Unpacking Global Health : A Critical Sociology of Knowledge III

1. Unpacking Global Health: A Critical Sociology of Knowledge III Societies of the World 25 Arthur Kleinman September 10, 2009

2. Social Construction of Reality • A Definition • Persons or groups form mental conceptions about the world, which over time come to act reciprocally, as though they were of the world. • When these conceptions are shared and standardized, they are said to be institutionalized and become part of the social world. • People’s knowledge and beliefs about the world become legitimized in society, and society is therefore said to be socially constructed.

3. Illness/Disease/Sickness • Illness: the experience of symptoms and the response to them by laypersons and their networks/communities • Disease: the reinterpretation of symptoms as pathophysiology as understood from the practitioner’s framework • Sickness: symptoms and pathology understood at the population level in the broadest societal context

4. Weber’s types of authority • charismatic authority (familial, religious, personality-based) • traditional authority (patriarchs, patrimonalism, feudalism) • legal authority (modern law, the state, and its institutions)

5. Charismatic Authority • "resting on devotion to the exceptional sanctity, heroism or exemplary character of an individual person, and of the normative patterns or order revealed or ordained by him." - Weber

6. Bureaucratic Authority • Hierarchical structure of subordination; vocations clearly defined • Bureaucrats have "expert training" "functional specialization of work” • Bureaucrat = "single cog in an ever-moving mechanism with fixed march”

7. Weber’s “technical rationality” Weber predicted that institutions would become the most powerful social structures in society, greater than family or community, because they could generalize and quantify and would be more efficient This would result in the technologization and bureaucratization of everyday life via technical rationality (i.e. protocols, technical jargon, neologisms, simplifications, reductionism, standardization, rule-driven) Technical rationality would come to be so intertwined with the political economy that legitimated categories would determine financial reward (for example, ICD and DSM and the reimbursement of doctors) and would define legal procedure (only approved AMA and APA categories used in forensics)

8. Technical Rationality • Advantages • Less biased • Less ad-hoc • More efficient • More quantifiable • Disadvantages • Risk being stuck in the “iron cage of rationality” • Loss of traditions, sentiment, and rule of thumb

9. The “Iron Cage” • NIH • In the routine research review process only grants that don’t challenge the scientific status quo get funded and out-of-the-box, creative ideas are rejected. As a result NIH complemented RO1’s with Pioneer Awards, etc. • Institutional Review Boards (IRBs) standardized nomenclature, methods and processes of ethical review. Certification of foreign institutions follows the same American format and does not legitimate local values and procedures. • Harvard University • When I came to Harvard in 1970 there were very few rules and very few administrators. Most problems were dealt with by picking up a telephone and talking directly to a dean or department chair. Now, besides layers of bureaucracy there are books filled with rules governing just about every aspect of instruction and faculty relations.

10. Social Suffering: Definition • Pain and suffering caused by social forces: Global and local economics, politics, social institutions, social relationships, culture, e.g. structural violence. • The interpersonal experience of suffering, experience of chronic illness. • The contribution that society and its institutions make to the causality or worsening of social and health problems. • This concept is meant to be omnibus and to mix together social and health problems of every sort : for example coordinating social policy with health policy in responding to the clustering of inner city violence, substance abuse, depression, suicide.

11. Social Suffering: Types • Structural violence • “…such suffering is ‘structured’ by historically given (and often economically driven) processes and forces that conspire – whether through routine, ritual or as is more commonly the case, the hard surfaces of life – to constrain agency. For many, including most of my patients and informants, choices both large and small are limited by racism, sexism, political violence, and grinding poverty.” (Farmer, 40) • e.g. Poverty as a major risk factor for infant and maternal mortality and adult infectious diseases • Interpersonal experiences • Illness experience • e.g. the experience of diabetes, asthma, arthritis, heart disease, etc. • Suffering caused or intensified by bureaucratic indifference and the unintended consequences of bureaucratic action • For example PTSD among Iraq veterans, previously not accepted for disability claims.

12. Suffering and Inequality • If poverty is the major risk factor for a number of disorders how can we separate the issues of inequality and medical care? • Heath disparities across class, ethnic groups, gender and age cohort mean that suffering and inequality is at the heart of global health policy

13. Foucault and Biopower (1) • “If one can apply the term bio-history to the pressures through which the movements of life and the processes of history interfere with one another, one would have to speak of bio-power to designate what brought life and its mechanisms into the realm of explicit calculations and made knowledge-power an agent of transformation of human life.” - Foucault (HOS 143)

14. Foucault and Biopower (2) • “Biopower refers to controls over life, denoting ‘what brought life and its mechanisms into the realm of explicit calculation and made knowledge-power an agent of transformation of human life’” - Foucault • Such transformation are said to occur at two levels: that of the human body as the object of discipline and surveillance, and the of the population as the object of regulation, control and welfare • Foucault’s example was 18th century France when the consolidation of the centralized state’s administrative power worked through counting and controlling the health and social welfare of populations. .

15. Foucault and Biopower (3) • Biopower is opposed to sovereign power which is expressed in right to kill, a right of seizure. Foucault said that history moved from sovereign power to governmentality (policy based government) and that biopower was one of the examples of governmentality. • Biopower seeks to exert a positive influence on life, i.e. it endeavors to administer, optimize, and multiply it, subjecting it to precise controls and comprehensive regulations • For example measuring the size and distribution of populations, categorizing populations by gender, age, occupation, fertility, mortality, etc. are examples of how biopower works as a political form of control – the census is a case in point

16. Biopower and Global Health (1) • Anthropometric measurements of the skull and racial science: the construction of an invidious evolutionary ladder with Africans at the bottom and Europeans at the top • The construction of stereotyped and bureaucratized divisions between ethnic groups • Tutsis as a military and royal caste vs. Hutus as peasant farmers, issued IDs that codified racial differences that later marked people for genocide and exacerbated ethnic tensions • British reification, intensification and codification of caste differences as a form of governance

17. Biopower and Global Health (2) • The development of psychiatry in British colonial Africa • Psychiatric hospitals built for colonials and ex-pats • Racist construction of categories of pathology: Africans could not have depression • British psychiatrists used by the colonial government in the Mau-Mau insurrection for purposes of political control

18. Biopower and Global Health (3) • Bhopal – A Union Carbide Corporation pesticide factory in India leaks poison gas in 1984, killing 8,000 and affecting 500,000 • Legal procedure devised to count victims uses inadequate medical criteria, and ends up excluding many affected • Historical and geographical notion of the Old City in Bhopal as a Muslim and low caste area leads to categorizing Bhopal as a “Muslim problem” • High caste physicians think of gas survivors as low caste or Muslim or dirty, and sometimes refuse to touch them during medical examinations

19. Biopower and Global Health (4) • Chernobyl – 1986 explosion at nuclear plant in Ukraine • Aftermath leads to discrepancy between medical researchers and the disability system • Medical researchers claim only 2,000 people were affected, but 1/3 of the Ukrainian population is on disability as a result • Adriana Petryna calls this phenomenon “biological citizenship.” She writes: • “One can describe biological citizenship as a massive demand for but selective access to a form of social welfare based on medical, scientific, and legal criteria that both acknowledge biological injury and compensate for it.” (Life Exposed p. 6)

20. Kleinman’s Categories • Local Worlds: the networks of relationships and communities in which we live and experience social life • Subjectivity: the inner world of the person

21. Moral Experience: • Life is about values. Just being alive, negotiating important relations with others, doing work that means something to us, and living in some particular local place indicate that moral experience is inescapable. • Ethics: • Ethics as a professional discourse (A normative language of elites) • Ethics in moral life (The translocal aspirations of individuals to act morally)

22. Ethics and Suffering: Emmanuel Levinas “the suffering for the useless suffering of the other, the just suffering in me for the unjustifiable suffering of the other, opens suffering to the ethical perspective of the inter-human” -- Levinas means that suffering takes its ethical significance from the response of others to the person who is suffering -- Values in global health are usually unstated and unexamined but are critical. We believe the ethical demands of suffering of those in greatest need with least resources should be prioritized (one example is Farmer’s “preferential option for the poor”). • From: Levinas, E. (1998). Useless Suffering. Entre nous: Thinking-of-the-Other. New York, Columbia University Press. Page 65.

23. social experience local cultural representations subjectivity CHANGES IN POLITICAL ECONOMY, POLITICS AND GLOBAL CULTURE |____________________________________________________________________________________________________| The remaking of moral life