Unpacking Global Health : A Critical Sociology of Knowledge II

1. Unpacking Global Health: A Critical Sociology of Knowledge II Societies of the World 25 Arthur Kleinman September 8, 2009

2. The Biosocial • The intertwining reality of biological and social factors in health. Biological processes and social processes affect each other and thereby influence health and disease • Allows for a focus on interactions, rather than relying solely on deterministic biological or social explanations • Useful explanatory and exploratory framework

3. Malaria • Settlement patterns in areas where the required mosquito vector flourishes contributes to disease causation • Campaigns involving insecticides, nets, and anti-malarials illustrate both the politics and logistics of disease control and can contribute to disease resistance as well as eradication • Frequently simpler, cheaper, environmental improvement initiatives are not undertaken because they, unlike medical and technological interventions, do not bring profits to industry and business and there is often no powerful constituency for them

4. Heart Disease • Diet is a crucial risk factor for heart disease, and is influenced by economic status, education level, cultural traditions, and modernization, as in elevated cholesterol levels following the introduction of higher levels of animal fats into diets • The global epidemic of diabetes – a major contributor to heart disease – is in part the result of a greater amount of sugar in diets

5. STIS • In 1949 there were 90,000+ prostitutes in Shanghai. With the communist victory prostitution was outlawed, and prostitutes were rehabilitated with job training for other occupations. By the early 1950’s the high rates of STIs – syphilis, gonorrhea etc. – had disappeared. • Under China’s economic reform starting in 1978 prostitution returned to China. There are now more prostitutes in China than there were in the 1930’s and 40’s. STI rates have skyrocketed and sexual transmission has contributed to the spread of HIV/AIDS.

6. Other Examples • Stress-related disorders (chronic fatigue syndrome, chronic anxiety, chronic pain) • The association of psychological depression with economic depression • The direct correlation of rate of unemployment to rate of disability • The relation between the epidemic of traffic-accident caused death and injury and the quality of transportation infrastructure, licensing of drivers, long haul truck regulations etc.

7. The Unintended Consequences of Purposive Action (Merton) • Reasons for unintended consequences • Limits to the existing state of knowledge • The possibility of error, or the “rigidity of habit” • “The imperious immediacy of interest” (901) • Values do not allow foreseeing possible outcomes • Expectations affecting ultimate outcome

8. Examples of “unintended consequences” • Robert Moses and the American highway system destroying inner cities • The Great Leap Famine (1959-61) in China • The Grassy Knoll Indians of Ontario • Refugee camps after the Rwandan genocide • Unintended environmental and health consequences of widespread pesticide use (such as DDT) • Overuse and misuse of MRIs in the American healthcare system (over 60 million per year for 300 million Americans – radiation exposure and social cost)

9. Social Construction of Reality (Knowledge) • “The sociology of knowledge must concern itself with whatever passes for “knowledge‟ in a society, regardless of the ultimate validity or invalidity (by whatever criteria) of such “knowledge”. -Berger & Luckmann • “To understand the state of the socially constructed universe at any given time, or its change over time, one must understand the social organization that permits the definers to do their defining. Put a little crudely, it is essential to keep pushing questions about the historically available conceptualizations of reality from the abstract “What?‟ to the socially concrete “Says who?‟ -Berger & Luckmann

10. The Normal and the Abnormal in Medicine • Ideas about what constitutes the normal and the abnormal have been central to the practice of medicine. • However, in recent times much interest has been paid to the relationship between these categories and how they have been remade through medical interventions, particularly the marketing of pharmaceuticals. • Along with our focus on the expanding category of the abnormal, it is important to pay attention to the concomitant processes of normalization, through which the normal is redefined.

11. Medicalization • Turning existential angst into anxiety disorders & grief into depressive disorder • The making over of trauma into PTSD • Increase in the numbers and kinds of attitudes and behaviors that have come to be defined as illnesses. Their treatment is regarded as belonging within the jurisdiction of medicine SOURCE: Renee C. Fox, “Essays in Medical Sociology”

12. Medicalization • Shift from discourse of sin, crime, and deviance to illness and disease categories • Rise of health, illness, and medicine as major portions of gross national product • Rise of medical industrial complex: pharmaceutical and biotechnology industry • Rise of bioethics

13. Other illustrations of the social construction of illness • Neurasthenia and depression • Chronic pain and the American disability system • Early AIDS epidemic seen as a Haitian disease and a disease of homosexuals • Meanings and TB • 19th century European romanticism • 20th century inner city American immigrant disorder • 21st century MDR-TB as untreatable

14. 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

15. 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)

16. 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

17. 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”

18. 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)

19. 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

20. 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.

21. Social Theory and Global Health • How can we apply these ideas to contemporary problems? That is one of the objectives of this course.