S207 Week 10 6 March 2007   Agenda: What might be on the horizon..

opportunity to take stock of the discipline of medical sociology. Professional authority. Political economy of medicine. McKinlay – one person’s idea of what the project of medical sociology should be about. In many ways, he expresses where med soc came from. even though this is a time to look ahead, there’s a lot we still haven’t done yet. Freidson – role of professions in the contemporary world. he was continually engaged with whether professionalism is still a logic/language, a way of organizing the social practices of medicine.. and what is to be done about professionalism today? Rabinow and Rose – biopower today. sentiment of these things being on the horizon, yet it’s too soon to tell. people who are into social critique/social theory are quick to say something is biopower in action; they have a very considered/modest way of saying these things are still ongoing. we need to keep asking certain kinds of questions instead of deciding they’ve been answered once and for all (genomics, etc.). Pescosolido – earlier we read an article of hers re: the status of medical sociology. she’s always been intrigued by the contributions of med soc to the larger discipline and vice versa (explicitly contextualized it as part of sociology). looking at health/disease/health care has important things to say to the larger discipline.  interested in looking at broader currents within social theory/what’s happening. we have a different set of anxieties and concerns. maybe there’s more uncertainty about the role of expert knowledge. simultaneously there might be less dependence on experts. things becoming so much more complex and uncertain.. medicine might be calling for greater reliance on expert knowledge. unsettled assessments of postmodern society.  what’s happening in society writ large, medicine and health care = a microcosm of that.  it’s important to think about what’s going on in society more broadly, and see if those anxieties/uncertainties exist in medicine.  John: she links it to capital. in many ways, capital has displaced role of government  Beth: displaced? maybe supplemented.  John: privatization of social services = displacement of role of government  Beth: I didn’t read it as displacement in the sense of taking over. maybe it’s a shift, not a replacement. foundation of medicine is still expert knowledge about health. it’s not profit it’s founded on; it’s a mechanism to move that knowledge.  Navarro would say capital was always there all along, there’s no displacement happening here, it’s just becoming much more explicit. they’re no longer trying to ideologically veil what capital is doing. I don’t know he would say there’s all that much difference between what’s happening now and what happened at the height of professionalism. most of these readings make an argument re: what we should do from here on out. they’re not policy recommendations per se, but they present an agenda for what needs to happen next. how can we keep the medically oriented sciences alive and well going forward? each of these agendas is premised upon a diagnosis of the problem. where do you aim the intervention, and at what level?

McKinlay  Beth: he takes a political economy of illness perspective. he argues the fight is on the wrong level; we’re not going far enough upstream; destined to lose. we can say people should eat healthy or exercise, but that’s not upstream enough – that’s midstream. upstream is having legislation or something on a more macro level. the risk-to-benefit tax, where if you’re producing a product that causes a health hazard, you have to pay a tax to cover the health services needed to treat the problem.  Martine: by creating a macro level intervention like that, you will have had to raise a lot of awareness and bring together many interest groups. the long-term effects may still be detrimental to the company.  a lot of this sounds like what used to be taken as an externality that was paid by everybody in society, and making the company producing that externality pay for it. the whole premise of a tax is that it’s a redistribution of capital in some way - not only of money, but of who pays and who benefits. so far it’s the manufacturers of illness who have solely benefited from the manufacturer of illness (producing problem upstream, and setting up health care system to wait for them downstream). whole idea of a tax is to make people who used to just benefit into also being payers (e.g., into a health care system aimed at improving health).  Beth: HC system we have today is not focused on preventive medicine. it’s focused on acute care and chronic disease management. it’s not focused on the things he’s talking about. make companies pay for bike paths, etc. instead of HC system.  John: but plenty of dollars already available for bike paths.  Beth: he’s saying tax they pay would have to go to something health-related. idea of putting money into acute care / allopathic system is not going to reduce problem; we should invest instead in healthy communities. invest money upstream. he says preventive is midstream.  in this reading, I don’t think he’s particularly interested in what we use the money on; he’s interested in taxing illness-producing industries. tax = way to reduce riskpromoting corporate actions  McKinlay makes a link .. he talks about at-risk-ness .. these manufacturers are tying at-risk behaviors to dominant culture. if you engage in at-risk behavior, you’re doing something that is seen as desirable in American culture.  Jonathan: glorification of alcohol, violence  Beth: war = legitimation of force as way of solving problems  Elena: I think the problem is not just at the level of corporations.. I think it’s more systemic  Krista: you can’t just tell a smoking culture not to smoke  now that US smoking rates are stabilizing/decreasing, tobacco companies now going overseas, where cultures receptive to glorification of smoking  Elena: ads in Finland re: health  Erica: ad in US re: kids asking for heart disease, etc.  type A personality. since been debunked. gradient has gone the other way.  it’s not so much a cohesive personality type, there are specific components within it that are more associated with heart disease. debunked idea of upper middle class busy CEO being at risk for heart disease.. it’s actually the poor factory worker.

hostility stems from materially having a lack of control over your work conditions, life circumstances, not having flexibility in your life, etc. Freidson  trust is fundamental in the provision of health services. he appeals to this universal human experience of illness as a state that requires and that demands and calls for trust in people who are taking care of you. he doesn’t necessarily say this, but he’s sort of appealing to this universal vulnerability that illness leaves you in – it’s less an issue of a social role and more an issue of a basic human need: when you’re sick, you need to be able to trust the person caring for you.  professionalism as a third logic. the logic of the free market, the logic of bureaucracy, and the logic of professionalism.  do we agree that we need to boost the authority of health professionals?  Beth: it needs to be remade as a different kind of professionalism. medicine has always been a bit bureaucratic. it needs to be remade in that structure around way health services are provided basically pigeonholes .. every provider provides particular services, so there’s no flexibility/fluidity. need more interdisciplinary team approach. to a certain extent, it’s only the health professionals themselves who can create this for themselves. any outside intervention will be seen through a management lens.  Jonathan: technology so expensive, physicians will never be able to buy an MRI.. there will always be influence by people who are interested in making money, not caring for people. neither physicians nor patients will have control over it. logic of bureaucracy may be a permanent fixture.  Beth: way health professionals interact is a problem in itself. whoever you are, you’re just complaining about the other, and if you look in your own profession, you’re just complaining about the young.  John: if people had more idealism and they could sustain it, maybe these things could work.. but consumers need to get smarter. we’ve been told for the last several decades that we just need to keep working harder and things will get better. some would say people are getting lazy, some would say they’re getting cynical, some would say they’re wising up.  Beth: I don’t think he goes where McKinlay goes. he’s talking about the health care system, providers who work in the health care system. I don’t think he goes much out of that. he talks about their engagement with political elites. I think that the scope of what he’s talking about is within the HC system.  the scope is definitely within the HC system. but he and McKinlay start at almost the same place. given the enormous amount of money we put in our HC system, why aren’t we in better health? they don’t necessarily phrase it that way. but look at the parable McKinlay starts with.  John: I was trying to add that people in HC professions don’t feel real good about being there. they feel they’re getting screwed and pressured.  Beth: not the dentists  still a lot of professions seen as small-shop cottage industry, not your regular capitalism

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John: whether or not the HC system works, the people doing it need to be really engaged in what they’re doing. perhaps people go in with ideals and then get trapped Jonathan: people in residency, whatever they went in for, they get that beaten out of them Beth: United Way, etc. all getting milked for their altruism. we’d shoot ourselves if we were doing those boring finance jobs. I don’t think the frustration is limited to just the health care profession. John, is your point that, given where the professionals are now, we can’t rely on them to carry through with the change that Freidson is advocating? John: it’s possible Freidson would say the impingement of the logic of managerialism … Jonathan: managerialism a tool to extract more out of professionals? John: government workers demoralized too. takes more than management to bring that back Freidson is arguing you don’t use management to bring it back. the three logics in conflict with one another. to mix the models as HC is currently doing = ultimately trying to implement initiatives that cancel each other out. maybe this is what Alford meant by dynamics w/o change, politics with not much actually going on. John: now I agree with Freidson Martine: are we going back to the heyday of professionalism? Beth: more an evolution. Rabinow said maybe we’re at a point where it’s too early to tell.. we know in 30 years, we’re going to have a different model. given the pressures, what’s the next step in the evolution? we spend so much money on a particular part of HC delivery that isn’t as big as we think it is. it needs to be reorganized.. it’s not that people aren’t going to need the hospital, it’s that it’s not the end-all be-all of where we should put our money. p. 195 – he’s trying to come to grips with his agenda for reviving professionalism. this is what a lot of people dismissed, that he lived in a world with a medicine that didn’t exist anymore. halfway down, that first paragraph he talks about technological/economic/political circumstances.. “change cannot affect all professions alike.. some cannot escape dependence on large amounts of capital for their work, yet it may make a great difference to their fate whether capital provided by the state, private investors, or national or transnational organizations.” he’s talking about redistributing capital and redistributing ownership of capital. he doesn’t flesh it out anymore, but I wonder if he would have said we need to think about where money comes from and where it flows, and how organizations can be structured, and what incentives everyone in the HC system responds to. how effective or beneficent a HC system can we have? several of the theorists talked about their idea of the historical story re: the flush of the golden era of medicine. we set up all these technological demands and desires. now we don’t have the resources, so we’re left with the desire and the demand and the organizational infrastructure that relies on promoting this very expensive form of health care. Cindy: most important thing I’ve learned from this class.

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debate between whether this development = an accident of fate, or a more deliberate construction of capital or class or professionals or what have you Cindy: how do these theorists pinpoint these things and develop these theoretical perspectives without being inside the HC system? Freidson did some empirical studies earlier in his career. he relied on other people’s scholarship about particular professions. his larger project was to theorize across professions – professionalism as a particular way of doing work. he and lots of other people would say that being in the trenches is what prevents you from having the systemic, outsiders’, more global view. in sociology more generally as a discipline, some people have been dismissive of armchair theorizing. theorizing only helps us if it helps us understand what’s actually going on in the world around us. bigger intellectual imperative now to couple the empirical with the theoretical. it doesn’t make sense to do one without the other. it’s not a new idea; Marx talked about theory and praxis all the time. at the same time, Freidson talks about the 3 ideal types. he readily admits they don’t exist. but it serves an important theoretical purpose to say, ideally, what would this look like? it serves to highlight what is peculiar about the free market system and what is peculiar about bureaucracy. theoretical constants and contingencies of the three different kinds of markets. medicine in reality an amalgamation of elements of the three types of markets. John: each of those three logics has an important role to play in the delivery of HC. free market might be best way to set up hospitals, but not best way to allocate care. who gets care is better regulated by professionalism. bureaucracy good for generating some stability across generations of professionals. but Freidson talks about the three logics being antithetical to each other. why would a bid be made for a hospital when you can’t choose who’s allowed through the door? Freidson is saying the logics are incompatible with each other. his whole point is you gotta pick one, and the others are just supporting members of the one you pick. in a classic economic free market, everyone has full information, and you vote with your feet. but in HC, people aren’t rational actors, and we have imperfect knowledge as consumers. hospital report cards one way to try to get HC market to act more like a free market. in many ways, McKinlay and Freidson have this very similar point of departure. trying to come to terms w/ what’s going on in the HC system, why it’s so costly, why it has such a messed-up cost:benefit ratio. yet they go in completely different directions. their diagnoses are different, so the solutions they advocate are different as well. analytic + prescriptive. attempt to analyze what’s going on leads to certain kinds of prescriptions.

Farmer  he has a very prescriptive agenda, very ambitious idea about the role of intellectuals..  John: he’s pretty harsh. he sets the example by his work.  Jonathan: Berkeley business + public health collaborating to distribute Nokia SmartPhones in rural Africa to improve coordination of care (as “real world strategy to reduce poverty”)

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Romi: he talks about right and wrong. the other things we read haven’t been that explicit. Krista: is there a Farmer equivalent in medical sociology? in some ways, anthropology is becoming known within medicine. if you talk to a lot of HC workers, they kind of know what an anthropologist does. it’s a naturalistic way of doing research. you immerse yourself in the local culture and how things are done, and you do a lot of observation, informal/formal interviews. sociology is methodologically kind of all over the place. we’re really divided. lot of contestation over methods. we don’t have that disciplinary identity that anthropologists have. there are a lot of public sociologists (Diane Vaughan, Challenger disaster).. but are there medical sociologists who are public figures? honestly I can’t really think of someone. if you could talk about human rights, that’s a Big Question. in medical sociology, whether it’s just a peculiarity of the way questions are asked/debated.. you know about policy implications/recommendations, and that seems to be the way a lot of medical sociologists are trying to negotiate their way into the conversation. I assigned Farmer b/c he does think Big Thoughts. and I think sometimes we medical sociologists strain ourselves .. Farmer is talking to a wider audience. people talk about zero sum gain; he’s saying there is money. the problem is the complete maldistribution of resources. Krista: a lot of people in anthropology criticize Farmer as not being an anthropologist (too political, not grounded enough in the data) Martine: I don’t think he’s even trying to align himself with anthropology. Pescosolido. age-old dilemma b/c theories, practice, policy. how much of what we do should have an intent to change? why is it if you’re so politically grounded, that somehow undermines the legitimacy or objectivity of one’s work? Cindy: what’s the sense of doing something purely esoteric.. Krista: ..or just descriptive? the other critique is that theorists who have advocated being apolitical or not letting their political commitments hang out.. in fact, there is an underlying way of looking at the world that is partial. every theory about how the world works is a particular way of thinking that the world works in these ways. I always think there’s a politics underlying that. it’s not politics in the conventional sense where you have to make these public proclamations; it’s politics in that there’s an underlying theory of power, underlying theory of relationships, social relationships, on what bases these relationships are structured.. that, for me, are often about relationships of power, how it’s distributed, who has access, gains it, who speaks, whose voices are heard. so for me personally, intellectually I’m suspicious when someone says I don’t have any political commitments or advocate for anything in particular. but underlying the work and whatever theoretical position you take, as much as you wish it’s theoretical and not political, I can’t help but think that underlying it is a vision of how the world works and operates. what defines science, the historical dependence on what is scientific, on what is seemingly objective. people like Donna Haraway talks about there being a voice from somewhere.

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Farmer does talk about what he thinks are the problems. Jonathan: active efforts by those in power to maintain power within medical anthropology, in the late 1990s/early 2000s, there was a group interested in structural violence. it was their way .. anthropology had critique of being intensely descriptive. completely thorough view of what particular culture looks like; downside was that nothing was done with it (no prescriptive agenda). implicit critique that they weren’t as attentive to issues of inequality. everything seen as culturally relative, particular to a community. things were attributed to culture that Farmer/Kleinman would argue is not a cultural peculiarity; it’s structural, about money, about inequality – there are more universal things you can say. they got into issues that sociologists are traditionally interested in. what dynamics characterize inequality, what are the consequences of inequality, how does one change the shape of inequality. structural violence was the notion they came up with to encompass these things. violence doesn’t just exist in what things do to one another; it’s in fact done by the structural arrangements that societies and globally we participate and are part of and are subject to. includes race, ethnicity, gender ,class, and other dimensions of inequality. subfield within medical anthropology that Farmer is coming out of. that’s their diagnosis of the problem. Jonathan: he talks frequently about pragmatic solidarity – genuine empathy with those who are suffering. a lot of his ideas come from liberation theology/philosophy. Krista: utilitarian. it’s an injustice that some people get so much health care, and others do not. subtitle to his book is “Health, Human Rights, and the New War on the Poor.” he is looking at globalization, which is an emerging phenomenon. part of his point is to place the rampant spread of TB in Russian prisons and human rights organizations’ inability to provide antibiotics to stem that, and women dying of AIDS in Haiti, to globalization. the poor will tell you we’re not living in separate worlds; we’re living in one world. one of the points he made re: pragmatic solidarity and why people in medical professions need to step up to the plate .. symbolic capital that public health has. scientific knowledge is not normative and it’s not tightly tied to power; it’s vulnerable to being deformed by ideology (p. 235). in contrast to law (which is normatively/ideologically tied to power), medicine is not normative. Elena: biomedicine could be a product of hegemonic ideology as well. maybe in a way that’s not as obvious as law, but it’s still could be a product Romi: when you link progress with medicine with care for the poor, its real agenda has the potential to become even more hidden Krista: b/c it’s “pure good” unmitigated good Cindy: seems to me that Farmer is so individually focused, which is so typical of clinicians. p. 235 is just him going on and on about how more regulations are not going to help, laws protect states but not citizens.. to me, Farmer really advocates going to the grassroots. focusing less globally, starting with individuals.

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one thing about taking up a human rights discourse.. Rabinow/Rose: the way we think about freedom today is in the language of rights. but biopower is also the way it’s become manifest. we pick up the language of “the right to life” or [Farmer’s] “right to survive.” that’s always been part of the discourse around citizenship. Parsons’ idea of rights and obligations, how you can’t get one without the other.. that’s very much part of the language of citizenship. that’s a concept more and more people are talking about. what does it mean to be a citizen in contemporary society? is it the right to this and that.. what are the reciprocal obligations that come with it? has there been a rethinking of rights, obligations, and hence citizenship? human rights discourse does end up being implemented and thought about at the individual level. is this individual having his rights to happiness and life. are they being preserved or not? Krista: mapping questions of biopolitics onto Paul Farmer. he’s interested in global large-scale health issues, and you could maybe map that onto biopolitical questions of control of population, control of disease. Farmer saying biomedicine is not ideological, he’s saying biopolitics go to hell. Rabinow an anthropologist and so is Farmer, but they’re speaking totally different languages. Farmer might say there’s things that we know work; why aren’t people getting them? he doesn’t problematize scientific knowledge and technological fixes. to a large degree, why would he? he’s a physician, he uses them all the time. these are fixes that are readily available to those who have health care coverage in the first world. it’s not just that he’s a physician, it’s a critique of a lot of social construction. are you saying socially constructed medical knowledge isn’t real? whereas people like Rabinow/Rose would say medical knowledge is always.. they might not use the word ‘ideological’.. if Farmer says ‘are you telling me drugs won’t cure TB in Russian prisons?’ Rabinow/Rose not interested in challenging efficacy claims of technology/drugs. their project is about the political implications and biopolitical implications and political (broadly conceived re: power, shape of power relations).. how does knowledge get in the game – not in a conspiratorial way, but in a way that tells us something about ourselves. they talk about the new reproductive technologies. plethora of social science literature re: remaking ourselves, what it means for our identities. playing around with kinship and identity and what it means to be a human. they say b/c in fact it doesn’t affect a lot of us, it’s not a major site where we could see biopolitics at work. it affects such a small proportion of the population.. it’s not the kind of manifestations of power Foucault was interested in. they turn to looking at strategies for population control; they say that would probably be a political issue. Elena: Rose/Rabinow don’t seem too interested in the poor not interested in issue of social vs. not social Elena: he’s not interested in the social any longer b/c there is no hope in the social, b/c it’s corrupt or hegemonized Krista: or he’s interested in science and the practice of science that’s a place more and more sociologists and anthropologists are thinking about. less us/them critique, and more of a search for common ground for collaboration. science is not going to go away.. it’s part of the foundation that makes our society modern. how is it that we’re going to intervene. if we say that the critique is about how

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science has professed objectivity and being apolitical, then how is it we can get them to acknowledge there’s politics there, and what should scientists do about that? what would a more ethical scientific practice look like? one place Farmer, Rabinow, Rose might disagree on is.. Farmer talks about the right to survive (the right to live is so thoroughly undermined in so many places). Rabinow and Rose would talk about the move from issues of mortality (“making die”) to how now we’re all in this biopolitical age (“making live”) optimizing life? I’m just trying to survive. Farmer would argue we’re not in a biopolitical age yet. for much of the world, we’re not. John: has anyone taken up the question of why people in trying conditions have so many children? Beth: lack of birth control John: is that simple? maybe women are not in a power to say ‘let’s use birth control.’ Martine: lot of good ethnographies re: maternity and power relations. Death Without Weeping. maternal love not being a universal. this is how structural violence impacts something seen as so basically/intrinsically human as mother love John: Children of Men.

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if you remember from Week 6 (through 1970s), we came up with a list of prevailing themes. go back to your notes. so from my list, I have things about sickness as a social imperative, idea that medicine evolved to fulfill a social role. the influence of capitalism on medicine. I want to look at that list and think about how that list might look differently now. the relationship of medicine to the state and to the economy. professional autonomy. what makes a profession. professional power. nature of authority. medical knowledge as ideology. sociology of vs. in medicine. from that list, what do you see as carrying over now, or how have those concerns changed? what’s the contemporary twist on it? Beth: medicalization, manufacture of illness, construct of illness itself and the role it plays in society. problematizing what illness means. Krista: role of science and technology Freidson did talk about the social construction of illness Beth: but was it in the broader sense re: how we talked about medicalization? Freidson did talk about medicine as agent of social control and re: deviance. medicalization = the reconfiguration of those kinds of concerns. Krista: what is medical sociology? what are we doing here? goes back to issue of medical sociologists have disparate views of methodology role of intellectual. Pescosolido. not just within sociology.. how can we illuminate what’s happening in this ever-increasingly complex world around us? Cindy: professional autonomy is very different from Weeks 1-6 and Weeks 6-10. now professional autonomy is part of an organization. it doesn’t create a sense of dominance John: talk about the nature of authority transformed into discussion of power once we got into Foucault Foucault’s power-knowledge and knowledge-power

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professional power – one thing that’s changed theoretically(not that it didn’t exist before).. we started to theorize how power occurs both within and outside the clinic, permeating everyday life. qualitatively different shift. issue of agents. Panopticon. authority without having agents of authority. agents unnecessary for authoritative knowledge to perform its work John: we’ve globalized the conversation Jonathan: the social justice issue John: sickness as social imperative, and now health as social imperative this is a thread that’ll go into next quarter too. that it’s less about the medicalization of disease and more about the biomedicalization of health John: could be a postmodern thing too. lot of themes about enhancement, optimization, maximization. I think the other thing = relations to capital are so much more complicated now. there was worry about doctors becoming proletarianized, and relations w/ capital and the state.. and now they’re all just mixed in with each other maybe power has become much more diffuse in Foucauldian sense. power is not just something that somebody possesses by virtue of what they have. it’s a matter of where one is located. this quarter more about HC institutions, doctors, professionalism. next quarter more about patient perspective.

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