Social Suffering, Biopower, and Local Moral Worlds: A Critical Sociology of Global Health

1. Why Theory Matters Three More Social Theories: Social Suffering, Biopower, and Local Moral WorldsA Critical Sociology of Global Health III Societies of the World 25 Arthur Kleinman September 10, 2013

2. 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.

3. 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.

4. 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

5. 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)

6. 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. .

7. 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

8. 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

9. 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

10. 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

11. 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)

12. Local Moral Worlds: Kleinman’s Categories (1) • Local Moral Worlds: "Local moral worlds are settings of moral experience which express what is most at stake for people in their local networks of relationships in communities. These worlds are no longer limited to the bounded spaces of traditional ethnography such as the village, work setting, shantytown, or household – but extend to networks where everyday life is enacted and transacted, where individuals’ inner subjective experience is in interaction with the practices and engagements of other people. These could be transcontinental and trans-national, or professional and business as well as domestic. Here, lived values of the individual and those of the network may be in concert or conflict, involving constant contestations and compromises.”

13. Kleinman’s Categories (2) • Subjectivity: the inner world of the person • 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)

14. 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.

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

17. Paradox: Caregiving and Global Health • Many students and professionals are attracted to global health because of a passionate interest in caregiving. • Paradoxically, the quality of caregiving is not a major focus of global health policy and research, which, to be fair, largely focus on the question of access. • But what does it mean for global health that the existential and moral stimulus for entering the field has become such a small part of what the concerns of the field are in practice?

18. Local Moral Experience • Why is it important for global health practitioner-anthropologists to take the local into account in global health programs and initiatives?

19. Social Theory, Political Economy, and Global Health • How does political economy relate to the social theories we are exploring in this course? • What about moral economy and its relation to social theories and their applications in global health?