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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
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
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
 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 all-
encompassing
 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
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.