S207 Week 8 20 February 2007 Inequalities  sociology’s study of inequality has been a prevailing theme, and even beyond

medical sociology (going back to beginning of public health movement), all that dates back to late 1800s  Engels wrote a lot re: inhospitable living conditions in living-class England during the Industrial Revolution  interest in social inequality as producing health inequality didn’t just spring from nowhere in the 1970s Globalization these are all empirical questions. a lot of the literature around globalization tends to be very politically trenchant. one of the things that sociologists and in particular medical sociologists can do (re: knowledge production) = the ability to raise it as an empirical question. is it really a zero-sum-gain? do governments divest in public health because private corporations can handle it? the globalization literature sensitizes us to the possibility of the private way of doing things, and profit-making activities becoming the bottom line and the motivation. we need to entertain this as an empirical possibility. we’ll talk more about this when we get to this week’s (and more so next week’s) material. how do things actually look in practice? what kinds of resistances might be in place? globalization looks very different in different places. one of the things that the literature does, when you look at it from a synthetic framework, is it sensitizes us to different kinds of globalization. biomedicine is a kind of culture re: how the body works. technology seen inherently as good = very culturally specific way of looking at medicine and healing. is biomedicine as a culture being exported? how successfully or unsuccessfully? when, on the surface, people seem to be assuming Western biomedicine, are they pragmatically taking it up, or are they philosophically believing in the mechanistic view of the body as a machine? globalization of biomedicine as a culture making profit from medicine and from healing (cultural and economic set of practices)  the very idea of health care as a need organizations can fulfill. what sort of economic or organizational implications flow from that? specific questions need to be asked about how medicine is being globalized. importing this very Western way, this liberal political philosophy about health, that we have individual responsibilities to take care of ourselves. this is a very ideological/political philosophy, this neoliberalism that’s talked about. replacing homegrown systems of health care. Paul Farmer talked about whether it’s possible to argue coronary artery disease in Western culture is somehow linked to rates of tuberculosis in Haiti. is there a way to think about the distribution of diseases as being globally linked in some way? it raises certain kinds of questions about what might be going on, and how social inequality on different levels might be expressing itself.. the question is, can we think about that

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globally. in the present day, at a moment in time, can you link the health of people in one place with the health of another 3,000 or 6,000 miles away? even if exposure is completely even, there are some regions that simply have more resources to (in Link and Phelan’s words) minimize the consequences once the disease hits what does it mean when notions/programs/systems are exported to states with more centralized governments?  one could argue that for the level of income Cuba has, they enjoy a much higher overall level of health than what one would extrapolate from income alone (we need to look at the level of income inequality in the society) Wilkinson would argue that it’s manifestation of expression of certain priorities do you need commercial or capitalist interest to drive medicalization processes? Jonathan: but without profit, would there be incentive to develop high-tech innovations? Beth: a lot primarily funded by gov’t Martine: are those really beneficial, universally speaking? you could argue, as Elena suggested earlier, that life or the possibility of life is not always the best option. we look at not choosing life as the most detrimental option Medicalization one of the organizing concepts within medical sociology. people attribute the first mention to different people, but it was around 1968, 1972.. Zola excerpt from one of the first big treatises about taking up medicalization and what it means sociologically, and to us in this human condition. why did the notion of medicalization arise in the early 1970s?  John: the pill was made available in the mid-1960s, medicalizing pregnancy, and people started taking a pill for something that was not a disease  Jonathan: deviance – confine people or give them thorazine medicalization is a critique — part observation/description, part critique. why did that critique come up at that particular time? what else was going on that made people see something in a way they hadn’t seen it before? Jonathan: Medicare formalized a relationship that had previously existed on an informal basis, freezing in time the model of the individual patient encounter for an acute phase of illness, also preserving the physician as the gatekeeper to all sorts of services (home health services, rehab services. etc.) that didn’t have anything to do with the germ theory of disease how did that contribute to the rise of a critique of medicine? Jonathan: when people saw medicine demanding that its position of preeminence fortified in law, they might have started questioning Romi: people writing more about physicians as a profession up until this time, we’ve been somewhat reading chronologically – professional dominance, inequalities in knowledge.. there’s a certain element in theorizing that took it for granted (Parsons) and then its implications for democratizing knowledge.. there’s a whole branch of medical sociology that we’ve been reading here and there about social constructionism and interactionist approaches, and what those really bring to life is that experience counts for something, and lay knowledge counts for something. that’s something the women’s health movement really crystallized. collective ideas about an illness experience and that collective

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knowledge were in fact legitimate bases to begin to critique this tower of medicine, both in terms of its content and in terms of its practice. John: shift from the realm of church into the realm of science Beth: deinstitutionalization Martine: war on drugs within mental health, there was this reaction to these incredibly invasive/aggressive technological fixes to an emphasis more on rehabilitation within the community. rehabilitative aspects that included deinstitutionalization. Beth: does that relate to Reagan closing down institutions? no, this was about finding more humane approaches to mental health. it’s not just demedicalization. deinstitutionalization does not equal demedicalization; is it just a different kind of medicalization, now happening out in the community? Jonathan: when catatonic patients started receiving psychotropic drugs, they could go out in the community and live with their family Beth: if they stay on drugs. if they don’t, they end up in prison. mentally ill in prison, where they should not be. medicalization taking on more of the social control component need to not assume just what the consequences of what medicalization are or are not. unintended consequences of medicalization/demedicalization that become interpolated as remedicalization Beth: or criminalization one of the really revolutionary things that medicalization as a way of thinking as a theory/sensitizing concept points to is cracks open this black box of medical knowledge, the very content of what constitutes medicine and professional power. medicalization, for the first time, the public, sociologists were able to question the very content what had been up to this point more or less untouched (science = fact). that veneer begins to crack. medicalization brings up a lot of what Zola mentioned.. it’s a socially accomplished act. contestation of medicine and medical knowledge on its own terms. one of the big reasons it came around when it did. chronological parade of different versions of medicalization, biomedicalization. similarities and differences between what these medicalization theories propose. what are the similarities? one of the conceptual moves – naming something as being medicalized (?). John: shifting locus of responsibility Romi: moral component .. you owe it to society to do < > is medicalization pointing to and critiquing medicine as a coercive institution? Tony: most readings focused on the physician or political economy. the reading is more about the consumer / the patient, who can make their own choice to receive the therapy or service Elena: cooptation of the patient into this scheme John: increased intrusion of technology into people’s lives the availability and the expansion of technology becomes this imperative that furthers medicalization John: increased rationalization and standardization of medical practices

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one of the commonalities is that the structure and organization of medicine matters in terms of medicalization. it has certain kinds of consequences for the degree to which something is medicalized and how it is medicalized and what gets medicalized. and consequently, thinking about a lot of the structural changes from the 1970s onward, has consequences for changing the face of medicalization and what and how and the degree to which things are being medicalized. part of all these medicalization theories is that it’s this cultural notion.. it’s not just top-down coercion – “you must think this,” in medical terms. it’s really from the ground up, remaking our ideas about what is natural to think about in medical terms vs. not natural. there must be some technological fix to this. remaking our world view about our bodies and conditions and relations to each other. from the inside out, it’s productive (in the Foucauldian sense) – it’s positive, not just negative coercion. this cultural aspect to it. also organizational and structural aspect. deep consequences for medicalization and how it happens. a lot of them do this very overt statement or qualification that they don’t see this medical conspiracy it’s to claim that even if one is not a Marxist or neo-Marxist, medicalization still has resonance and theoretical significance – it says something about and accurately describes some aspects of social life in this time. Krista: Ehrenreich article more overtly Marxist the Ehrenreichs say on p. 42 not to view it as a conspiracy insistence that it’s not a vast conspiracy or medical imperialism/colonialism or moral entrepreneurship points again to how it’s not a top-down process.. it’s social, infrastructural change that’s very profound and that changes the way we think about ourselves and how we intervene. Beth: the pushback / the movement of going back to natural childbirth wouldn’t be happening without medical technology, c-sections, which is a safety blanket in case something goes wrong Martine: doesn’t change the fact that pregnancy is still being medicalized. reverting to natural childbirth is still a decision within a medicalized notion of childbirth. you have to go through stages of being prenatally conscious, and if you don’t, you’re seen as being a deviant I would caution against trying to label any kind of social phenomenon as good or bad. it’s always going to be complicated. some situations will differ, not just across individuals, but across places and times and populations. it’s an empirical question, empirical work. what are the differences? Zola  Elena: universities/science become the new repository of truth, instead of religion  this refers to one of the commonalities – some of the theorists call it labeling, other call it claims-making, others call it legitimation.. it’s a deliberate act (not in a conspiratorial sense), claiming something to be under the jurisdiction of medicine, it does particular kinds of cultural and social work. in our scientifically minded society, it does the work of making things legitimate, normalized.. there’s particular ways of framing the problems and solutions, and they’re to be found in medicine  what’s this myth of accountability that he’s talking about?

he’s talking about the idea that medicalization alleviates responsibility; through medicalization, moral responsibility and stigma becomes erased. he’s arguing that that is, in fact, a myth. what are the processes he’s pointing to.. with medicalization, what’s going on?  Beth: expansion of social control under the guise of medicine. regulation of what’s normal in society.  he’s talking about four specific processes.  it’s the idea that medicine has something to say about more and more areas.. and in converse, what’s already in medicine now, there’s more that we can use within that that has now become relevant for the good life.  Cindy: because medicine defines what the good life is.  his example – what medicine deems to be the good life – is what he claims is the most powerful process. he implies that almost regardless of what evidence backs that up, this is one of the most powerful ways that medicine, as an ideology/way of thinking, legitimates claims about almost anything.  using the language of genetics to offer a potential explanation for anything (Alzheimer’s, criminal behavior, political beliefs, religiosity)  it makes this whole idea about what the cause is of religious differences and differing disease incidents and addictive behavior.. genetics becomes a very powerful language to suggest that those things are rooted within individual genes.  there’s two other processes that he talks about.  Erica: the access to taboo areas  the sacrosanct areas, ability to say anything meaningful about when life begins and ends, intimacy and sexual lives, intimate habits.. in the normal course of social interaction, very few people would have access to discussing such issues.  final process: control over technical procedures  Krista: in terms of the philosophy of science, they say that there’s nothing outside their purview, no matter how meaningful or personal it is in the biomedicalization article by Clarke et al.. new awareness re: complementary medicine as key part of US health practices. what people paid for CAM rivaled what people paid for allopathic medicine. in that article, we were saying biomedicalization is different and does do something different. competing knowledge systems.. biomedicalization happens by coopting these competing systems of healing and trying to make them more scientific. e.g., Mt. Zion’s Center for Integrative Medicine running randomized clinical trials to legitimate or delegitimate CAM. displacing CAM’s own criteria for legitimacy with biomedical criteria.  allopathic or scientific Western medicine.. is that the kind of medicalization we’re talking about?  they never address the point, but judging from when they’re writing, it’s this historical .. my suspicion is that in the 1970s, there was no medicine other than allopathic. when people were talking about medicine, what they were talking about was Western scientific allopathic medicine. that’s the culture they argue was taking over expanding areas of life.  Beth: you could argue that CAM is just capitalizing on allopathic b/c it’s serving the consumer desire to have their unmet health care needs met 

given where we are now, and a lot of people either see allopathic medicine as being complementary, or whether they feel allopathic medicine doesn’t serve their needs.. given the sitaution we find ourselves in, maybe those going to alternative healer are thinking of it as resisting medicalization, trying to demedicalize themselves.  Beth: most people seem to not be using CAM as a substitute for allopathic  one of the critiques of biomedicalization is that it’s too totalizing and allencompassing  when Zola is talking about the ability of medicalization, the most powerful process of what in medicine is becoming relevant to the good life, he was talking about the power of a particular discourse/logic/vocabulary. it’s talking about it in very scientific terms, which is the basis for allopathic. is that discourse being used in other medicines?  medicine works for many different things and improves health on many different levels. the question is not, is it efficacious or not? the question revolves around the social implications that follow from this, irrespective of whether people get better or not, and it’s to not necessarily sidestep.. we’re not only in the business of trying to judge whether medicalization is good or bad, we’re trying to elaborate the consequences – immediate, long-term, intended, unintended – for consumers, etc.  a lot of the authors talk about how medicalization is a strategy for depoliticizing. we can see things not as social statements, but as pathology. anthropology (Ong at Berkeley) – mass sickness in Malaysian factory. the women.. it could be seen as protest against working conditions, but it was seen as contagious mental health pathology that needed medical remedy. can we differentiate between medicalization and self-governance?  Martine: the concept of medicalization as social control, and where that overlaps with or is distinct from governmentality and biopolitics  self-surveillance.. regime of regulating and governing ourselves  Martine: what’s the difference between medicalization and self-governance, the regime of help? is it the specific sites with which medicine has now become the dominant go-to answer, or..?  Beth: creating dependence in one population and empowerment in another. as things become medicalized, some people within society can self-govern around that issue, while it would create a dependency among others (who don’t have resources) on the medical system  Martine: medicalization in the readings is not site-specific.. it’s defined not by having to go to the doctor, but by being under the purview of medicine  Romi: you can have self-governance that has nothing to do with health  my answer is that different theories and different authors will have different answers to your question. Fox talks about health promotion, that one could be self-empowered to take care of one’s own health, and she uses that as an instance of how the critique of medicalization has taken hold. people who are refusing medicalization and taking care of themselves. …  Adele et al argue that you don’t have to go into the clinic or have an explicit relationship with a health care professional.. self-care relations are legitimate b/c medicine has said we need those for our health. reliance on biomedically legitimated knowledge, and a 

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particular kind of biomedical logic. our argument is that it is often seen as part and parcel of medicalization. the way we think about ourselves for ensuring a healthy future, that is how …  one of the things that biomedicalization was trying to point to was that one of the ways that medicalization happens is by coopting healing practices, alternative practices, alternative healing logics, and putting in a kind of scientific legitimation. doing clinical trials on acupuncture. for thousands of years, acupuncture did not need a standardized clinical trial to demonstrate its efficacy. but now we’re using biomedical standards of what is proven and efficacious to legitimize something that didn’t need those criteria to begin with. it’s undermining , it’s a wholly different way of knowing one’s body and intervening.  part of the argument in biomedicalization is that the involvement of capital has become so complex.. not only transnationally, but it creates this empirical imperative to follow the money. there are no motivations that are clearly humanitarian or simplistically capitalistic. our argument = in part that technoscience helps mobilize the < > and it’s changing how penetratingly things can become medicalized. technology / science / organizational and social arrangements to do something with that technoscience.. something qualitatively new is happening, and that thing is biomedicalization. modern/postmodern analogy.  microchips that can regulate your heart.. remakes/reengineers your heart to do what it’s supposed to do in the first place. allure of correcting it at the very root. it’s no longer controlling the disease outcomes or severity, it’s eliminating/curing them in a much more profound way.  we were all working on projects where patients think of themselves as cured in different ways from how they thought before. they think of themselves as remade in fundamental ways. regenerative. language of regeneration – “I’m young again.” our argument is that it’s these technoscientific innovations that make it possible to predict figure out a way to differentiate between medicalization, biomedicalization, and the different versions of medicalization. discuss this. moving forward, different understandings of power and the role of knowledge.. the ongoing issues about power, domination, politics, the organization of biomedicine, and how power is being exercised. next week we turn to theories that attempt to explain and elucidate how exactly power impels social action, how exactly a form of knowledge acts as a form of power. where power resides. when you have something amorphous, where does power actually sit/reside, and how does it motivate people to do things? it’s thinking about states and agents of social control in new ways. brings up ongoing questions crystallized by this week’s readings re: ethics, politics that get carried forward into next week.