The Social Lives of Health and Medicine

The Social Lives of Health and
A new global agenda
for health equity
• Our children have dramatically different life
chances depending on where they were born.
– Japan or Sweden 80 years; in Brazil, 72 years;
India, 63 years; and in one of several African
countries, fewer than 50 years.
• In countries at all levels of income, health and
illness follow a social gradient
– the lower the socioeconomic position, the worse
the health.
WHO (2009)
Inequities and Inequalities
• It does not have to be this way and it is not
right that it should be like this
• Where systematic differences in health are
judged to be avoidable by reasonable action
they are, quite simply, unfair.
• It is this that we label health inequity.
WHO (2009)
“It’s Not the Germs!”
• Etiology – disease causation
– Germs, nature, society, individual factors, supernature
• Ethnoetiology – local knowledge & practices
related to theories of disease causation
– Agents (personalistic)
– Contextual (naturalistic)
– Internalizing (physiological/internal mechanisms)
– Externalizing (events outside the body/external
pathogenic agencies)
The Blane Report (1977)
• 4 explanations for patterns of inequality in
– Statistical Artefacts: modes of measurement
– Outcome of natural or social selection (?)
• Health experience upward mobility & unhealthy
– Behavioral or cultural practices
– Class and health are linked by structural factors
WHO on Social Determinants of Health
• health inequities are caused by the unequal distribution of power,
income, goods, and services, globally and nationally, the consequent
unfairness in the immediate, visible circumstances of peoples lives –
their access to health care, schools, and education, their conditions of
work and leisure, their homes, communities, towns, or cities – and their
chances of leading a flourishing life.
• This unequal distribution of health-damaging experiences is not in any
sense a ‘natural’ phenomenon but is the result of a toxic combination of
poor social policies and programmes, unfair economic arrangements,
and bad politics.
• Together, the structural determinants and conditions of daily life
constitute the social determinants of health and are responsible for a
major part of health inequities between and within countries.
WHO (2009)
• Emphasizes social, political, economic factors
which adversely affect health
• Forms of social/econ./pol. org., environment,
health services, transport, economic conditions,
work practices
• We are born into society with a ‘material
structure’ (ascribed status?)
– ‘shapes us’
• Social org. rather than individual biology
• Foundation for health inequalities/
disparities/population health approaches
Three principles of action
• Improve the conditions of daily life – the circumstances in
which people are born, grow, live, work, and age.
• Tackle the inequitable distribution of power, money, and
resources – the structural drivers of those conditions of
daily life – globally, nationally, and locally.
• Measure the problem, evaluate action, expand the
knowledge base, develop a workforce that is trained in the
social determinants of health, and raise public awareness
about the social determinants of health.
WHO (2009)
Social class?
• How to define? What variables do we use?
– Occupation, income & wealth, prestige, education, residence, ethnicity,
gender, age, ?
• The adjective “Class” – descriptive
– collectively organized actors
– people become identified independently of kinship as a constituent of
– for example, biological differences or functions as defined in the culture
rather than social identities become increasingly important
• Class formation – the formation of collectively organized actors
• Class consciousness – the understanding of actors of their class
• Class struggle – the practices of actors for the realization of their class
– In contest
• Interrelationships of all these
How do we know social classes exist?
• Social stratification
• the unequal distribution of goods and services,
rights and obligations, power and prestige
• all attributes of positions in society, not attributes
of individuals
• there are significant breaks in the distribution of
goods services, rights, obligations, power prestige
• as a result of which are formed collectivities or
groups we call strata or “class”
Neoliberalism, Class, and Health
• Neoliberalism
– move from a bureaucratic welfare-based society
toward a meritocracy
– in the interests of business
– based on individual and economic liberty
• Health & health care consequences
– Individual centric
– Achieved health
• Class analysis?
Accounting for the Social
• Social Constructivism
• Social capital
• In contrast to:
– the ‘variable approach’
Social Constructionism
• how social phenomena develop in particular
social contexts
• a concept or practice which may appear to be
natural and obvious to those who accept it,
but in reality is an invention or artifact of a
particular culture or society -- SOCIAL
• Social constructs -- by-products of countless
human choices rather than laws resulting from
divine will, nature, OR ANY OTHER
Deconstructing Social Constructs
• uncover the ways in which individuals and
groups participate in the creation of their
perceived social reality
• looking at the ways social phenomena are
created, institutionalized, and made into
tradition by humans
• Socially constructed reality is seen as an
ongoing, dynamic process
• reality is reproduced by people acting on their
interpretations and their knowledge of it.
Deconstruction: Derrida
• A strategy of critical analysis
• understanding language as writing and how
this leads to the impossibility of a
straightforward theory of intentional meaning
• concepts in terms of their structure and
• Individual language users operate within a
system of meaning that is given to them from
• Meaning is therefore not fully under the
control of the individual language user
Health & Medicine as Social Construct
• Health & Medicine is a set of categories that
filters and constructs experience
• Health & Medicine produces its own objects
and subjects (subjectivity & subject positions)
– i.e. body mind dualism – nature is separate from
Disease as a natural fact ?
• recognizable by natural scientific methodology
• Statistical concepts of normality
• Diseases change independently of their biology –
TB steadily declined prior to discovery of
tubercule bacillus & vaccine
• Diseases produced in social environments
– Repetitive strain injury (RSI)
– Chronic fatigue syndrome
Pierre Bourdieu: 3 types of capital
• Economic capital: command over economic resources
(cash, assets).
• Social capital: resources based on group membership,
relationships, networks of influence and support.
• Cultural capital: forms of knowledge; skill; education;
any advantages a person has which give them a higher
status in society, including high expectations.
– E.g. Parents provide children with cultural capital, the
attitudes and knowledge that makes the educational system a
comfortable familiar place in which they can succeed easily.
Social Capital & Health in Canada
With regard to social capital, studies increasingly show
that communities supported by a substantial stock of
social capital have better economic and social
performance (Putnam, 2000).
Better health, health conditions, and health care.