Unpacking Global Health:

A Critical Sociology of Knowledge II

Societies of the World 25
Arthur Kleinman
September 8, 2009
Harvard
Anthropology

Medical Anthropology @ Harvard

The Biosocial
The intertwining reality of biological and social
factors in health. Biological processes and social
processes affect each other and thereby influence
health and disease
Allows for a focus on interactions, rather than
relying solely on deterministic biological or social
explanations
Useful explanatory and exploratory framework
Harvard
Anthropology

Medical Anthropology @ Harvard

Malaria
Settlement patterns in areas where the required mosquito vector
flourishes contributes to disease causation
Campaigns involving insecticides, nets, and anti-malarials illustrate
both the politics and logistics of disease control and can contribute
to disease resistance as well as eradication
Frequently simpler, cheaper, environmental improvement initiatives
are not undertaken because they, unlike medical and technological
interventions, do not bring profits to industry and business and
there is often no powerful constituency for them

Harvard
Anthropology

Medical Anthropology @ Harvard

Heart Disease
Diet is a crucial risk factor for heart disease, and is
influenced by economic status, education level,
cultural traditions, and modernization, as in
elevated cholesterol levels following the
introduction of higher levels of animal fats into
diets
The global epidemic of diabetes a major
contributor to heart disease is in part the result of
a greater amount of sugar in diets
Harvard
Anthropology

Medical Anthropology @ Harvard

STIS
In 1949 there were 90,000+ prostitutes in Shanghai. With
the communist victory prostitution was outlawed, and
prostitutes were rehabilitated with job training for other
occupations. By the early 1950s the high rates of STIs
syphilis, gonorrhea etc. had disappeared.
Under Chinas economic reform starting in 1978
prostitution returned to China. There are now more
prostitutes in China than there were in the 1930s and 40s.
STI rates have skyrocketed and sexual transmission has
contributed to the spread of HIV/AIDS.

Harvard
Anthropology

Medical Anthropology @ Harvard

Other Examples
Stress-related disorders (chronic fatigue
syndrome, chronic anxiety, chronic pain)
The association of psychological depression with
economic depression
The direct correlation of rate of unemployment to
rate of disability
The relation between the epidemic of trafficaccident caused death and injury and the quality of
transportation infrastructure, licensing of drivers,
long haul truck regulations etc.
Harvard
Anthropology

Medical Anthropology @ Harvard

The Unintended Consequences of

Purposive Action (Merton)
Reasons for unintended consequences
Limits to the existing state of knowledge
The possibility of error, or the rigidity of
habit
The imperious immediacy of interest (901)
Values do not allow foreseeing possible
outcomes
Expectations affecting ultimate outcome
Harvard
Anthropology

Medical Anthropology @ Harvard

Examples of unintended
consequences
Robert Moses and the American highway system
destroying inner cities
The Great Leap Famine (1959-61) in China
The Grassy Knoll Indians of Ontario
Refugee camps after the Rwandan genocide
Unintended environmental and health consequences of
widespread pesticide use (such as DDT)
Overuse and misuse of MRIs in the American healthcare
system (over 60 million per year for 300 million
Americans radiation exposure and social cost)
Harvard
Anthropology

Medical Anthropology @ Harvard

Social Construction of Reality

(Knowledge)
The sociology of knowledge must concern itself with
whatever passes for knowledge in a society, regardless of
the ultimate validity or invalidity (by whatever criteria) of
such knowledge. -Berger & Luckmann
To understand the state of the socially constructed universe
at any given time, or its change over time, one must
understand the social organization that permits the definers
to do their defining. Put a little crudely, it is essential to
keep pushing questions about the historically available
conceptualizations of reality from the abstract What? to
the socially concrete Says who? -Berger & Luckmann

Harvard
Anthropology

Medical Anthropology @ Harvard

The Normal and the Abnormal in

Medicine
Ideas about what constitutes the normal and the abnormal
have been central to the practice of medicine.
However, in recent times much interest has been paid to
the relationship between these categories and how they
have been remade through medical interventions,
particularly the marketing of pharmaceuticals.
Along with our focus on the expanding category of the
abnormal, it is important to pay attention to the
concomitant processes of normalization, through which the
normal is redefined.
Harvard
Anthropology

Medical Anthropology @ Harvard

Medicalization
Turning existential angst into
anxiety disorders & grief into
depressive disorder
The making over of trauma into
PTSD
Increase in the numbers and
kinds of attitudes and behaviors
that have come to be defined as
illnesses. Their treatment is
regarded as belonging within
the jurisdiction of medicine

SOURCE: Renee C. Fox, Essays in Medical Sociology

Harvard
Anthropology

Medical Anthropology @ Harvard

Medicalization
Shift from discourse of sin, crime, and
deviance to illness and disease categories
Rise of health, illness, and medicine as
major portions of gross national product
Rise of medical industrial complex:
pharmaceutical and biotechnology industry
Rise of bioethics
Harvard
Anthropology

Medical Anthropology @ Harvard

Other illustrations of the social

construction of illness
Neurasthenia and depression
Chronic pain and the American disability system
Early AIDS epidemic seen as a Haitian disease
and a disease of homosexuals
Meanings and TB
19th century European romanticism
20th century inner city American immigrant disorder
21st century MDR-TB as untreatable
Harvard
Anthropology

Medical Anthropology @ Harvard

Illness/Disease/Sickness
Illness: the experience of symptoms and the response to
them by laypersons and their networks/communities

Disease: the reinterpretation of symptoms as

pathophysiology as understood from the practitioners
framework

Sickness: symptoms and pathology understood at the

population level in the broadest societal context
Harvard
Anthropology

Medical Anthropology @ Harvard

Webers types of authority

charismatic authority (familial, religious,
personality-based)
traditional authority (patriarchs,
patrimonalism, feudalism)
legal authority (modern law, the state, and
its institutions)

Harvard
Anthropology

Medical Anthropology @ Harvard

Charismatic Authority
"resting on devotion to
the exceptional
sanctity, heroism or
exemplary character of
an individual person,
and of the normative
patterns or order
revealed or ordained by
him." - Weber
Harvard
Anthropology

Medical Anthropology @ Harvard

Bureaucratic Authority
Hierarchical structure of subordination;
vocations clearly defined
Bureaucrats have "expert training" "functional
specialization of work
Bureaucrat = "single cog in an ever-moving
mechanism with fixed march

Harvard
Anthropology

Medical Anthropology @ Harvard

Webers technical rationality

Weber predicted that institutions would become the most powerful
social structures in society, greater than family or community,
because they could generalize and quantify and would be more
efficient
This would result in the technologization and bureaucratization of
everyday life via technical rationality (i.e. protocols, technical
jargon, neologisms, simplifications, reductionism, standardization,
rule-driven)
Technical rationality would come to be so intertwined with the
political economy that legitimated categories would determine
financial reward (for example, ICD and DSM and the reimbursement
of doctors) and would define legal procedure (only approved AMA
and APA categories used in forensics)

Harvard
Anthropology

Medical Anthropology @ Harvard

Technical Rationality
Advantages

Less biased
Less ad-hoc
More efficient
More quantifiable

Harvard
Anthropology

Disadvantages
Risk being stuck in
the iron cage of
rationality
Loss of traditions,
sentiment, and rule
of thumb

Medical Anthropology @ Harvard

The Iron Cage

NIH

In the routine research review process only grants that dont challenge
the scientific status quo get funded and out-of-the-box, creative ideas
are rejected. As a result NIH complemented RO1s with Pioneer
Awards, etc.
Institutional Review Boards (IRBs) standardized nomenclature,
methods and processes of ethical review. Certification of foreign
institutions follows the same American format and does not legitimate
local values and procedures.

Harvard University

When I came to Harvard in 1970 there were very few rules and very
few administrators. Most problems were dealt with by picking up a
telephone and talking directly to a dean or department chair. Now,
besides layers of bureaucracy there are books filled with rules
governing just about every aspect of instruction and faculty relations.

Harvard
Anthropology

Medical Anthropology @ Harvard

Social Theory and Global Health

How can we apply these ideas to
contemporary problems? That is one of the
objectives of this course.

Harvard
Anthropology

Medical Anthropology @ Harvard