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S207

30 January 2007
Week 5

due next week: prospectus for paper


 outline or several paragraphs
 comparative (2 or more theoretical perspectives) (don't care Navarro (Marxism) to Alford
(political economy, which is derived from Marxism)
 maybe relative advantages or disadvantages of one vs. another
 central problem or situation
 description of the question
 why you chose it
 how you see it applying
 an idea / preliminary literature that you're looking at (readings from course you're drawing
on, and citations that you're planning on drawing on)
 should be based on an issue that you’re interested in

political economy
 around 18th century, lot of writings/philosophers re: economic questions that culminated into
set of econ theories re: how the free market operated and what the rules of exchange were
(Adam Smith, J.S. Mills).
 early 19th century, econ as discipline separates from other domains of inquiry that
concentrated on social or moral or political kinds of issues. they took up a strand of this
early/liberal political economy that was primarily interested in how the free market operates.
 another person who was associated w/ this earlier liberal political economy (not that he
himself was a liberal, but he was writing about it) was Karl Marx
 in 20th century, we have the rise of radical political economy, which takes up the Marxist
portion of that political economy, and tries to resurrect its modes of inquiry, and how it looks
at society, and its interpolation of questions of economic order, political order, social
organization. cannot understand economic order without understanding political order, and
vice versa. see: political economy of aging, political economy of disability
 Tania: how is this different from social exchange?
 rooted in neo-Marxism. problems in HC system, how corporations/state/physicians interact
within the HC system can be understood by referencing them to and relating to the capitalist
mode of production
 phrase used a lot that’s often taken for granted, but it’s an explicit theoretical move, and an
explicit theoretical statement when someone in med soc says they’re doing a political
economy of something. in its conventional use in med soc, it has this attribution or origin
within neo-Marxist thought
 it’s something that feels somewhat familiar to us as sociologists, that of course questions of
econ organization cannot be divorced from questions of social organization
 Parsons 1950s and 1960s = very explicit statement to say our theorizing is of a different kind,
convention, tradition
locating different theorists in the typology
pluralist perspective
 individuals coming together in the political arena
 consensual, equal playing field
 how does a political order or political decision come about? democracy
 things depend on resources of individuals (you see this a lot.. depends on resources and
convincing others of the merits of one’s resources)
 depicts a notion of power that’s situational
 John: if the circumstances chance, the power will manifest itself differently too
 Krista: doesn’t it depend on outcome of particular situation? whether group gets what it
wants in a given situation?
 Janet: idea that when you say anything is situational, it depends on the particular
circumstances of that situation, so the outcome cannot necessarily be predicted ahead of
time by looking at the relative superiority or domination of different groups. every
political encounter depends predominantly on the circumstances, the interests, the
individuals, the skills present in the situation itself
 Navarro would say capital/corporate interests will always win out in the end. however,
when power is seen situationlly, outcomes are not so predetermined (this is a view on
how things work)
 dispersed inequalities, as opposed to systematic inequalities.

managerial perspective. what are its views on the state, what is the nature of power?
 state composed of organizations or networks of organizations
 in the pluralist perspective, any organizing/entity almost arises organically from
individuals coming together and figuring out where their common interests lie. in
managerial, organizations take on a life of their own.. they’re battling for resources
 pluralists would say democracy is there, managerial would say that organizations are
taking power away from democracy
 power is structural

class perspective
 power defined as systemic
 what does that even mean?
 John: idea of hegemony, things are less likely to be criticized
 Cindy: insidious, people don’t even realize it’s at play
 Krista: means of production = essentialized cause of the systemic relations of power
 Janet: power is much more provisional and multidirectional. for Marxists, power is very
unidirectional and class relations are ultimately determinative of power relations
 Romi: Gramsci
 Janet: systematized throughout all the different institutions.. cultural ideas in education
system, into value system, closely aligned w/ economic system. very thorough, deep,
permeating structure, not in a conspiratorial sense, but that the econ mode of production
is highly determinative of all these things. given one of the functions of the state is to
provide ideological infrastructure that we all accept capitalist production as
natural/progressive, that’s the notion of which power is at the systemic level.
 Romi: you can’t step outside of it.
 Janet: but not that it’s completely totalizing, b/c there is opportunity for resistance and
struggle (working class science, etc.)
 Romi: there is hope for class consciousness.

placing different theorists in this typology


 Parsons
 Beth: pluralist. functional, sick role. dispersed inequality.
 Janet: these theoretical perspectives are associated w/ a broad theoretical perspectives
about how society works. the way A&F talk about them here are particular to how we
organize ourselves politically, and how political outcomes come about. it’s not an origin
story – so the issue of individuals getting together in a democratic arena .. they’re not
saying/implying that’s how the sick role comes about. it’s not necessarily meant to be a
description of how everything in society works
 Parsons’ notion of sick role = it was the most efficient way to get someone back into the
productive labor force. superficial resonance with the class perspective. Parsons felt
social roles arise out of universal values that people share and are socialized to share, and
it’s those fundamental assumptions that you need to keep in mind.
 Beth: just some things that potentially don’t map for me.
 Elena: can we say that Parsons is subconsciously serving a class perspective? it’s
important to be productive, to work, to recover and go back to work?
 Janet: makes sense. Navarro makes similar argument for Starr’s arguments re: the rise
and fall of medicine. Navarro makes the point that it’s an apologist claim for capitalist
interests
 Sick Role Reconsidered, Parsons’ response to critiques. one of the primary critiques =
asymmetric relationship between MD and patient. Parsons said that this asymmetry only
existed within that relationship, as long as those 2 people were occupying those 2 social
roles. as soon as they were not in that institutional relationship, then the person who was
the patient could perhaps be more powerful. it’s not a reflection of systemic relations of
power. power as situational.
 Navarro
 class perspective (power differences reflection of more fundamental inequality)
 Starr
 Beth: his corporate argument lends itself to managerial perspective.
 Janet: I place him in the managerial perspective. Beth, you’re right he points to cultural
authority as the baseline. it’s difficult b/c he’s doing historical analysis. to me, he seems
to be saying that cultural authority is necessary but not sufficient condition for bringing
physicians to dominant position / professional autonomy. it’s added element of
organizing, and organization has resources at its disposal that makes it possible to acquire
professional autonomy/dominance. his explanation of the fall of medicine is all about
how conflicts between organizations and the unintended consequences of
industrialization and rationalization have taken over the HC system. so those are the
ways in which he represents a managerial perspective. there’s certainly room/places in
which he speaks more of the quality of a pluralist perspective. this is just a continuum,
not boxes they need to fit in. like any other sort of theoretical device, typologies are
useful to think with.

 Freidson
 each perspective has different key questions.
 pluralist: playing within the game; outcomes = how well people play that game.
 managerial: who gets to set the rules of the game, who asks the important questions.
Freidson talks a lot about how physicians were able to persuade the public that their
answers were the right way to go. issue of legitimacy. physicians have not lost a lot
of autonomy; things look more the same than they look different. it’s not the way
corporate medicine has elaborated itself. it’s still dependent upon physicians and
medical knowledge. notion of professional autonomy has been challenged but not
fundamentally undermined.
 Brown
 Martine: managerial. role of philanthropists in organizations taking on power.
 Krista: seems pluralist instead.
 Janet: I classify him as class perspective. where does the money for the foundations
come from?
 Craig: the money’s not coming from the little people.
 Janet: his analysis is much more meso-level of corporations and philanthropic
organizations. but at the same time, especially at end of reading, he talks about how
those orgs are very closely allied w/ corporate interests, and MDs – for all the dominance
they obtained – were unable to change the market character of medicine. so I had him in
between the managerial and the class. but I thought we could probably out him as a neo-
Marxist.
 Martine: he didn’t come out and say it, he was implying it the whole time.
 Cindy: Gates Foundation
 Craig: political decision to fund AIDS in Africa but not AIDS elsewhere
 Elena: Gates donating money = seen as good.
 Janet: legitimation function.

 in a nutshell, this is sort of what you want to do in your papers. where does political order
come from? what accounts for economic order? etc.
 Elena: have other authors come up w/ other typologies?
 Janet: the ones I’ve seen, the ends are similar. consensus theory vs. conflict theory. the
middle sometimes differs. but when you’re talking about the role of the state, and political
sociology, which we’re doing a version of here in terms of thinking re: the role of the state,
and how the HC system is or is not a product of political organization. A&F’s emphasis on
rationalization is a little different from others I’ve read, but organic vs. systemic, you see a
lot.
Alford – 1972 – Political Economy of Health Care
 John: he was right
 Elena: don’t agree w/ Alford’s assertion on p. 146 that community representatives have no
power
 Beth: interesting dichotomy between state and private/foundation funding. when you apply
for a grant, you make your project sound like something the foundation wants.
 Alford might say that when you bring vested inters to the table, what you end up with is a
solution that doesn’t satisfy any of those vested interests.. essentially leaving the system the
way it was before. that said, the class perspective does have limitations. it’s kind of a self-
fulfilling prophecy. everything ties into this totalizing, dominating system of cultural,
economic, and political production. and anything that might be seen as possible change is
turned into legitimation, or has some sort of ideological function. it doesn’t quite leave a
possibility that for real people, there is real change. there are good things that come out of
scientific medicine.
 the point that Alford, Navarro, Estes make is that whatever gets pushed forward is still going
to leave the broad outline of our system of HC untouched. it’s not going to be undermined.
 disconnect when 60% of Americans want a change but policymakers can’t pass a bill
 crisis of legitimation and crisis of capital accumulation. what’s happened in HC, a class
perspective theorist would argue, is the logical outcome = capital accumulation, trying to find
ways to garner more and more profit from social needs (public hospitals being bought out, or
public hospitals acting like for-profit institutions). privatization/bureaucratization = all ways
to extract more capital from the HC system.
 whole premise = figuring out how to turn money into more money
 the very fact a nursing home needs private investors – and that those investors are in it to
make money – point to the overriding capitalist mode of production, which leaves out
questions re: other ways we could organize our HC system
 Alford argues we’ve been continuing along this track since the 1930s
 HC seen as increasingly capital-intensive sector.. has become highly technological, firms
trying to recoup costs of R&D.. we get caught up in details (physician-induced demand, etc.)
– medical sociologists are not trying to figure out what the “right” level of med care is for
people. they’re trying to figure out whether that is the right question to ask. it’s a quality of
thinking and a way of problematizing what those questions are. it’s not accepting that those
questions are the only questions that need to be asked, or whether there’s a “right” answer to
those questions. that’s why sociology ends up being so much about politics and power.
 think about these theoretical perspectives as different ways to systematize the disparate,
complex, seemingly fragmented/chaotic HC system into some systematic account. and that’s
really the challenge for sociological theory.

how does change happen?


 class perspective’s notion of social change: major division that characterizes society is class
division.
 if class isn’t the primary way people organize/identify themselves, do we need working class
struggle/uprising to generate reform?
 your answer to this question is a good way to gauge where you yourself lie on this theoretical
continuum
 maybe a lot of what we’re struggling with is a way to talk about power