense, the realisation that the marks you give to this student on this day could economically impact them for years to come, that your assessments of their abilities could do something harmful to them psychologically. I don’t think that you should ever forget this weight. I have always been aware that when you reject an article that you might not only be damaging someone's career, you might be killing an entire line of research that would otherwise have come into being. At the same time, you need to try to uphold standards and you can’t be paralysed by inaction. You have to try to be exact, and consistently exact, and fair while trying your best to be good. It's not an easy balance if you are doing it right.

Medical Sociology is an international discipline, but it can have inflections. Once you start the job properly you will be faced with a series of decisions that you have to make and which you might not be fully conscious of. You need to decide whether you are qualitative or quantitative in orientation. In my country, if you decide that you are purely a qualitative health researcher you might struggle to find work. You need to decide whether you are a scientist or whether, as the Medical Sociologist Bryan Turner has said, you are fighting a rearguard action against Darwinism. This was always easy for me. I have always seen myself as a scientist. You need to decide whether you will be driven by ideology or whether you will be driven by pragmatism, centrism. Given the difficulty of surviving in the system being highly ideological probably give you a long-term survival advantage. You need to decide the extent to which you are a pure Medical Sociologist, or the extent to which you will hybridise yourself with other disciplines such as Nursing and Public Health. You will need to decide whether you are a specialist in Medical Sociology, or a generalist Sociologist with a strong interest in health. You will need to decide whether you are policy/health services orientated or whether you are more academic in focus. Such decisions then trigger a cascade of follow-ups, such as what topics to study, what journals to publish in, what students to supervise, what grants to go for, what groups to work with, whether or not you will be promoted, how much money you will make, perhaps ultimately (Sociology teaches that everything is connected) maybe the circumstances in which you will die and what you can leave to your children. Decisions made in relation to each of these questions will then lead to benefits, but may generate iatrogenic risks of various kinds. Some may surprise you.

Beginnings

In some ways, I think, I never moved beyond my starting points. My father has Type 1 diabetes which influenced my decision to do my PhD on Type 1 diabetes. After I did my PhD the only correction that I was asked to make was to write about my feelings about my father's diabetes and how they influenced my project. I think that I wrote something small. At the time I just wanted the project, and that time in my life, to be over and done with. Some people view their PhD as their life's work. It's more useful to view it, as a friend of mine, a scholar of Buddhism, was told, as a driver's license. It gets you on the road grasshopper. The acceleration is yet to come. It is only really as time has passed and diabetes has worked its damage that I have become conscious that there is something there that I am not always fully aware of. I can look at it, but I want to look away from it when I do. When I was young I would hear my father leave for work. I knew that one day that he would not come back.

My parents had a different life than I did. They started out in more difficult circumstances. My mother was a lifeguard. My father worked in bars all of his life. We had an outdoor toilet when I was young. Our car was burned out. The house could be cold. I think that I remember that. They got myself and my brother whatever we wanted when they didn’t have the money to do so. I would come down on Christmas and find Optimus Prime, Ultra Magnus, Metroplex. They bought me Use Your Illusion 1. My father bought me Dungeons and Dragons in Virgin Megastore in Dublin. I read the book, confused about what it was (I had liked the cover), gradually realising that it was an instruction manual for creating worlds and systems in your mind. You could create and fight diseases. I have a detailed knowledge now, in my early forties, thirty years later, of multiple role-playing game systems. I can keep myself amused sometimes by modelling disease outbreaks in my mind, and figuring out how to bring them under control using the rules of whatever system I am thinking about (“I think we need a level 14 cleric for that one”). There was an article in the Lancet a number of years ago about a disease outbreak in the World of Warcraft. The disease spread uncontrollably and killed everything in the game. The game designers had to destroy the world to save it, which Lifton would have understood. Fantasy isn’t reality though. Sometimes diseases aren’t dramatic and you can’t do anything about them.

My son was born when I was thirty-eight years of age. Because of the precarious nature of the job I couldn’t economically risk having a child before that time, though I was also conscious that trying to manage economic risks was just increasing biological risks. I was told to expect to be in the delivery ward for a while. Things went a lot quicker than that. I got talking to the Midwife before things went quick but after the epidural. After a few minutes of talking she said “I know you. You taught me Medical Sociology”. I looked at her. I had never actually met any of my former students after they started work, so this was new to me. I have taught about two thousand Nurses and Midwives, so the chance of meeting one of them here was remote but not non-existent. I watched her work while we were waiting for the oxytocin to do its job. The walls were soundproofed but sometimes you could hear screams coming through the walls. Too late for their epidural she told us. She was professional, totally competent. She reminded me of an airline pilot, constantly checking her computer, going back to my wife's body to validate the computer's analysis. Sometimes other Doctors and Nurses came and went, and talked about things like where they were going on holidays. You could tell though that they were doubled in themselves; even when talking about other things, their eyes never left the machines. There is a concept in Sociology called medicalisation, which is often, though not always, used to criticise medical approaches to childbirth, promote more ‘natural’ approaches. The truth is though that we are medical/technical forms of life. After the baby was born I did not see her again. She moved on to other patients. I wanted to talk to her (to say thank you? to ask her to tell me that everything was going to be alright?). But I understood; she was a professional. I had once processed her. She had now processed me. We both in our own ways worked in rationalised systems characterised by productivity, quantification, technology. By control.

Before having my son I was told by one academic that having a baby would kill my academic career. I think that I probably smiled noncommittally. After my son was born I encountered another academic who said that having a baby was going to enhance my academic career. I think that I probably smiled noncommittally. Maybe I didn’t. My son doesn’t care. He is totally of himself. He tries to go down lego slides that are centimetres tall. He puts paper bags over his head, finding it hilarious that we can’t see him because he can’t see us. I push him on a swing and at the furthest arc the light coming through the trees catches his face and makes his eyes golden. He is partly here, on the swing, and partly somewhere else.

I have seen this light before.

I am standing by a river. There is a woman standing next to me. The sky is cold. There are no clouds. The sun is behind us. I think that it is late afternoon, but time is stretched here. The sun catches the back of her hair and turns it into fire. The front of her hair, not caught by the sun, is dark. There is ice floating on the river in front of is. Each disc is swirling, forming a pattern, but it breaks apart. We are surrounded by the wreckage of totalitarianism. In Summer she is walking backwards through the long grass in front of me. Butterflies are flying around her and landing on her and she is delighted. They have been caterpillars not so long ago, have dissolved themselves under the Summer sun, blind to what was coming. Somewhere inside me an imaginal disc, which I do not understand, understand later, too late, is beginning its work.

Recommendations for policy and practice

I have worked in the field of Medical Sociology now for twenty years. It has been a while since I last woke up at 4 a.m. thinking, as I did for many years, that my contract is going to run out soon and that I could lose everything. Sometimes in meetings I am surprised to realise that I am now one of the more senior people there. Medical Sociology is an important subject. It's perhaps especially important in a country like Ireland where administrative systems sometimes, because they are steered by what Weber calls logics of instrumental and purposive rational action, seem to veer towards indifference to suffering; and where people are often viewed in terms of their exchange value, their economic cost or benefit to a system, rather than their inherent value, or what Marx calls their use value. Even if the profession of Sociology is difficult to make it in, there is something true I think, in a fundamental sense, about at least some of the findings of the subject, truths that can help to make sense of the suffering in the world. I return again and again to Marx and to Goffman to help me to make sense of things, the latter to make sense of the surface of the world, the former to understand how the world really works underneath the surface. Sociology highlights the economic and structural constraints which surround you, limit you, make certain actions more or less possible, set the circumstances and conditions of your life. Medical Sociology also tells you, and this is something that I find reassuring, that things can always get worse. There is no lie in this. It is, after all, the second law of thermodynamics.

It is not surprising, therefore, that sometimes people who understand the truth of this will tell you things like it is what it is. That whatever happens, it's not personal, it's only business. That you and they are working in a system and operating under its constraints. It's not that we don’t like you, it's just that there's nothing that can be done for you. You will probably say in response to them that it is what it is. Your reply is a ritual reply. It is good to be pleasant. You have read Goffman and Hochschild. You know how this works. However what you do not say, maybe what you never say, but what you must never forget, is that it is what it is -until it isn’t.

Sometimes, though, despite everything, despite all of your best efforts, you will try your best and it just might not work out. Be kind to yourself. There are some situations that you can’t really do much about. When you were young you were loved for who you were, loved unconditionally. You were not seen in terms of exchange value, in terms of profit and capital, in terms of an economic bottom-line. You were loved for you. Remember that day in the park when you were a child. Remember the cold blue of the sky, the traces of the clouds. Remember that energy that you and the world had. Remember what that person, that person who loved you, told you.

Remember what I told you.

Focus. Trust yourself. Now fast as the wind.

Go.