Clarke Adele 2003

Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S.
Biomedicine
Author(s): Adele E. Clarke, Janet K. Shim, Laura Mamo, Jennifer Ruth Fosket and Jennifer
R. Fishman
Source: American Sociological Review, Vol. 68, No. 2 (Apr., 2003), pp. 161-194
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/1519765 .
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BIOMEDICALIZATION:
TECHNOSCIENTIFIC TRANSFORMATIONS OF
HEALTH, ILLNESS, AND U.S. BIOMEDICINE
ADELE E. CLARKE JANET K. SHIM
University of California, San Francisco University of California, San Francisco
LAURA MAMO JENNIFER RUTH FOSKET

University of Maryland, College Park University of California, San Francisco
JENNIFER R. FISHMAN
University of California, San Francisco
The first social transformation of American medicine institutionally established medi-

cine by the end of World War II. In the next decades, medicalization-the expansion of
medical jurisdiction, authority, and practices into new realms-became widespread.
Since about 1985, dramatic changes in both the organization and practices of contem-
porary biomedicine, implemented largely through the integration of technoscientific
innovations, have been coalescing into what the authors call biomedicalization, a
second "transformation" of American medicine. Biomedicalization describes the
increasingly complex, multisited, multidirectional processes of medicalization, both
extended and reconstituted through the new social forms of highly technoscientific
biomedicine. The historical shift from medicalization to biomedicalization is one from
control over biomedical phenomena to transformations of them. Five key interactive
processes both engender biomedicalization and are produced through it: (1) the po-
litical economic reconstitution of the vast sector of biomedicine; (2) the focus on
health itself and the elaboration of risk and surveillance biomedicines; (3) the in-
creasingly technological and scientific nature of biomedicine; (4) transformations in
how biomedical knowledges are produced, distributed, and consumed, and in medical
information management; and (5) transformations of bodies to include new properties
and the production of new individual and collective technoscientific identities.
HE GROWTH OF medicalization-de- twentieth century in the West (Bauer 1998;

fined as the processes through which as- Clarke and Olesen 1999; Conrad 1992,
pects of life previously outside the jurisdic- 2000; Renaud 1995). We argue that major,
tion of medicine come to be construed as largely technoscientific changes in biomedi-
medical problems-is one of the most potent cine1 are now coalescing into what we call
social transformations of the last half of the
Sara Shostak, and especially Leigh Star, Herbert
Direct correspondence to Adele E. Clarke, De- Gottweis, Vincanne Adams, and the ASR Editors
partmentof Social and Behavioral Sciences, Uni- and anonymous reviewers. This paper is part of
versity of California, San Francisco, Box 0612, an ongoing collaboration initiated by Clarke; co-
3333 California Street, Suite 455, San Francisco, authors are listed in random order.
1
CA 94143-0612. We thank our generous col- Following Latour (1987), we use the term
leagues who read and commented on the paper: "technoscience" to indicate an explicit move past
Isabelle Baszanger, Simone Bateman, Ilana scholarly traditions that separated science and
Lowy, Jean-Paul Gaudilliere, Phil Brown, technology conceptually and analytically. We ar-
Monica Casper, Peter Conrad, Eliot Freidson, gue that these two domains should be regarded
Donald Light, Virginia Olesen, Guenter Risse, as co-constitutive; we thus challenge the notion
AMERICAN SOCIOLOGICALREVIEW, 2003, VOL. 68 (APRIL: 161-194) 161

162 AMERICAN SOCIOLOGICAL REVIEW
biomedicalization2 and are transformingthe cumulative over time and have now reached
twenty-first century. Biomedicalization is critical infrastructural mass in the shift to
our term for the increasingly complex, biomedicalization.
multisited, multidirectional processes of Clinical innovations are, of course, at the
medicalization that today are being both ex- heart of biomedicalization. Extensive trans-
tended and reconstituted through the emer- formations are produced through new diag-
gent social forms and practices of a highly nostics, treatments, and procedures from
and increasingly technoscientific biomedi- bioengineering, genomics, proteomics, new
cine. We signal with the "bio" in biomedi- computer-based visualization technologies,
calization the transformations of both the computer-assisted drug developments, evi-
human and nonhuman made possible by dence-based medicine, telemedicine/tele-
such technoscientific innovations as molecu- health, and so on. At the turn of the twenty-
lar biology, biotechnologies, genomization, first century, such technoscientific innova-
transplantmedicine, and new medical tech- tions are the jewels in the clinical crown of
nologies. That is, medicalization is intensi- biomedicine and vectors of biomedicaliza-
fying, but in new and complex, usually tion in the West and beyond.
technoscientifically enmeshed ways. The extension of medical jurisdiction over
Institutionally, biomedicine is being reor- health itself (in addition to illness, disease,
ganized not only from the top down or the and injury) and the commodification of
bottom up but from the inside out. This is health are fundamentalto biomedicalization.
occurring largely through the remaking of That is, health itself and the proper manage-
the technical, informational, organizational, ment of chronic illnesses are becoming indi-
and hence the institutional infrastructuresof vidual moral responsibilities to be fulfilled
the life sciences and biomedicine via the in- throughimproved access to knowledge, self-
corporation of computer and information surveillance, prevention, risk assessment,
technologies (Bowker and Star 1999; the treatment of risk, and the consumption
Cartwright2000; Lewis 2000; National Re- of appropriate self-help/biomedical goods
search Council 2000). Such technoscientific and services. Standardsof embodiment, long
innovations are reconstituting the many in- influenced by fashion and celebrity, are now
stitutional sites of health-care knowledge transformed by new corporeal possibilities
production, distribution, and information made available through the applications of
management(e.g., medical informationtech- technoscience. New individual and collec-
nologies/informatics, networked or inte- tive identities are also produced through
grated systems of hospitals, clinics, group technoscience (e.g., "high-risk" statuses,
practices, insurance organizations, the bio- DNA profiles, Syndrome X sufferers).
scientific and medical technology and sup- Biomedicalization processes are situated
plies industries, the state, etc.). These meso- within a dynamic and expanding politico-
level organizational/institutionalchanges are economic and sociocultural biomedical sec-
tor. In this sector, the incorporationof tech-
noscientific innovations is at once so dense,
thatthereare "pureforms"of scientificor tech-
nological researchtotally distinguishablefrom dispersed (from local to global to local), het-
their practicalapplications.Similarly,the term erogeneous (affecting many different do-
"biomedical" featuresthe increasinglybiological mains simultaneously), and consequential
scientific aspects of the practices of clinical for the very organization and practices of
medicine.Thatis, the technoscientificpractices biomedicine broadly conceived that they
of the basiclife sciences("bio")areincreasingly manifest a recorporation-a reconstitution-
also partof appliedclinicalmedicine-now bio- of this historically situated sector. We term
medicine. this new social form the "Biomedical
2 Otherscholarshaveused the term"biomedi-
TechnoService Complex, Inc."3The growth
calization" (C. Cohen 1991, 1993; Estes and
Binney 1989; Lyman 1989; Weinstein and
Weinstein1999). They were not, however,con- 3 This conceptmergesthe "medicalindustrial
cerned with technoscience. See Clarke and complex," a term coined by HealthPAC
Olesen(1999) andClarkeet al. (2000) for earlier (EhrenreichandEhrenreich1971),withthe"New
formulationsof these ideas. WorldOrder,Inc."coinedby Haraway(1997).

BIOMEDICALIZATION 163
of this complex since World War II is clear. duction of new individual and collective
The U.S. health sector has more than tripled technoscientific identities. These processes
in size over the last 50 years from 4 percent operate at multiple levels as they both en-
to 13 percent of GNP, and it is anticipated to gender biomedicalization and are also
exceed 20 percent by 2040 (Leonhardt (re)produced and transformed through bio-
2001). At the same time, Western biomedi- medicalization over time. Our argument,
cine has become a distinctive sociocultural thus, is historical, not programmatic.
world, ubiquitously webbed throughout We begin by examining the historical shift
mass culture (e.g., Bauer 1998; Lupton from medicalization to biomedicalization.
1994). Health has been the site of multiple We then elaboratethe five key historical pro-
old and new social movements (e.g., Brown cesses through which biomedicalization oc-
et al. 2001). Biomedicine has become a po- curs. We conclude by reflecting on the im-
tent lens through which we culturally inter- plications of the shift to biomedicalization.
pret, understand,and seek to transformbod-
ies and lives. That is, if the concept of the
FROM MEDICALIZATION TO
Biomedical TechnoService Complex, Inc.
BIOMEDICALIZATION
particularly captures some politico-eco-
nomic dimensions of biomedicalization, the Historically, the rise in the United States of
concept of biomedicine as a culture per se, Western (allopathic) medicine as we know it
as a regime of truth (Foucault 1980: 133), was accomplished clinically, scientifically,
particularly captures some sociocultural di- technologically, and institutionally from
mensions. 1890 to 1945. This first "transformationof
Although we can conceptually tease apart American medicine" (Starr 1982) was cen-
organizational, clinical, and jurisdictional tered not only on the professionalization and
axes of change and their situatedness within specialization of medicine and nursing but
a politico-economic and sociocultural sec- also on the creation of allied health profes-
tor-however vast-the ways in which these sions, new medico-scientific, technological,
changes are simultaneous, co-constitutive, and pharmaceutical interventions, and the
and nonfungible inform our conceptual- elaboration of new social forms (e.g., hospi-
ization of biomedicalization. That is, a fun- tals, clinics and private medical practices)
damental premise of biomedicalization is (Abbott 1988; Clarke 1988; Freidson 1970,
that increasingly important sciences and 2001; Gaudilliere and Lowy 1998; Illich
technologies and new social forms are co- 1976; Lock and Gordon 1988; Pauly 1987;
produced within biomedicine and its related Pickstone 1993; Risse 1999; Stevens 1998;
domains.4 Biomedicalization is reciprocally Swan 1990). Then, in the decades after
constituted and manifest through five major World War II, medicine, as a politico-eco-
interactive processes: (1) the politico-economic institutional sector and a sociocultural
nomic constitution of the Biomedical "good," grew dramatically in the United
TechnoService Complex, Inc.; (2) the focus States through major investments, both pri-
on health itself and elaboration of risk and vate (industry and foundations) and public
surveillance biomedicines; (3) the increas- (e.g., the National Institutes of Health
ingly technoscientific nature of the practices [NIH], Medicare, Medicaid) (Kohler 1991;
and innovations of biomedicine; (4) transfor- NIH 1976, 2000a, 2000b). The productionof
mations of biomedical knowledge produc- medical knowledges and clinical interven-
tion, information management, distribution, tions-goods and services-expanded rap-
and consumption; and (5) transformationsof idly.5
bodies to include new propertiesand the pro- As medicine grew, sociologists and other
social scientists began to attend to its impor-
4 For reviews of the historyand sociology of
medical technologiesand relatedpractices,see 5We use the to signalthat
plural"knowledges"
Marks(1993) andTimmermans(2000). Co-con- knowledgesare heterogeneousand may be in-
stitutionis defined as the mutualand simulta- commensurate andcontested.On the production
neous productionof a social phenomenon;for a of "situated knowledges," see Haraway (1991);
discussion,see Jasanoff(2000). for an exemplar,see ClarkeandMontini(1993).

tance, especially as a profession (Abbott Conrad 1975, 2000; Conradand Potter 2000;
1988; H. Becker et al. 1961; Bucher 1962; Conrad and Schneider 1980; Figert 1996;
Bucher and Strauss 1961; Freidson 1970; Fox 1977, 2001; Halpern 1990; Litt 2000;
Parsons 1951; Starr 1982; Strauss, Lock 1993; Riessman 1983; Ruzek 1978;
Schatzman, et al. 1964). The concept of Schneider and Conrad 1980; Timmermans
medicalization was framed by Zola (1972, 1999). Social and cultural aspects and mean-
1991) to theorize the extension of medical ings of medicalization were elaborated even
jurisdiction, authority,and practices into in- further and, as we argue next, largely
creasingly broader areas of people's lives. through technoscientific innovations. For
Initially, medicalization was seen to take example, conditions understood as undesir-
place when particular social problems able or stigmatizable "differences"
deemed morally problematic and often af- (Goffman 1963) were medicalized (e.g., un-
fecting the body (e.g., alcoholism, homo- attractiveness through cosmetic surgery;
sexuality, abortion, and drug abuse) were obesity through diet medications), and the
moved from the professional jurisdiction of medical treatment of such conditions was
the law to that of medicine. Drawing from normalized (Armstrong 1995; Crawford
interactionist labeling theory,6 Conrad and 1985). These were the beginnings of the bio-
Schneider (1980) termed this a transforma- medicalization of health, in addition to ill-
tion from "badness to sickness." Simulta- ness and disease-the biomedicalization of
neously, some critical theorists viewed phenomena that heretofore were deemed
medicalization as promoting the capitalist within the range of "normal" (Arney and
interests of medicine and of the medical in- Bergen 1984; Hedgecoe 2001).
dustrial complex more broadly (e.g., Then, beginning about 1985, we suggest,
Ehrenreich and Ehrenreich 1978; McKinlay the nature of medicalization itself began to
and Stoeckle 1988; Navarro 1986; Waitzkin change as technoscientific innovations and
1989, 2001). associated new social forms began to trans-
Through the theoretical framework of form biomedicine from the inside out. Con-
medicalization, medicine came to be under- ceptually, biomedicalization is predicated
stood as a social and cultural enterprise as on what we see as larger shifts-in-progress
well as a medico-scientific one, and illness from the problems of modernity to the
and disease came to be understood as not problems of late modernity or post-
necessarily inherent in any particularbehav- modernity. Within the framework of the in-
iors or conditions, but as constructedthrough dustrial revolution, we became accustomed
human (inter)action (Bury 1986; Lupton to "big science" and "big technology"-
2000). Further,medicalization theory also il- projects such as the Tennessee Valley Au-
luminated the importance of widespread in- thority, the atom bomb, and electrification
dividual and group acceptance of dominant and transportationgrids. In the currenttech-
sociocultural conceptualizations of medicine noscientific revolution, "big science" and
and active participationin its diverse, inter- "big technology" can sit on your desk, re-
related macro, meso, and micro practices and side in a pillbox, or inside your body. That
institutions, however uneven (Morgan 1998). is, the shift to biomedicalization is a shift
Gradually the concept of medicalization from enhanced control over external nature
was extended to include any and all in- (i.e., the world around us) to the harnessing
stances of new phenomena deemed medical and transformation of internal nature (i.e.,
problems under medical jurisdiction-from biological processes of human and nonhu-
initial expansions around childbirth, death, man life forms), often transforming"life it-
menopause, and contraception in the 1970s self." Thus, it can be argued that medical-
to post-traumatic stress disorder (PTSD), ization was co-constitutive of modernity,
premenstrualsyndrome (PMS), and attention while biomedicalization is also co-constitu-
deficit hyperactivity disorder (ADHD) in the tive of postmodernity (Clarke 1995).
1980s/1990s, and so on (Armstrong 2000; Important to the shift are the ways in
which historical innovations of the medical-
6 For a review and extendedcitationsto this ization era (organizational, scientific, tech-
theoreticalapproach,see Pfohl(1985). nical, cultural, etc.) became widely elabo-

BIOMEDICALIZATION 1 65
rated and dispersed material infrastructures, Table 1 offers an overview of the shifts
resources and sociocultural discourses, and from medicalization to biomedicalization
assumptions of the biomedicalization era cobbled and webbed together throughthe in-
(Clarke 1988). Biomedicalization is charac- creasing application of technoscientific in-
terized by its greater organizational and innovations. One overarching analytic shift is
stitutional reach through the meso-level in- from medicine exerting clinical and social
novations made possible by computer and control over particular conditions to an in-
information sciences in clinical and scien- creasingly technoscientifically constituted
tific settings, including computer-based re- biomedicine also capable of effecting the
search and record-keeping.The scope of bio- transformation of bodies and lives (Clarke
medicalization processes is thus much 1995). Such transformationsrange from life
broader, and includes conceptual and clini- after complete heart failure to walking in the
cal expansions through the commodification absence of leg bones, to giving birth a de-
of health, the elaboration of risk and surveil- cade or more after menopause, to the capac-
lance, and innovative clinical applications of ity to genetically design life itself-veg-
drugs, diagnostic tests, and treatmentproce- etable, animal and human. Of course, many
dures. This includes the production of new biomedically induced bodily transformations
social forms through "dividing practices" are much less dramatic, such as Botox and
that specify population segments such as risk laser eye surgery, but these are no less
groups (Rose 1994). These groups are to be technoscientifically engineered.
given special attention through new "assem- The rest of Table 1 describes shifts from
blages" (Deleuze and Guattari 1987) of medicalization to biomedicalization within
spaces, persons, and techniques for care-giv- the five key processes that co-constitute bio-
ing. Innovations and interventions are not medicalization. Analytically, the shift from
administered only by medical professionals medicalization to biomedicalization occurs
but are also "technologies of the self," forms unevenly across micro, meso and macro lev-
of self-governance that people apply to els. Significantly, biomedicalization theory
themselves (Foucault 1988; Rose 1996). emphasizes organizational/institutional/
Such technologies pervade more and more meso-level changes, and these are high-
aspects of daily life and the lived experience lighted here in order to describe the pro-
of health and illness, creating new bio- cesses and mechanisms of action and change
medicalized subjectivities, identities, and in concrete-if widespread-practices. Bio-
biosocialities-new social forms constructed medicalization is constituted through the
around and through such new identities transformation of the organization of bio-
(Rabinow 1992). We seek to capture these medicine as a knowledge- and technology-
changes in the ordering of health-related ac- producing domain as well as one of clinical
tivities and the administrationof individuals application. Computerand informationtech-
and populations7-including self-adminis- nologies and the new social forms co-pro-
tration-referred to as governmentality.8 duced through their design and implementa-
tion are the key infrastructuraldevices of the
7 The term new genres of meso-institutionalization
"population health" is increasingly
used to refer to studiesof particularpopulation (Bowker and Star 1999). The techno-organi-
groups (the aged, women, ethnic groups, adoles-
zational innovations of one era become the
cents, etc.). (often invisible) infrastructuresof the next
8 Governmentality is a Foucauldian concept (Clarke 1988, 1991).
used to referto particularkinds of power often The following points are at the core of our
guidedby expertknowledgesthatseek to moni- argument about the shift from medical-
tor, observe,measure,andnormalizeindividuals ization to biomedicalization. We offer an al-
and populations (Foucault 1975, 1980, 1988, ternative understandingof historical change
1991). This kind of power relies not upon brute
coercion, but instead upon diffuse mechanisms
such as discourses that promote the pursuit of connote various governing rationalities based in
happiness and healthiness through certain modes disciplining and surveillance, biopower, and
of personal conduct including self-surveillance, technologies of the self (also see Rose 1996;
and self-regulation. We use "governmentality"to Turner 1997).

1 66 AMERICAN SOCIOLOGICAL REVIEW
beyond that of technological determinism Many of the themes we develop here are
(e.g., Jasanoff 2000; Rose 1994). While we not new; but their synthesis within an argu-
see sciences and technologies as powerful, ment for technoscientifically based biomedi-
we do not see them as determining futures. calization is. Further,the shifts are shifts of
With other science, technology, and medi- emphasis-these trends are historical and
cine studies scholars, we start with the as- historically cumulative from left to right
sumption that sciences and technologies are across Table 1, not separate and parallel.
made by people and things working together Traditionalmedicalization processes can and
(e.g., Clarke 1987; Latour 1987). Human ac- do continue temporally and spatially at the
tion and technoscience are co-constitutive, same time as more technoscientifically
thereby refuting technoscientific determin- based biomedicalization processes are also
isms (M. Smith and Marx 1994). Although occurring. Innovations accumulateover time
the changes wrought by biomedicalization such that older, often "low(er)" technologi-
are often imaged as juggernauts of techno- cally based approaches are usually simulta-
logical imperatives (Koenig 1988) bearing neously available somewhere, while emer-
distinctive Western biomedical assumptions gent, often "high(er)" technoscientifically
(Lock and Gordon 1988; Tesh 1990), the based approaches also tend over time to
new social/cultural/economic/organiza- drive out the old. There is no particularevent
tional/institutionalforms routinely produced or moment or phenomenon that signals this
as part and parcel of technoscientific inno- shift, but rather a cumulative momentum of
vations are usually analytically ignored increasingly technoscientific interventions
(Vaughan 1996, 1999). That is, the realms throughoutbiomedicine since roughly 1985.
and dynamics of the social inside scientific, The unevenness of biomedicalization per-
technological, and biomedical domains are sists and will continue to persist historically
too often rendered invisible. At the heart of and geographically in the United States and
our project lie the tasks of revealing these elsewhere.
new social forms and opening up critical We turn next to an elucidation of the con-
spaces to allow greater democratic partici- crete practices and processes of biomedical-
pation in shaping human futures with ization.
technosciences.
Therefore, central to our argument is the KEY PROCESSES OF
point that in daily material practices, bio- BIOMEDICALIZATION
medicalization processes are not predeter-
mined but are quite contingent (Freidson Biomedicalization is co-constituted through
2001; Olesen 2002; and Olesen and Bone five central (and overlapping) processes:
1998). In laboratories, schools, homes, and major political economic shifts; a new focus
hospitals today, workers and people as pa- on health and risk and surveillance bio-
tients and as providers/health system work- medicines; the technoscientization of bio-
ers are responding to and negotiating biomedicine; transformationsof the production,
medicalization processes, attempting to distribution, and consumption of biomedical
shape new technoscientific innovations and knowledges; and transformations of bodies
organizational forms to meet their own and identities. We emphasize historical de-
needs (Strauss, Schatzman, et al. 1964; velopments in the transitional and current
Wiener 2000). In practice, the forces of bio- biomedicalization era.
medicalization are at once furthered, re-
sisted, mediated, and ignored as varying lev- 1. ECONOMICS: THE U.S. BIOMEDICAL
els of personnel respond to their constraints
TECHNOSERVICE COMPLEX, INC.
and make their own pragmatic negotiations
within the institutions and in the situations One theoretical tool for understanding the
in which they must act (Lock and Kaufert shift from medicalization to biomedicaliza-
1998; Morgan 1998; Olesen 2000; V. Smith tion is the concept of the "medical industrial
1997). As a result, the larger forces of bio- complex" put forward in the 1970s in the
medicalization are shaped, deflected, trans- midst of the medicalization era. Changes in
formed, and even contradicted. medicine in that era were critically theorized

as reflecting the politico-economic develop- shapes how we think about social life and
ment of a "medical industrialcomplex" (tak- problems in ways that constitute biomedical-
ing off from President Eisenhower's 1950s ization. The most notable socioeconomic
naming of "the military industrial complex" changes indicative of and facilitating bio-
consolidated through World War II). This medicalization are, as indicated in Table 1,
concept was coined by a progressive health (1) corporatizationand commodification; (2)
activist group, HealthPAC (Ehrenreich and centralization, rationalization, and devolu-
Ehrenreich 1971), and subsequently was tion of services; and (3) stratified biomedi-
taken up inside mainstream medicine by calization.
Relman (1980), then editor of The New En- CORPORATIZATION AND COMMODIFI-
gland Journal of Medicine (also see Estes, CATION. Trends in corporatization and
Harrington, and Pellow 2000). For the cur- commodification are embodied in the moves
rent biomedicalization era, we offer a paral- by private corporate entities to appropriate
lel concept-the Biomedical TechnoService increasing areas of the health-care sector un-
Complex, Inc. This term emphasizes the der private management and/or ownership.
corporatized and privatized (rather than In biomedicalization, not only are the juris-
state-funded)research,products and services dictional boundaries of medicine and medi-
made possible by technoscientific innova- cal work expanding and being reconfigured,
tions that furtherbiomedicalization. The cor- but so too are the frontiers of what is legiti-
porations and related institutions that consti- mately defined as private versus public
tute this complex are increasingly multina- medicine, and corporatized versus nonprofit
tional and are rapidly globalizing both the medicine. For example, in the United States,
Western biomedical model and biomedical- federal and state governments have been in-
ization processes per se. strumental in expanding the private health-
The size and influence of the Biomedical care sector by inviting corporations to pro-
TechnoService Complex, Inc. are significant vide services to federally insured beneficia-
and growing. The health-care industry is ries. Historically, since the Social Security
now 13 percent of the $10 trillion annual Act established the government as a direct
U.S. economy. In the economic downturnof provider of medical insurance coverage
late 2001, the health-care sector was even through the Medicaid and Medicare pro-
viewed by some as the main engine of the grams in 1965, most recipients have been
U.S. economy, offering a steadying growth. treated in public and/or not-for-profit clin-
Pharmaceutical-sectorgrowth is estimated at ics, hospitals, and emergency rooms. As
about 8 percent per year (Leonhardt 2001). health-care costs and competitive pressures
Americans spent more than $100 billion on for personnel and revenues escalated, how-
drugs in 2000, double the amount spent in ever, many of these facilities closed or were
1990 (Wayne and Petersen 2001). The emer- bought out and consolidated by for-profit
gence of a global economy dominated by corporations. By the late 1990s, efforts were
flexible accumulation by interdependent underway to move such patients into private
multinational corporations (Harvey 1989), HMOs, effectively privatizing social health-
streamlined production arrangements, new care programs (e.g., Estes et al. 2000).
management technologies (V. Smith 1997), Second, under pressure from powerful
and increased specialization enables many of biomedical conglomerates, the state is in-
the biomedicalization processes discussed creasingly socializing the costs of medical
here.9 research by underwriting start-up expenses
Through its sheer economic power, the of research and development yet allowing
Biomedical TechnoService Complex, Inc. commodifiable products and processes that
emerge to be privatized-that is, patented,
9 For discussions of trends in the political distributed, and profited from by private in-
terests (Gaudilliere and Lowy 1998; Swan
economyof healthcare, see, for example,Bond
and Weissman(1997), Estes (1991), Estes et al. 1990). The Human Genome Project is one
(2000), Estes and Linkins(1997), Light (2000a, high-profile example. What began as a fed-
2000b), Navarro (1999), Robinson (1999), erally based and funded research effort cul-
Salmon(1990), andWhiteisandSalmon(1990). minated in the shared success of sequencing

Table 1. The Shift from Medicalization to Biomedicalization
Medicalization Biomedicalization
Control Transformation
Institutionalexpansionof professionalmedical Expansionalso throughtechnoscientifictransfor-
jurisdictioninto new domains mationsof biomedicalorganizations,infrastruc-
tures,knowledges, and clinical treatments
Economics:The U.S. BiomedicalTechnoServiceComplex,Inc.

Foundation-and state-funded(usually NIH) bio- Also increasingprivatizationof researchincluding
medical, scientific, and clinical researchwith university/industrycollaborationswith increased
accessible/publicresults privatizationand commodificationof research
results as proprietaryknowledge
Increasedeconomic organization,rationalization, Also increasedeconomic privatization,devolution,
corporatization,nationalization transnationalization/globalization
Physician-dominatedorganizations Managedcare system-dominatedorganizations
Stratificationlargely throughthe dual tendencies Stratificationalso throughstratifiedrationaliza-
of selective medicalizationand selective exclu- tion, new population-dividingpractices,and new
sion from care based on ability to pay assemblagesfor surveillanceand treatmentbased
on new technoscientificidentities
The Focus on Health, Risk, and Surveillance

Worksthrougha paradigmof definition,diagnosis Worksalso througha paradigmof definition,
(throughscreeningand testing), classification,and diagnosis (throughscreeningand testing), class-
treatmentof illness and diseases ification, and treatmentof risks and commodi-
fication of health and lifestyles
Healthpolicy as problem-solving Healthgovernanceas problem-defining
Diseases conceptualizedat the level of organs,cells Risks and diseases conceptualizedat the level of
genes, molecules, and proteins
(Continuedon nextpage)
the genome between Celera Genomics and including academic medical centers (combi-
government-funded scientists. In related de- nations of medical schools, hospitals, clin-
velopments, genetic and tissue samples col- ics, and research units) that had been feder-
lected from the bodies of individuals and ally funded for 30 years. The U.S. Balanced
communities have become patented com- Budget Act of 1997 cut an estimated $227
modities of corporateentities that offered no billion, with large cuts of hospital budgets,
patient or community reimbursement while federal indirect medical education
(Adams 2002; Landecker 1999; Rabinow payments were also trimmed (L. Fishman
1996). Another striking example is the pat- and Bentley 1997). Strappedacademic medi-
enting of the BRCA1 genes (breast cancer cal centers are filling this gap in partby con-
markers)by Myriad Genetics. The company ducting extensive clinical trials for pharma-
not only receives royalties each time a ge- ceutical companies, requisite to bringing
netic test for breast cancer is given but also new products to market. Special contracts
holds sole proprietor rights over research units, a new social form, have been estab-
conducted on those genes (Zones 2000), lished at major medical centers, often within
though ownership of such rights is being their "offices of industryand research devel-
challenged in the company's own country opment," to negotiate blanket contract over-
(Canada) and in France (Bagnall 2001). head rates with pharmaceuticalcompanies.
Further,as suggested in Table 1, industry- Trends toward increased pharmaceutical
academy collaborations are also becoming company sponsorship of research have be-
routine sources of funding for universities, come highly problematic, however. The cur-

(Table1 continuedfrompreviouspage)
Medicalization Biomedicalization
The Technoscientizationof Biomedicine
Highly localized infrastructureswith idiosyncratic Increasinglyintegratedinfrastructureswith

physician, clinic, and hospitalrecordsof patients widely dispersedaccess to highly standardized,
(photocopyand fax are majorinnovations) digitized patients' medical records,insurance
informationprocessing, and storage
Individual/case-basedmedicine with local (usually Outcomes/evidence-basedmedicine with use of
office-based) control over patientinformation decision-supporttechnologies and computerized
patientdata banksin managedcare systems
Medical science and technologicalinterventions Biomedical technoscientifictransformations
(e.g., antibiotics,chemotherapy,radiation,dialysis, (e.g., molecularization,biotechnologies,geneti-
transplantation,new reproductivetechnologies) cization, nanoscience,bioengineering,chemo-
prevention,genetic engineering,and cloning)
New medical specialties based on body partsand New medical specialties based on assemblages-
processes and disease processes (e.g., cardiology, loci of practiceand knowledge of accompanying
gynecology, oncology) assumedto be universal distinctivepopulationsand genres of sciences
across populationsand practicesettings and technologies (e.g., emergencymedicine,
hospitalists,prison medicine)
Transformationsof Information,and the Productionand Distributionof Knowledges

Professionalcontrol over specialized medical Heterogeneousproductionof multiplegenres of
knowledge productionand distribution,with information/knowledgeregardinghealth, illness,
highly restrictedaccess (usually limited to medical disease, and medicine, widely accessible in
professionals) bookstoresand electronicallyby Internet,etc.
Largely top-downmedical professional-initiated Also heterogeneouslyinitiatedinterventions

interventions (examplesof new actors include health social
movements,consumers,Internetusers, pharma-
ceutical corporations,advertisements,websites)
Transformationsof Bodies and Identities

Normalization Customization
Universaltaylorizedbodies; one-size-fits-all Individualizedbodies; niche-marketedand indivi-
medical devices/technologiesand drugs; dualizeddrugsand devices/technologies;custom-
superficially(includingcosmetically) modified ized, tailored,and fundamentallytransformed
bodies bodies
Frombadnessto sickness; stigmatizationof Also new technoscientificallybased individualand
conditions and diseases collective identities
rent and former editors of 13 major medical CENTRALIZATION, RATIONALIZATION,

journals stated in an editorial in Journal of AND DEVOLUTIONOF SERVICES. Central-
the American Medical Association that they ization of facilities, health-care services, and
would reject any study that does not ensure corporate health-care coverage has been on
that the sponsor gave researchers complete the rise through the merger and acquisition
access to data and freedom to report on find- of hospital facilities, insurers, physician
ings (Davidoff et al. 2001). Further, a new groups, and pharmaceuticalcompanies. This
study found that industry-sponsoredresearch has resulted in the loss of many community,
is 3.6 times more likely to produce results public, and not-for-profitfacilities that either
favorable to the sponsoring company, impli- could not compete or were acquired ex-
cating both universities and individual sci- pressly for closure. The underlying objec-
entists (Bekelman, Li, and Gross 2003). tives are to boost the efficiency and unifor-

mity of services, to centralize and rational- ness and instabilities of medicalization pro-
ize decision-making about service provision, cesses, remindingus that medicalization was
to capturemore marketsand arenasof health not monolithic and unidirectionalbut hetero-
for profit, and to exert greatereconomic con- geneous and fraught with paradoxical prob-
trol within these arenas. In practice, lems of exclusion, inclusion, participation,
Foucauldian panoptical patterns of physical and resistances. Such arguments were ini-
decentralizationwith administrativecentral- tially elaborated in Ehrenreich and
ization are common (Foucault 1975, 1991). Ehrenreich's (1978) critical elucidation of
These patterns are greatly facilitated by the dual tendencies of medicalization. The
meso-level computer and information sci- first tendency, cooptative medicalization, re-
ence practices and programs that automati- fers to the jurisdictional expansion of mod-
cally monitor highly dispersed developments ern medicine-extending into areas of life
for centralized management operations. previously not deemed medical. The second
Although such health-care consolidations tendency, exclusionary disciplining, refers to
bring some efficiency, they also pose numer- the simultaneous exclusionary actions of
ous dangers as a result of corporate concen- medicine that erect barriers to access to
tration. Such dangers include, for example, medical institutions and resources that tar-
inflationary tendencies from the concentra- get and affect particularindividuals and seg-
tion of pricing power, new administrative ments of populations. Historically, these
burdens,and the enhanced political power of dual strategies have stratified the U.S. medi-
conglomerates. Such consolidations now ex- cal market by race, class, gender, and other
ert significant leverage over political and attributes. For example, cooptative tenden-
regulatory processes, as well as decision- cies have long predominated for white
making that affects provider groups, patient middle- and upper-class groups, especially
care, and service options in highly stratified women, while exclusionary tendencies or
ways (Waitzkin2001; Waitzkinand Fishman particularkinds of cooptative medicalization
1997). For example, in Northern California (such as provision/imposition of birth con-
recently, Blue Cross (a health insurance trol and sterilization) have prevailed for
company) and Sutter Health (a for-profit peoples of color and the poor (Riessman
corporatizedprovider network) were locked 1983; Ruzek 1980; Ruzek, Olesen, and
in contractual conflicts over reimbursement Clarke 1997). Medicalization was stratified,
rates. Because of Sutter's acquisition of and so too is biomedicalization.
large numbers of health-care facilities in the We term the reformulationand reconstitu-
area, it was able to effectively deny services tion of such processes in the biomedicaliza-
to many Blue Cross subscribers by not action era stratified biomedicalization.10 The
cepting Blue Cross insurance, eventually cooptative and exclusionary tendencies
compelling the insurer to agree to higher noted above persist and become increasingly
rates. complex, and new modes of stratificationare
Devolution of health-care services also also produced. Even as technoscientific in-
demonstrates the trend toward rationaliza- terventions extend their reach into ever more
tion. That is, there are attempts to routinize spaces, many people are completely by-
and standardize health services while also passed, others impacted unevenly, and while
shifting increasing proportionsof the expen- some protest excessive biomedical interven-
sive labor of hands-on care to families and tion into their lives, others lack basic care.
individuals (Timmermans and Berg 1997). Such innovations are far from the goal of
Outpatient surgery, home health care, and universally accessible and sustainable health
elaborating subacute care facilities (e.g., care promoted by some bioethicists and oth-
skilled nursing facilities, nursing homes) are ers (e.g., Callahan 1998).
a few examples of devolution. Devolution Even rationalization itself is stratified,
also contributes to the fragmentation of producing fragmentation. For example,
health care and its geographic dispersal, availability of routine preventive care,
making rationalizing more difficult.
STRATIFIED BIOMEDICALIZATION. Mor- 10We borrowaspectsof
GinsburgandRapp's
gan (1998) recently reasserted the uneven- (1995) framingof stratifiedreproduction.

screening services, pharmaceutical cover- physicians in private practice. Here, indi-

age, and "elective" services such as bone- viduals pay providers an annual amount
marrow transplants or infertility treatments (from a few thousand dollars to many thou-
are differentially available depending on sands of dollars). In returnthey get appoint-
one's health insurance plan, or lack thereof. ments within 24 hours and for longer dura-
There are still over 1,000 different insurers tions than the average patient, cell phone and
in the United States, all providing different e-mail access to their physicians, house
kinds of coverage, and thus, as a whole, the calls, and so on. High-end versions (at about
system is highly uncentralized, inefficient, $13,000 per year) are located in chic spa-like
and uncertain-the very things that, in offices with marble baths, terry robes, and
theory, rationalization attempts to eliminate. complete privacy, and are being organized
In 2001, the share of the population through franchises. This "concierge" model
wholly uninsured for the entire year rose to is popular with wealthy seniors, people with
14.6 percent or 41.2 million people up from chronic illnesses, and the youthful rich
14.2 percent in 2000 and an increase of 1.4 (Heimer 2002). In short, even "good" medi-
million people (Mills 2002:1). In 2001 and cal insurance no longer ensures good pri-
2002, about 75 million people under age 65 mary care.
went without health insurance for at least In sum, the politico-economic transforma-
one month; nearly 3 in 4 were in working tions of the biomedical sector are massive
families and more than half were white and ongoing, ranging from macro structural
(Meckler 2003:A4). moves by industries and corporations to
Cutbacks in government coverage of meso- and micro-level changes in the con-
medical care are also widespread, and are crete practices of health and medicine. Not
being made in concert with reductions in a only do such transformations produce new
range of social services that affect the health and elaborated mechanisms through which
status of individuals and groups down- biomedicalization can occur, but also bio-
stream. There has even been research on the medicalization, in turn, drives and motivates
efficacy of group medical appointments for many of these economic and organizational
the poor instead of (or with) short individual changes.
examinations (McInaney 2000). Such gate
keeping becomes ever more imperative in 2. THE FOCUS ON HEALTH, RISK,
efforts to eke economic profits from increas-
AND SURVEILLANCE
ingly expensive and highly technological
procedures, and from providing services to In the biomedicalization era, what is perhaps
less desirable but financially still necessary most radical is the biomedicalization of
markets and population groups. health itself. In commodity cultures, health
At the same time, there are dramatic in- becomes another commodity, and the bio-
creases in stratifying fee-for-service options medically (re)engineered body becomes a
for those who can afford them. The most prized possession. Health mattershave taken
common and affordable alternatives are on a "life of their own" (Radley, Lupton, and
choosing high-end preferred providers Ritter 1997:8).
through such an insurance plan. Here pro- HEALTH AS MORAL OBLIGATION. Specifi-
viders to whom you pay a higher co-pay- cally, health becomes an individual goal, a
ment are often more available (within weeks social and moral responsibility, and a site for
rather than months) and may have better routine biomedical intervention.1l Increas-
reputations. Some plans offer high-end hos- ingly what is being articulated is the indi-
pital options-you pay more to go to certain vidual moral responsibility to be and remain
"better" hospitals. Out-of-pocket boutique
medicine options usually range from cos-
l For more on the links betweenhealthand
metic surgeries to new reproductive/concep-
tive technologies to some organ transplants. morality,see for exampleBunton,Nettleton,and
Burrows(1995), Crawford(1985, 1994, 1999),
In addition, there are emerging options for
Edgley and Brissett (1990), Howson (1998a),
"boutique or concierge primary care" based Illich (1976), Lupton(1993, 1995),Tesh (1990),
on privately paid annual fees to individual Williams(1998, 1999), andZola (1972).

healthy (e.g., Crawford 1985) or to properly veillance, and the management of compli-
manage one's chronic illness(es) (Strauss, cated regimens aroundrisk and chronic con-
Corbin, et al. 1984), rather than merely at- ditions.12
tempt to recover from illness or disease It is no longer necessary to manifest symp-
when they "strike" (Parsons 1951). In the toms to be considered ill or "at risk." With
biomedicalization era, the focus is no longer the "problematisationof the normal"and the
on illness, disability, and disease as matters rise of "surveillance medicine" (Armstrong
of fate, but on health as a matter ongoing 1995:393), everyone is implicated in the
moral self-transformation. process of eventually "becoming ill"
Health cannot be assumed to be merely a (Petersen 1997). Both individually and col-
base or default state. Instead, health becomes lectively, we inhabit tenuous and liminal
something to work toward (Conrad 1992; spaces between illness and health, leading to
Edgley and Brissett 1990), an ongoing the emergence of the "worried well" (Will-
project composed of public and private per- iams and Calnan 1994), rendering us ready
formances (Williams 1998, 1999), and an subjects for health-related discourses, com-
accomplishment in and of itself (Crawford modities, services, procedures, and tech-
1994, 1999). Terms such as "health mainte- nologies. It is impossible not to be "at risk."
nance," "health promotion," and "healthy Instead, individuals and populations are
living" highlight the mandate for work and judged for degrees of risk-"low," "moder-
attention toward attaining and maintaining ate," or "high"-vis-a-vis different condi-
health. There has been a steady increase in tions and diseases, and this then determines
mandates for self-regulation until, with bio- what is prescribed to manage or reduce that
medicalization, there is a shift in the general risk. Thus, biomedicalization is elaborated
cultural expectations of whole populations. through daily lived experiences and prac-
In this constant, self-disciplining and other/ tices of "health"designed to minimize, man-
public-disciplining, there is no rest for the age, and treat "risk" as well as through the
weary. specific interactions associated with illness
RISK FACTORS AND SELF-SURVEIL- (Fosket 2002; Press, Fishman, and Koenig
LANCE. In the biomedicalization era, risk 2000). Risk technologies are therefore "nor-
and surveillance practices have emerged in malizing," not in the sense that they produce
new and increasingly consequential ways in bodies or objects that conform to a particu-
terms of achieving and maintaining health. lar type, but more that they create standard
Risk and surveillance concerns shape both models against which objects and actions are
the technologies and discourses of biomedi- judged (Ewald 1990).
calization as well as the spaces within which Of particular salience in the biomedical-
biomedicalization processes occur (Bud, ization era is the elaboration of standardized
Finn, and Trischler 1999; Fosket 2002). Risk risk-assessment tools (e.g., to assess risk of
and surveillance mutually construct one an- breast cancer, heart disease, diabetes, hyper-
other: Risks are calculated and assessed in tension, etc.) that take epidemiological risk
orderto rationalize surveillance, and through statistics, ostensibly meaningful only at the
surveillance risks are conceptualized and population level, and transform them into
standardizedinto ever more precise calcula- risk factors that are deemed meaningful at
tions and algorithms (Howson 1998b; the individual level (Gifford 1986; Rockhill
Lupton 1995, 1999). et al. 2001). For instance, currentbreast can-
Risk and surveillance are aspects of the cer risk-assessment technologies construct a
medical gaze that is disciplining bodies.
They are aspects of biomedicalization that, 12On risk factors, see, for
in a quintessential Foucauldian sense, are no example, Armstrong
longer contained in the hospital, clinic, or (1995), Castel (1991), and Petersen (1997). On
even within the doctor-patient relationship techniques of self-surveillance, see, Crawford
(1994), Edgley and Brissett (1990), Featherstone
(Armstrong 1995; Waitzkin 1991). Rather, (1991), and Turner (1984; 1992). On chronic
they implicate each of us and whole popula- conditions, see, Charmaz (1991), Hunt and Arar
tions through constructions of risk factors, (2001), Strauss and Corbin (1988), Strauss and
elaborated daily life techniques of self-sur- Glaser (1975), and Strauss, Corbin, et al. (1984).

standardized category of "high risk" for computer and information technologies and
breast cancer in the United States. Women the organizational structures developed to
classified as "high risk" are given the option articulate them into the flows of biomedical
of taking chemotherapy-pharmaceuticals and related work (Berg 1997, 2000; Star
usually used only to treat cancer because of 1995; Wiener 2000). These changes, we ar-
their toxicity and other negative side ef- gue, have spurredbiomedicalization and are
fects-to "treat"the risk of cancer (Fosket also manifest in how it is effected.
2002). Genomic technologies and profiling We describe three overlapping areas in
techniques mark the next wave in such risk which the technoscientization of biomedi-
assignments (Fujimura1999; Shostak 2001). cine is manifest: (1) computerization and
Further,with the institutionalizationof the data banking; (2) molecularizationand gene-
assumption that everyone is potentially ill, ticization of biomedicine and drug design;
the health research task becomes an increas- and (3) medical technology design, develop-
ingly refined elaboration of risk factors that ment, and distribution.
might lead to future illnesses. Such research COMPUTERIZATION AND DATA BANK-
and knowledge production-as well as its ING. Fundamental to biomedicalization is
active consumption by patients/consumers the power (past, present, and especially fu-
and providers-are primary and fast-grow- ture) of computerization and data banking.
ing components of biomedicalization and These technoscientific advances are pivotal
will continue to be major contributorsto the to the meso-level (re)organization of bio-
development of "surveillance medicine" medicine. That is, many of the biomedical
(Armstrong 1995) and to new forms of pub- innovations of the twenty-first century are
lic health in the twenty-first century (Shim situated in organizations that are themselves
2000, 2002a, 2002b). Health is thus para- increasingly computer-dependentin hetero-
doxically both more biomedicalized through geneous ways that in turn are increasingly
such processes as surveillance, screening, constitutive of those organizations. The ap-
and routine measurements of health indica- plication of computer technologies within
tors done in the home, and seemingly less multiple biomedical domains and their orga-
medicalized as the key site of responsibility nizational infrastructuresare thereby mutu-
shifts from the professional physician/pro- ally constructed, creating new social forms
vider to include collaboration with or reli- for orchestrating and performing the full
ance upon the individual patient/user/con- range of biomedically related work.13
sumer. One important computer-based organiza-
tional innovation involves the reorganization
of and much wider access to individual
3. THE TECHNOSCIENTIZATION OF
medical records. Centralized storage and ac-
BIOMEDICINE
cess to patient records have been hopes of
The increasingly technoscientific nature of doctors, hospitals, and insurers since at least
the practices and innovations of biomedicine the nineteenth century (Blois 1984). Recent
are, of course, key features of biomedical- technological breakthroughs in hardware,
ization. While science and technology be- software, and data processing and storage
came increasingly constitutive of medicine technologies have allowed the integration of
across the twentieth century, in its final de- medical data into heterogeneous and widely
cades, technoscientific transformations dispersed databases to become routine in
gained significant momentum. These systemic and ubiquitous ways. Considerable
changes are part of major shifts in the social pressure is being brought to bear to comput-
organization of biomedicine itself, the ob- erize all medical records according to stan-
jects of biomedical knowledge production,
the ways in which biomedicine intervenes, 13Theconsequencesof organizations
and the objectives with which it does so. perse on
scientific and technicalwork are only recently
Moreover, innovations are increasingly being addressed beyond traditional concerns
likely to be hybrid ones that are generated aboutproductivity(e.g., Vaughan1996, 1999).
simultaneously through sciences and tech- On workorganization,see Mechanic(2002) and
nologies and new social forms-most often V. Smith(1997).

dardized formats that can be webbed across have long irked segments of the American
multiple domains. Thus, as noted in Table 1, medical profession (Reverby 1981). As the
from paper versions of medical records production of biomedical knowledge is ac-
dwelling in individual physicians' offices, celerated through the use of computer tech-
clinics, and hospitals, common during the nologies, both behavioral and outcomes re-
era of medicalization, patient information search are increasingly defining new bio-
can now be uploaded and accessed via statistical criteria for what counts as "scien-
cybersites managed by HMOs, pharmacies, tific." Such research allows for the "objec-
and other third-party entities in far away tive" statistical identification of "industry
places for multiple purposes. Also, new standards" (Porter 1995), and insurance
companies are engineering "doctor-friendly" companies are already moving toward cov-
formats (Lewis 2000; National Research ering only those proceduresdemonstratedas
Council 2000). "valid"through such standardizingresearch.
These new and elaborating meso-level in- Such developments will likely cut in many
frastructures are facilitating many of the different and even paradoxical directions si-
downstreamprocesses requisite for biomedi- multaneously. For example, vis-a-vis
calization, not only enabling the expansion women's health, "unnecessary" yet costly
of medical jurisdiction, but also producing hysterectomies and Cesarean sections, so
infrastructures for greater public-private long criticized by feminists (e.g., Ruzek and
linkages and new iterations of biomedical Hill 1986), will be highlighted for deletion.
governmentality. Computerization allows Other highly vaunted treatments, such as
more aspects of life to be scrutinized, quan- bone-marrow transplants for breast cancer
tified, and analyzed for their relationships to and estrogen replacement therapy for meno-
health and disease. Integration and compat- pausal symptoms, have already been chal-
ibility of data across various sites are articu- lenged due to such outcomes studies (Weiss
lated via specialized software that increas- et al. 2000; Writing Group 2002).14
ingly imposes standardized categories and Further, such protocols are being devel-
forms of information (Bowker and Star oped in concert with the spread of another
1999). Such formats make it all but impos- new social form, the specialty of "hospi-
sible to enter certain kinds of data in the talists"-physicians who practice only in
medical record, especially highly individu- hospitals and to whose care medical respon-
alized informationcommon to medical prac- sibility is almost completely shifted from the
tice on unique individual bodies. At the same patient's own primary physician upon hos-
time, these data formats render it all but im- pitalization (Pantilat, Alpers, and Wachter
possible not to record other kinds of data, 1999). A major rationale here is that the
such as the information required to comply technoscientific infrastructure of hospital
with "clinical decision-support technolo- medicine is so complex and rapidly chang-
gies" (Berg 1997) and highly detailed diag- ing that only a localized specialist can keep
nostic and treatmentregimens. These are the up with its applications in acute patient care.
very meso-level techno-organizationaltrans- Finally, error in medicine-mistakes at
formative "devices" that biomedicalization work-is a recent focus of researchusing the
demands and is. new massive computer databases (Institute
Decision-support technologies are gener- of Medicine 1999). Preventionof such errors
ated through outcomes research and evi- and the knowledge thought to be gleaned
dence-based medicine that depend on major from analyses of centralized data will likely
computerized databases, as noted in Table 1
(Ellrodt et al. 1997; Traynor2000). Here the 14 Bastian
safety and efficacy of specific protocols and (2002) notes thatone pharmaceuti-
treatments are assessed based on data from cal companyattemptedto stem its losses from
hormonereplacementtherapyreductionsby pro-
very large populations of patients and pro-
viders across time and space. The geo- motingan alternativeproductvia a campaignto
hairdressers with free salon capes bearing the
graphic variations in "conventional" treat- product logo, "scripted messages" to insert in
ments and the different "community stan- conversations, and fact sheets to hand out to cli-
dards"revealed by regional health statistics ents.

drive the rhetoric that justifies the dramatic just patented "gene-pill") and related inno-
losses of privacy and the creation of new vations are beginning to hit the market
vulnerabilities caused by the computeriza- (Genteric 2001). Further,re-engineering hu-
tion of medical records. Thus, the potential man germ lines through choosing and as-
generatedby the compilation, storage, analy- sembling genetic traits for offspring will be-
sis, and control of computerized patient data come possible and desired by some, a "do-
furthers the possibilities of biomedicaliza- it-yourself evolution" (Buchanan et al.
tion processes in new and importantways. 2000), while strongly opposed by others as
The guiding assumptions common to these furtherstratifyingreproduction(Rapp 1999).
developments are that care and treatment These applications of molecular biology
services can and should be better rational- and genomics to medicine are themselves
ized such that variationsare indicative of up- highly dependent on computer and informa-
to-date scientific decision-making rather tion sciences, and the convergence of these
than "unnecessary"or "discretionary"treat- two domains was further fueled by the an-
ment. However, provider discretion about nouncement in 2001 of the completion of the
individual case treatment,continuity of care, first rough map of the human genome. For
doctor/patientrelationships, situationally ap- example, software to analyze and predict
propriatecare, privacy of treatment,and pa- how genome interactions might promote
tient involvement in treatment decision- health or cause disease, developed by scien-
making will likely be drastically, though un- tists at the National Human Genome Re-
evenly, limited and stratified. search Institute, are being scaled up to run
MOLECULARIZATION AND GENETICIZA- on supercomputers. Such large-scale infor-
TION. Second, the biomedical sciences of the mation technologies are being enlisted by
new millennium are being transformed by biotechnology and pharmaceuticalgroups to
molecular biologies. Molecular biological crunch throughhundredsof such genome in-
approaches initiated in the 1930s yielded in teractions to find potential intervention
the 1950s the discovery of DNA structure. points (Abate 2000a). In the process, novel
This and related developments in basic sci- meso-level organizational partnerships are
ence and research technologies are now pro- being forged among government entities, in-
pelling attempts to understand diseases at formation technology companies, and bio-
the (sub)molecular levels of proteins, indi- technology firms. The mutual constitution
vidual genes, and genomes (proteomics, ge- and dependency of computerization and
netics, and genomics), partially displacing molecularization trends is reflected in new
previous emphases on germs, enzymes, and hybrid professions like bioinformatics,
biochemical compounds (Chadarevian and which pairs biology with computer science.
Kamminga 1998). The study of differences Dubbed "the career choice of the decade"
among humans is also devolving to the level (Wells 2001), bioinformatics is spawning
of the gene-called "geneticization" new well-funded training programs to pro-
(Hedgecoe 2001; Lippman 1992). duce a workforce able to sort through and
In current treatment and drug develop- translate the findings of genomic and pro-
ment, these developments have generated a teomics research into informationeventually
shift from "discovery" of the healing prop- usable for medical purposes.
erties of "natural"entities to computer-gen- Biotechnological pursuits of genomic ma-
erated molecular and genetic "design," or nipulations are today at the pinnacle of
what Jacques Loeb would have called "engi- technoscience. While computerization is
neering" (Pauly 1987), that can be targeted standardizing patient data, it paradoxically
precisely at diseases and/or conditions likely also enables the further tailoring and cus-
to generate high profits (e.g., baldness, obe- tomization of bodies (Conrad 2000), central
sity). Pharmacogenomics-the field that ex- to processes of biomedicalization. The basic
amines the interaction of genomic differ- medical assumption about interventionin the
ences with drug function and metabolism- United States and other highly/overdevel-
offers the promise that pharmaceuticalthera- oped countries will be that it is "better"
pies can be customized for groups and indi- (faster and more effective though likely not
viduals. Such gene therapies (including the cheaper) to redesign and reconstitute the

problematic body than to diagnose and treat nologies are increasingly digitized, facilitat-
specific problems in that body.15Molecular ing their resolution, storage, and mobility
biologies and genomics will make such re- among multiple providers, distributed sites
design possible "from the inside out" or of care such as telemedicine, and agencies
transformatively,ratherthan operatingexter- or entities interested in centralizing such in-
nally as most prosthetics traditionally do formation (Cartwright 2000). The costly
(Clarke 1995). reading of cytological and pathological
MEDICAL TECHNOLOGY DEVELOPMENT. specimens such as Pap smears and biopsies
Third, medical technology developments of is also being computerized after decades of
all kinds are being transformedthroughdigi- effort (Bishop, Marshall, and Bentz 2000).
tization, miniaturization, and hybridization Finally, transplant medicine has shifted
with other innovations to create new genres from a local medical charity to a trans-
of technologies. These extend the reach of national web of organizations made pos-
biomedical interventions and applications in sible through computer and information sci-
fundamentally novel ways. For instance, re- ences, ranging from local hospitals to cut-
cent advances in material sciences make ting edge biotechnology firms to multina-
possible hybrid and bionic devices. Ex- tional distribution organizations (Hogle
amples from corneal implants to computer- 1999). But this is also intensifying the
driven limbs, continuously injecting insulin stratification of biomedicalization globally
packs for diabetics, electronic bone growth through organ purchasing by the rich from
stimulation devices, and heart and brain the poor, largely arrangedonline (L. Cohen
pacemakers (the latter initially used for 1999; Delmonico et al. 2002; Organs Watch
treatment of depression) are becoming rou- 2001; Scheper-Hughes 2000).
tine in boutique Western medicine. Hybrid- Biomedicine is increasingly part of what
ization is also apparent in the next genera- Schiller (1999) calls digital capitalism. The
tion of transplant medicine, termed "tissue Internet is a key reorganizing/transforming
engineering," which will include new kinds device and hence a key technology of bio-
of implants: body parts custom-grown medicalization. The Internet has recently
through molecular means, modified through been called "the first global colony," in part
materials science, and triggered by "biologi- because its economics and individualist cul-
cal switches" (Hogle 2000). ture "feel awfully American" (Lohr 2000:1).
Digitization has also transformedmedical The National Research Council (2000) pub-
technologies in ways that further their gaze lished recommendations and guidelines for
and reach into both the interior of the body extending health applications of the Internet,
and its behaviors. In addition to the com- from virtual (remotely guided) surgery to
puterization of patient data, including ge- education, consumer health, clinical care, fi-
nomic, behavioral, and physiologic infor- nancial and administrativetransactions,pub-
mation, visual diagnostic technologies are lic health, and research. An important digi-
also elaborating rapidly with technical in- tal aspect over the coming decades is likely
novations, at times outpacing local organi- to be the application of distance learning
zational capacities to use them safely and techniques and technologies to professional
effectively (Kevles 1997). Imaging tech- education for all kinds of health-care ca-
reers, also easily globalized.
15 This is alreadythe situationin infertility In sum, the ongoing technoscientization of
medicine,wherethe notionof a sequentiallad- biomedicine is at the heart of biomedicaliza-
der of appropriate care fromless to moreinter- tion. Theorizing these technoscientific trans-
ventionhas largelybeen abandonedin favor of formations of biomedicine requiresthat their
immediateapplicationof high-techapproaches
meanings and their material forms and prac-
that are more certainto producebabiesregard-
less of cost (G. Becker2000). Forlesbiansusing tices, including embodied corporealtransfor-
assisted reproductivetechnologiesto get preg- mations and manifestations, be conjointly
nant,the social category"lesbian"often serves studied and analyzed as co-constitutive
as thebasisfor high-techinfertilityinterventions, (Casper and Koenig 1996; Gray, Figueroa-
regardlessof the completeabsenceof infertility Sarriera, and Mentor 1995; Haraway 1991,
diagnoses(Mamo2002). 1997; Hayles 1999).

4. TRANSFORMATIONS OF INFORMATION which they may be eligible. Numerous pri-

AND THE PRODUCTION AND vate companies also provide medical infor-
DISTRIBUTION OF KNOWLEDGES mation. The information provided on these
websites comes from a variety of sources.
Informationon health and illness is prolifer- Although there is still a reliance on medical
ating through all kinds of media, especially professionals for answers to health ques-
in newspapers, on the Internet,in magazines, tions, sites often have discussion boards
and through direct-to-consumerprescription where users exchange their own knowledges
and over-the-counter drug advertising. In and experiences with others. Another rapidly
fact, biomedicine, more than being a subcul- growing source of medical knowledges is
ture, is today so much a fundamental ele- patient advocacy groups that have their own
ment of mass culture that Bauer (1998) sug- organizations, newsletters, websites, and se-
gests that its constant presence in popular rious stakes in knowledge production and
media points to the medicalization of science dissemination (Brown 1995; Brown et al.
news and of society generally: 2001).
Medicineis the currentcore of popularrep- In principle, these changes democratize
resentations of science.... [O]ur evidence production and access to medical and health
of the dominanceof healthnews is an em- knowledges in new ways. In practice, the
pirical indicator of the advent of a waters are muddy (e.g., Kolko, Nakamura,
medicalized society. . . . [The] medicaliza- and Rodman 2000; National Research
tion of science news is a correlateof these Council 2000; Yates and Van Maanen
larger changes in society, celebratingthe 2001). First, it is often difficult to know
successes of medicalsciences, anticipating whether the seemingly "objective" informa-
breakthroughs on the healthfront,and motion located on the Internet is produced by
bilizingan ever greaterdemandfor medica- medical experts holding professional cre-
tion and services. (P. 747, 744; also see
dentials and/or what kinds of financial and/
HodgettsandChamberlain1999)
or scientific stakes they might have in pre-
The cultural imaginary of biomedicine trav- senting information in a particularway. Po-
els widely and is locally and flexibly ac- tential profits rise every time someone logs
cessed and (re)interpreted. onto the growing number of health-care
Thus, the production and transmission of websites on the Internetthat couple the pro-
health and medical knowledges are key sites vision of information with the marketing of
of biomedicalization in terms of both the products (including alternative medicine
transformationof their sources and distribu- products and dietary supplements). In addi-
tion channels and the reformulation of who tion, corporate agreements with search en-
is responsible for grasping and applying gine companies have found ways to limit
such knowledges. Biomedicalization also the access of Internet consumers to the di-
works through the co-optation of competing versity of information sites available on the
knowledge systems, including alternative Web. Companies can purchase "primetime"
medicine and "patient-based"social move- and "sole supplier" status from search en-
ments (Adams 2002; Belkin 1996). Finally, gines, thereby preempting access to their
techniques for the legitimation of biomedi- competition, and consumers are often un-
cal knowledge claims are also changing. aware of such agreements (Rogers 2000).
HETEROGENEITY OF PRODUCTION, DIS- Last, it is unknown whether do-it-yourself
TRIBUTION, AND ACCESS TO BIOMEDICAL sites are more or less common or more or
KNOWLEDGES. First, the sources contribut- less likely to be hot linked (National Re-
ing to the production of health-relatedinfor- search Council 2000). However, the hetero-
mation have both increased and diversified. geneity of knowledge sources also can be
In cyberspace, for example, federally spon- interpreted as disrupting the division of
sored websites target not only researchers "expert" versus "lay" knowledges and en-
and health-care providers, but also Internet- abling new social linkages. For many, these
savvy health-care consumers. On one such new modes of access to health information
site (http://www.clinicaltrials.gov), potential are a welcome change; for others, they con-
human subjects can find clinical trials for found more than they clarify. For yet others,

the "digital divide" is all too real and access 2000), known among health NGOs as astro-
remains elusive and stratified. turf ratherthan grass-roots based.
Second, biomedical knowledges have In the biomedicalization era, while knowl-
been transformedin terms of access, distri- edge sources proliferateand access is stream-
bution, and in the allocation of responsibil- lined in ways purportedlyin the interests of
ity for grasping such information. Histori- democratizing knowledge, the interests of
cally in the United States, nonexperts' abil- corporate biomedicine predominate. This
ity to obtain biomedical information was point is highlighted by the loosening, in
severely limited, as such knowledges 1997, of the criteria under which direct-to-
dwelled almost exclusively in medical li- consumer advertising of prescription phar-
braries and schools that were closed to the maceuticals is allowed by the Food and Drug
public, creating what amounted to a profes- Administration (FDA), a profound shift in
sional monopoly on access to information. social policy on the proper relationship be-
Popularized "lay" health information was tween the public and biomedical knowledge.
also scarce. Health sections in bookstores Previously, provider-patient relationships
were rare and small until the 1970s, when were based on a notion of protecting "lay"
women's health and consumer health move- people from knowledge best left to profes-
ments began producing self-help books. Ac- sionals. Now, pharmaceuticalcompanies en-
tivists in such movements were instrumen- courage potential consumers to first acquire
tal in altering the self-help landscape, in- drug information and then proactively ask
cluding the Boston Women's Health Book their providers about the drugs by brand
Collective's first Our Bodies, Ourselves in name. In 2001, the industry spent about $2.5
1970.16A breast cancer patients' movement billion on consumer advertising (Freuden-
challenged the use of radical mastectomies heim and Petersen 2001:1,13). One recent
as the de-facto treatment, advocating survey found that 30 percent of Americans
greater patient involvement in surgical deci- surveyed who viewed direct-to-consumer
sions (Montini 1996), and AIDS activists advertising said they talked to their doctor
successfully challenged NIH's clinical trial about a specific medication they saw adver-
practices (Epstein 1996). In each case, ac- tised, and 44 percent of those reportthat their
tivists challenged the professional mo- doctors provided them with the prescription
nopoly over the production of medical medicine they asked about (Kaiser Family
knowledges by insisting on their own par- Foundation 2001:18-20). While direct-to-
ticipation as they acquired and disseminated consumer advertisements do help to educate
scientific information, and demanded im- the public about potential treatmentoptions,
mediate access to innovative health care. such marketing undeniably boosts pharma-
Today, individuals, enabled by computer ceutical revenues: Prescriptions for the top
technologies, are organizing to articulate 25 drugs directly marketedto consumersrose
new research interests, fund research stud- by 34 percent from 1998 to 1999, compared
ies and, at times, to open up new research with a 5.1 percentincrease for otherprescrip-
frontiers (Brown 1995; Brown et al. 2001; tion drugs (Charatan2000: 783). This both
J. Fishman 2000; Kroll-Smith and Floyd transforms doctor-patient relationships and
1997). Some groups are even starting to increases the power and profit of the phar-
fund their own science directly maceutical industry, furthering biomedical-
(Rabeharisoa and Callon 1998). Because of ization (Woloshin et al. 2001).17
increasing Congressional responsiveness to But all is not new knowledge and infor-
their demands, some supposed "patients' mation. Within these new technoscienti-
groups" are now started by scientists, phar-
maceutical companies, and/or professional 17The birth control
medical organizations (Zola 1991; Zones pill was an early event in
this shift (Oudshoorn 2002). "The pill" was the
first serious pharmaceuticaldesigned to be taken
16This book has been adaptedand translated by healthy asymptomaticpeople (women). Grave
into 19 languages and has sold over 4 million doubts that people would take powerful drugs in
copies (http://www.ourbodiesourselves.org/ the absence of illness were quickly erased by its
jamwal.htm). immediate success.

fically based knowledge sources, there is within the structuresof Westernbiomedicine

also ramped up access to older cultural dis- has been a marked increase of interest in
courses of stratification. Through what are such approaches. At the turn of the twenti-
called "re-mediations,"new visual technolo- eth century, Western biomedicine dealt with
gies such as computergraphics and the Word such approaches by organizing anti-quack-
Wide Web "aredoing exactly what their pre- ery committees and recruiting the state to
decessors [film, television, photography] make such practices illegal (Gevitz 1988);
have done in (re)enacting similar inequities similar efforts continue today (Adams 2002).
... yet they present themselves as refash- Additionally, at the turn of the twenty-first
ioned and improved versions of other me- century, Western biomedicine is attempting
dia" (Bolter and Grusin 1999:14-15). The to co-opt and incorporate many elements of
continuities are significant, as the media of- alternative medicines. As understandingsof
ten import historic cultural stratificationsre- health and healing systems from other cul-
garding sex, race, sexuality, and gender- tures have spread, and as people knowing
and patienthood as well-that usually re- such systems have migrated globally, there
main unquestioned. For example, Forsythe have been interesting nomenclature shifts in
(1996) studied a patient information system Western medical fields, from considering
for migraine sufferers that was intended to "other"people's health/life/healing systems
provide information distinct from that pro- as "superstitions"to "culture-basedhealing
vided by physicians. She found the system systems" to "alternativemedicines" (Ander-
"in fact offers information characterized by son 2002; Arnold 1988). Numerous large-
the same assumptions and deletions as that scale clinical trials are testing the "effective-
provided by neurologists" (Forsythe ness" of alternative medical practices and
1996:551). Intended to empower migraine therapies (Adams 2002).18 Major pharma-
patients, the system may instead reinforce ceutical companies now market their own
rather than reduce power differentials be- brandsof herbal and nutritionalsupplements
tween doctor and patient. and vitamins.
CO-OPTATION OF COMPETING KNOWL- Similarly, biomedicalization includes co-
EDGE SYSTEMS. Another transformationof optation of organizational and ideological
knowledge constitutive of biomedicalization shifts and innovations brought about by
is the co-optation of competing knowledge grassroots social movements such as
systems and the reconfiguration of health- women's health movements, disability
care provision and organizations in ways rights, AIDS activism, and other disease-
originally proposed and implemented by so- specific movements (Belkin 1996; Worces-
cial movements. ter and Whatley 1988). For example, early
The last decades of the twentieth century feminist consumer activism centered on ex-
in the United States saw a profound rise in panding patient access to drug information
the use of alternative and complementary via "patientpackage inserts" and medical in-
medicines. In 1993, one study estimated that formation via readable materials on health
$10.3 billion consumer dollars a year were and illness (e.g., Boston Women's Health
spent on alternative medicines in the United Book Collective 1971) and feminist
States (Eisenberg, Kessler, et al. 1993:346). women's health centers (Ruzek 1978). Dis-
In 1998, a follow-up study conservatively placing feminist centers, biomedicine now
estimated out-of-pocket patient expenditures offers "sleeker" versions of women's health
for alternative medicines at $27 billion, (Worcester and Whatley 1988). Building on
which is comparable to the out-of-pocket decades of efforts by women's health move-
costs to patients for all physician services
(Eisenberg, Davis, et al. 1998:1569). These 18 University of California, San Francisco
findings, perceived as an economic threat to
Western biomedicine, clearly repositioned (UCSF) researchers,for instance,are currently
alternative medical knowledge systems as conductingmajorclinicaltrialsto assess the im-
pacts of traditionalChineseherbsand acupunc-
legitimate (at least to users/consumers), tureon negativeside effects arisingfromcancer
shifting them from the margins of health treatment.The OsherCenterat UCSFreceiveda
care to the center. The response from deep $5 milliongrantfor this work.

ments, AIDS activists in the 1980s and racial minorities in NIH-funded clinical
1990s provoked major changes in the test- studies, and the 1998 FDA requirementthat
ing and approvalof new drugs. Rapid patient clinical trials produce explicit data on
access to experimental therapies for AIDS women and minorities (Epstein forthcom-
and many other conditions through innova- ing). Today, clinical trials are big business,
tive clinical programs is now administered offering new careers in clinical trial manage-
by the FDA (Epstein 1996) with participa- ment to nurses and others (Mueller 1997;
tion informationaccessible over the Internet. Mueller and Mamo 2000). However, serious
TECHNIQUES OF LEGITIMATION OF BIO- ethical problems, including patient deaths
MEDICAL CLAIMS. A final shift regarding attributedto conflicts of providers' interest,
knowledges within biomedicalization con- has led the NIH to close down all NIH-spon-
cerns techniques used for the legitimation of sored research temporarily at several major
biomedical claims-the standardsby which university medical centers in the past few
the innovations offered by biomedical sci- years.19 Informed consent and other trial
ences are tested and deemed acceptable. As protocols were typically found inadequate,
noted in Table 1, early standardsof care and and there was serious underreporting of
quality control over various drugs and tech- safety problems to the FDA, along with in-
nologies from about 1890 to 1940 were es- adequate record-keeping.
tablished throughthe classic individual case- These emergent forms of legitimation con-
observation method. Reform efforts and a tribute to a biomedicalization of clinical tri-
series of U.S. policies passed early in the als not only through a scientization of the
twentieth century created a federal "pure FDA's approval process, but also through
food and drugs" infrastructurefor oversight new linkages created among government
and regulation, acting through institutional agencies (e.g., the FDA), private industry
medicine and public health. New standards (e.g., pharmaceutical companies), and aca-
required drug manufacturersto submit evi- demic research institutions. These new as-
dence from "adequatetests" to demonstrate semblages, which often give rise to different
that a drug was "safe" before it could be li- criteria for drug approval, also create new
censed for sale. structural and infrastructural ties between
The development of the randomized clini- what were formerly known as the "public"
cal trial as the "gold standard"for the legiti- and the "private"(J. Fishman forthcoming).
mation of biomedical claims soon followed.
In 1962, after the Thalidomide crisis, in
5. TRANSFORMATIONS OF BODIES
which many children were born with birth
AND IDENTITIES
defects, in addition to securing evidence of
drug safety, the FDA began requiring phar- The fifth and last basic process of biomedi-
maceutical companies to obtain evidence of calization, as noted in Table 1, is the trans-
drug "efficacy" through "adequateand well- formation of bodies and the production of
controlled investigations incorporating 'ap- new individual and collective identities.
propriatestatistical methods"' (Marks 1997: There is an extension of the modes of opera-
129). The randomized controlled trial con- tion of medical research and clinical prac-
sisting of three phases of testing in human tice from attaining "control over" bodies
subjects has become the ideal instrumentfor through medicalization techniques (e.g., la-
producing "scientific" knowledges and evi- beling disease and concomitant medical in-
dence for the therapeutic appropriatenessof terventions) to enabling the "transformation
releasing any drug or medical device onto of' bodies to include desired new properties
the market. With the rise of biostatistics, and identities (Clarke 1995). As a
methods of drug evaluation have achieved a
distinctive form of scientific and bureau- 19Theseuniversitymedicalcentersincludethe
cratic standardization (MacKenzie 2001;
Marks 1997; Porter 1995). Major policy Universityof Illinois at Chicago,Universityof
Pennsylvania,and Johns Hopkins University,
events indicative of this shift in the science which receives the highest amountof federal
of legitimation include the 1993 NIH guide- NIH researchdollars (Riccardiand Monmaney
lines requiring the inclusion of women and 2000; RussellandAbate2001).

Foucauldian technique, regulation through (Mamo and Fishman 2001), targeting the
biomedicalization works "from the inside fastest growing U.S. population segment.
out" as a type of biomedical governance. It For another example, "Better Bodies" was
is achieved through alterations of biomedi- the name of a 2000 conference focusing on
calized subjectivities and desires for trans- innovations in cosmetic surgeries, sponsored
formed bodies and selves. The body is no by the UCSF Foundation and promoted to
longer viewed as relatively static, immu- major campus donors.
table, and the focus of control, but instead Such attention to customization applies
as flexible, capable of being reconfigured not only to bodily improvement and en-
and transformed(Martin 1994). Thus, oppor- hancement, including anti-aging strategies,
tunities for biomedicalization extend beyond but also to "health promotion" through ob-
merely regulating and controlling what bod- taining enhanced knowledge about individu-
ies can (and cannot) or should (and should alized susceptibilities and potential patholo-
not) do to also focus on assessing, shifting, gies. One of the newest incarnations of this
reshaping, reconstituting, and ultimately phenomenon is the public availability of "to-
transforming bodies for varying purposes, tal body scans"-high-resolution CAT scans
including new identities. Such opportunities of the body billed as preventive in that they
and imperatives, however, are stratified in may detect early signs of disease or verify
their availability-imposed, made acces- the healthiness of various parts of the body,
sible, and/or promoted differentially to dif- including the brain, heart, lungs, colon, ova-
ferent populations and groups. ries, abdomen, and kidneys. These imaging
FROM NORMALIZATION TO CUSTOMIZA- services are available on demand in many
TION. Where medicalization practices U.S. cities and suburbanmalls in stand-alone
seemed driven by desires for normalization offices, and are generally paid for out-of-
and rationalization through homogeneity, pocket.20The biomedical governmentalityto
techniques of stratified biomedicalization "know thyself' that is associated with such
additionally accomplish desired tailor-made bodily techniques often relies on a neo-lib-
differences. New technoscientific practices eral consumer discourse that promotes being
offer "niche marketing"of "boutique medi- "proactive" and "taking charge" of one's
cine" (Hannerz 1996) to selected health-care health.
consumers usually on a fee-for-service ba- In the move from universalizing bodies to
sis. Institutionally, customization has been customizing them, biomedicine has also al-
increasingly incorporated into biomedicine lowed for some destabilization of differ-
throughprojects such as computer-generated ences. Human bodies are no longer expected
images of the possible results of cosmetic to adhere to a single universal norm. Rather,
surgery,the proliferationof conceptive tech- a multiplicity of norms is increasingly
nologies promoting "rhetorics of choice" deemed medically expected and acceptable.
(Rothman 1998), and the promise of indi- Technoscience is seen as providing the
vidualized gene therapies and pharmacoge- methods and resources throughwhich differ-
netics. Such customization is often part of ences of race/ethnicity, sex/gender, body
the commodification and fetishization of habitus, age, and so on can be specified,
health products and services common in the measured, and their roots ascertained. Sig-
biomedicalization era, wherein health prod- nificantly, biomedicalization processes are
ucts and services become revered, valued, appropriating both the definition of and
and imbued with social import that has little management of bodily differences as within
to do with their use-value or physical prop- the proper jurisdiction of biomedical scien-
erties. tific research and technologies. This new re-
Such desires are concomitant with another gime of biomedical governance allows the
trend in stratified biomedicalization: "life- further stratified customization of medical
style" improvement. The pharmaceutical services, technologies, and pharmaceuticals
industry's attention to developing "lifestyle
drugs" such as Viagra exemplifies this 20 See, for
example, http://www.tbscenters.
movement toward enhancement and the con- com/tbs.htm and http://www.lifescore.com/
cern with "treating" the signs of aging heartfaq.htm.

to "manage" such differences (Lock and TECHNOSCIENTIFICIDENTITIES.Techno-

Gordon 1988), thus further biomedicalizing scientific identities is our generic term for
them. Examples of such stratified biomedi- the new genres of risk-based, genomics-
calization include "culturally competent based, epidemiology-based, and other
care," pharmacogenetics, and new social technoscience-based identities. The core cri-
forms-new systems of service provision terion is that such identities are constructed
designed to render increasingly customized through technoscientific means. That is,
care, ranging from high-end birthing clinics technoscientific identities are produced
to AIDS nursing care delivered in satellite throughthe application of sciences and tech-
offices located in single-room-occupancy nologies to our bodies directly and/or to our
hotels to avoid costly hospitalization. histories or bodily products including im-
How the body is conceived of and treated ages (Dumit 1997). These new genres of
by biomedicine has also changed over time identities are frequently inscribed upon us,
and constitutes another important site of whether we like them or not. For example,
biomedicalization. In the early twentieth individuals today may unexpectedly learn
century, conventional medical treatments they are genetic carriersof inheriteddiseases
focused on the ill body, emphasizing sur- (Karlberg2000) or may seek out such infor-
gery (as technologies of anesthesia and mation about themselves. The new sub-
asepsis were refined) and control of acute jectivities that arise through the availability
infectious diseases (such as tuberculosis, of these technosciences do so through a bio-
through quarantineand isolation). Over the medical governmentality that encourages
course of the twentieth century, improved such desire, demand, and need to inscribe
living conditions, the advent of antibiotics ourselves with technoscientific identities
around World War II, and successful inter- (Novas and Rose 2000). Of course, people
ventions into acute diseases gradually negotiate the meanings of such identities in
shifted the focus to management of chronic heterogeneous ways.
illnesses such as some cancers, heart dis- This is not to say that the identities them-
ease, and AIDS (Strauss, Corbin, et al. selves are all new, but ratherthat technosci-
1984; Strauss and Corbin 1988; Strauss and entific applications to bodies allow for new
Glaser 1975). In biomedicalization, the fo- ways to access and perform existing (and
cus shifts to behavioral and lifestyle modifi- still social) identities. There are at least four
cations (e.g., exercise, smoking, eating hab- ways that biomedical technoscience engages
its, etc.) literally promoted by the govern- in processes of identity formation. First,
ment among others. Such techniques have technoscientific applications can be used to
become part of conventional treatments, attain a previously unavailable but highly
with an enormous contiguous industry that desired social identity. For example, infertil-
has grown up around stress management ity treatments allow one to become a
regimens, wellness programs, the diet in- "mother"or "father,"while the identity of
dustry, and extensive direct-to-consumer "infertile" can be strategically taken on by
advertising of both prescription and over- lesbians and single women in order to
the-counter pharmaceutical and nutra- achieve pregnancy through technoscientific
ceutical technologies for "maintaining" means (Mamo 2002). Second, biomedical-
health and "controlling" chronic illness. ization imposes new mandates and perfor-
Thus, although in some respects no less mances that become incorporatedinto one's
normalizing or disciplining, biomedicaliza- sense of self. The subjectivities that arise out
tion enacts its regulation of bodies through of these performances of what it is to be
offering not just "control over" one's body healthy (e.g., proactive, prevention-con-
through medical intervention (such as con- scious, neo-rational) suggest how biomedi-
traception), but also "transformation of" cal technoscience indicates a type of govern-
one's body, selves, health. Thereby new mentality that can enact itself at the level of
selves and identities (mother, father, walker, subjective identities and social relations.
hearer, beautiful, sexually potent person) Third,biomedical technosciences create new
become possible. Some such identities are categories of health-relatedidentities and re-
sought out, while others are not. define old ones. For example, throughuse of

a risk-assessment technique, one's identity groups). "These [biosocial] groups will have
can shift from being "healthy"to "sick," or medical specialists, laboratories, narratives,
to "low risk" or "high risk" (Fosket 2002). traditions, and a heavy panoply of pastoral
Fourth, biomedicalization also enables the keepers to help them experience, share, in-
acquisition and performance of identities as tervene in, and 'understand' their fate"
patients and communities through new tech- (Rabinow 1992:244). However, attribution
noscientific modes of interaction, such as of identity does not equal acceptance of it
telemedicine. As new computer-based tech- (Novas and Rose 2000). Interactionistlabel-
nologies allow cosmopolitan providers to ing theory again becomes relevant, raising
"reach out and heal" people whom questions of power-who gets to label
Cartwright(2000) has called "remotelocals" whom, with what consequences, and what
in their communities, new social identities "responses" may occur? Technoscientific
and social formations are created. Tele- identities' origins stories usually lie in sites
medicine "is a method of reorderinggeogra- where technoscience successfully dwells: in
phy and identity throughnew styles of health research/medical/insurance/governmental/
managementthat involve new configurations legal domains, which are often socially and
of population and different ways of imagin- culturally highly privileged and potent. Yet
ing what global health is and will be ... un- on an individual basis, technoscientific iden-
hinged from local practices" (Cartwright tities are selectively taken on, especially
2000:348-49). One wonders what will hap- when accepting such identities seems worth-
pen, through such technoscientific interven- while, including access to what can be expe-
tions, to what Lock (1998:182) has called rienced as "medical miracles." Such an iden-
"local biologies," often centuries-long estab- tity can be handled as a "strategic" iden-
lished cultural differences in meaning-mak- tity,21seemingly accepted to achieve particu-
ing associated with what we today term bio- lar goals, but also (typically in other situa-
medical issues. tions) it may be refused. Such identities may
In discussing the relations between medi- also be ignored in favor of alternatives. Ne-
calization and disease concepts, Lock (1998: gotiations with biomedicalization processes
180) has noted the tendency to "streamline are ongoing.
and normalize" specific conditions/diseases
into entities wholly (or at least normally)
CONCLUSIONS
treatableby an available or soon-to-be-avail-
able drug, device, or procedure. The classic We have offered an analysis of the historical
case she examines is menopause, which was shift from medicalization to a synthesizing
transformedin the West from a complex and framework of biomedicalization that works
unevenly symptomatic syndrome into a stan- through, and is mutually constituted by, eco-
dardized "estrogen deficiency disease" treat- nomic transformationsthat together consti-
able by hormone replacementtherapies(now tute (1) the Biomedical TechnoService Com-
deemed dangerous after 60 years of increas- plex, Inc., (2) a new focus on health, risk,
ingly intense use). Here we see how the and surveillance, (3) the technoscientization
meaningful identities of disorders and dis- of biomedicine, (4) transformations of
eases as well as of persons and groups are knowledge production, distribution, and
also being redefined at this historical mo- consumption, and (5) transformations of
ment and also through technoscientific bodies and identities. We have argued that
means (also see J. Fishman and Mamo biomedicalization describes the key pro-
2002). Fleck ([1935] 1979) was among the cesses occurring in the domains of health,
earliest to alert us to such possibilities. illness, medicine and bodies especially but
The major framing of technoscientific not only in the West. We have asserted that
identities to date is Rabinow's (1992) con-
cept of biosocial identities and biosocialities 21
Spivak's(1988) conceptof "strategicessen-
that "underline[s] ... the certain formation tialism"assertsthe legitimacyof usingessential-
of new group and individual identities and ist/realistepistemologicalassertionswhen they
practices arising out of these new truths" maybe moreeffectivepoliticallythanassertions
(pp. 241-42) (e.g., neurofibromatosis of multiplicityor diversity.

the shifts are shifts of emphasis: Medicaliza- complex intersectionalities of culture, politi-
tion processes can and do continue tempo- cal economy, organization, and techno-
rally and spatially, if unevenly. Innovations science. The transformationsof biomedical-
thus are cumulative over time such that older ization are manifest in large, macrostructural
approaches are usually available simulta- changes as well as in new personal identities
neously somewhere, while new approaches and subjectivities, but especially at the
and technoscientifically based alternatives meso-level of new social forms and organi-
also tend to drive out the old over time. zational infrastructures. Further, we assert
In addition to being temporally uneven, that the processes and experiences of bio-
we have argued that biomedicalization is medicalization illustrate the importance of
stratified, ranging from the selective cor- interaction and contingency in social life.
poratization of "boutique" biomedical ser- Finally, biomedicalization demonstrates the
vices and commodities directed toward elite mutual constitution of political economic,
markets, to the increasingly exclusionary cultural, organizational,and technoscientific
gatekeeping made possible by new technolo- trends and processes. Our view of the com-
gies of risk and surveillance to the stratifica- plex transformations we are currently wit-
tion of rationalized medical care. Through nessing in Western biomedicine is that their
emergent "dividing practices," some indi- roots, manifestations, and consequences are
viduals, bodies, and populations are per- most often co-produced and reciprocally
ceived to need the more disciplinary and in- (re)constructed and (re)generated continu-
vasive technologies of biomedicalization, as ously over time.
defined by their "risky" genetics, demo- Those of us who dwell in the sociology of
graphics, and/or behaviors; others are seen health, illness, medicine, and related areas
as especially deserving of the customizable tend to vividly see the increasing pervasive-
benefits of biomedicine provided throughin- ness of biomedicine in everyday life. Al-
novative assemblages, as defined by their though not all-encompassing, its ubiquity
"good" genetics, valued demographics (e.g., must be negotiated by each of us on a daily
insurance and/or income status), and/or basis. We are awash in a sea of biomedi-
"compliant"behaviors. calizing discourses. And we agree, however
Stratified biomedicalization both exacer- anxiously, with Abir-Am (1985) that in the
bates and reshapes the contours and conse- sense that any advertising is good advertis-
quences of what is called "the medical di- ing, our project here cannot help but consti-
vide"-the widening gap between biomedi- tute and promote biomedicalization.
cal "haves" and "have-nots" (Abate 2000b). (Re)naming is creating;representingis inter-
Surveillance, health maintenance, increased vening (Hacking 1983).
knowledge, and extended health and bio- Yet biomedicalization is punctuated-in
medical responsibilities for self and others fact, rife-with contradictions and unantici-
are, however, promoted for all. This im- pated outcomes that complicate this trend
perative to "know and take care of thyself," relentlessly. The power-knowledges pro-
and the multiple technoscientific means duced by social sciences of, in, andfor bio-
through which to do so currently, have medicine transgressthose boundaries,perco-
given rise to new genres of identities, cap- late widely, and are potentially disruptive.
tured in our concept of technoscientific There are no one-way arrows of causation,
identities. The ubiquity of the culture of no unchallenged asymmetries of power, no
biomedicine renders it almost impossible simple good versus bad. In fact, the
(and perhaps not even desirable) to avoid blurrings of certain boundaries in the cre-
such inscriptions. ation of new social forms-public/private,
We believe the concept of biomedicaliza- government/corporation,expert/lay, patient/
tion offers a bridging framework for new consumer, physician/insurer, university/in-
conversations across specialty divides within dustry/state, among others-are unleashing
sociology and more broadly across disciplin- new and sometimes unpredictable energies.
ary divides within the social sciences. Bio- Thus, we refuse interpretationsthat cast bio-
medicalization engages the concepts of medicalization as a technoscientific tsunami
structure and agency, stratification, and the that will obliterate prior practices and cul-

tures. Instead we see new forms of agency, the University of California, San Francisco. Her
empowerment, confusion, resistance, re- research interests include health inequalities, the
social production of illness, the construction of
sponsibility, docility, subjugation, citizen-
difference and risk in medicine and public health,
ship, subjectivity, and morality. There are and the impacts of immigration, class, and gen-
infinite new sites of negotiation, percola-
der on health. Her current research projects-on
tions of power, alleviations as well as insti- the use of life-extending technologies in old age,
gations of suffering, and the emergence of the incorporation of epidemiological conceptions
heretofore subjugated knowledges and new of racialized, socioeconomic, and gendered risk
social and cultural forms. Such instabilities in cardiovascular care, and the experiences of
always cut in multiple and unpredictabledi- social dislocation of immigrantsand their conse-
rections (Strauss 1993). Thus we end by quences for well-being-emerge from her inter-
calling for case studies that attend to the het- ests in the interfaces of health and medicine, sci-
ence and technology, and race, class, and gen-
erogeneities of biomedicalization practices der. Her articles have appeared in Sociology of
and effects in different lived situations.22We
Health and Illness and Social Science and Medi-
have attempted to elucidate some rich con- cine.
tradictions here in hopes of provoking more
democratizing interventions. Laura Mamo received her Ph.D. in 2002 from
the University of California, San Francisco. She
Adele E. Clarke is Professor of Sociology and of is currently Assistant Professor in the Depart-
History of Health Sciences at the University of ment of Sociology at the University of Maryland,
California, San Francisco. Her work has cen- College Park. Her teaching areas include con-
tered on studies of science, technology, and temporarysocial theory,feminist theory, and cul-
medicine with special emphasis on common tural and social studies of science, technology
medical technologies that affect most women's and medicine. Her research explores the inter-
health, such as contraception, the Pap smear, section of gender and sexuality with experiences
and RU486. She is author of Disciplining Repro- of health and illness, processes of biomedicaliza-
duction: American Life Scientists and the 'Prob- tion, and new pharmaceutical technologies. She
lem of Sex' (University of California Press, is currently working on a book tentatively titled
1998), and with Joan Fujimura she coedited a Queering Reproduction: Lesbians, Biomedicine,
book focused on scientific practice, titled The and Reproductive Technologies.
Right Tools for the Job: At Work in Twentieth
Century Life Sciences (Princeton University Jennifer Ruth Fosket recently received her
Press, 1992; Synthelabo Press, Paris, 1996). Ph.D. from the Department of Sociology at the
With Virginia Olesen, she also coedited University of California, San Francisco. She will
be joining the sociology faculty at McGill Uni-
Revisioning Women, Health, and Healing: Cul-
tural, Feminist, and Technoscience Perspectives versity. Her dissertation entitled, "Breast Can-
cer Risk and the Politics of Prevention: Analysis
(Routledge, 1999). She is currently working on a
book on research methods, GroundedTheory Af- of a Clinical Trial," explored the histories, prac-
ter the Postmodern Turn: Situational Maps and tices, and implications of pharmaceutical inter-
ventions for the reduction of risk of breast can-
Analyses (Sage, 2004), emphasizing carto-
cer. Her work continues to explore women's
graphic and positional approaches to qualitative
data analysis. health, risk, and biomedical knowledge. She has
published on breast cancer and other topics.
Janet K. Shim is Assistant Adjunct Professor in
the Department of Social and Behavioral Sci- Jennifer R. Fishman is completing her Ph.D. in
ences and the Institute for Health and Aging at sociology at the University of California, San
Francisco. As of August 2003, she will be Assis-
tant Professor in the Department of Bioethics at
22 See Fosket
(2002) for a study of chemo- Case Western Reserve University. Her research
prevention as the biomedicalization of breast focuses largely on issues at the intersections of
cancer risk; see J. Fishman (forthcoming) for a gender, technology, and biomedicine and in-
study of the biomedicalization of sexuality; see cludes studies of new pharmaceutical develop-
Mamo (2002) for a study of the biomedicaliza- ments, genetic testing, and the use of the Internet
tion of lesbian reproduction; and see Shim to acquire medical and health information. Her
(2002a, 2002b) for a study of the biomedicaliza- dissertation is a socio-historical analysis of the
tion of race, socioeconomic status, and sex emergence of Viagra and other pharmacological
through epidemiology. See Clarke et al. (in therapies for the treatment of male and female
prep.). sexual dysfunction."

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Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S.

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LAURA MAMO JENNIFER RUTH FOSKET

The first social transformation of American medicine institutionally established medi-

HE GROWTH OF medicalization-de- twentieth century in the West (Bauer 1998;

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Table 1. The Shift from Medicalization to Biomedicalization

Economics:The U.S. BiomedicalTechnoServiceComplex,Inc.

The Focus on Health, Risk, and Surveillance

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The Technoscientizationof Biomedicine

Highly localized infrastructureswith idiosyncratic Increasinglyintegratedinfrastructureswith

Transformationsof Information,and the Productionand Distributionof Knowledges

Largely top-downmedical professional-initiated Also heterogeneouslyinitiatedinterventions

Transformationsof Bodies and Identities

rent and former editors of 13 major medical CENTRALIZATION, RATIONALIZATION,

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screening services, pharmaceutical cover- physicians in private practice. Here, indi-

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4. TRANSFORMATIONS OF INFORMATION which they may be eligible. Numerous pri-

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fically based knowledge sources, there is within the structuresof Westernbiomedicine

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to "manage" such differences (Lock and TECHNOSCIENTIFICIDENTITIES.Techno-

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REFERENCES Marketing Meeting, The Gala Event, The

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Scheper-Hughes, Laura A. Siminoff, Jeffrey pedia of Sociology, edited by E. F. Borgatta

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Kaiser Family Foundation. America. Berkeley, CA: University of Califor-

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Beacon. Journal of Health Services Research 29:215-

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