Why Theory Matters
A Biosocial Framework and Three Social
Theories:
Unintended Consequences; Social
Construction of Reality; and the Weberian
Vision of Modernity
A Critical Sociology of Global Health II
Societies of the World 25
Arthur Kleinman
September 5, 2013
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A Biosocial Framework
 The intertwining reality of biological and social
factors in health. Biological processes and social
processes affect each other and thereby influence
health and disease
 Useful explanatory and exploratory framework
 Allows for a focus on interactions, rather than
relying solely on deterministic biological or social
explanations
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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
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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
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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 1950’s the high rates of STIs –
syphilis, gonorrhea etc. – had disappeared.
 Under China’s economic reform starting in 1978
prostitution returned to China. There are now more
prostitutes in China than there were in the 1930’s and
40’s. STI rates have skyrocketed and sexual transmission
has contributed to the spread of HIV/AIDS.
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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.
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The Unanticipated Consequences of
Purposive Action (Merton 1936)
 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
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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 CT Scans in the American
healthcare system (over 60 million per year for 300 million
Americans – radiation exposure and social cost)
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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
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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.
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Medicalization
 One example of the social
construction of reality
 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”
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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
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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
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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 practitioner’s
framework
• Sickness: symptoms and pathology understood at the
population level in the broadest societal context
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Weber’s types of authority
 charismatic authority (familial, religious,
personality-based)
 traditional authority (patriarchs,
patrimonalism, feudalism)
 legal authority (modern law, the state, and
its institutions)
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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
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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”
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Weber’s “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)
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Technical Rationality
 Advantages
•
•
•
•
Less biased
Less ad-hoc
More efficient
More quantifiable
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 Disadvantages
• Risk being stuck in
the “iron cage of
rationality”
• Loss of traditions,
sentiment, and rule
of thumb
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The “Iron Cage”
 NIH
• In the routine research review process only grants that don’t challenge
the scientific status quo get funded and out-of-the-box, creative ideas
are rejected. As a result NIH complemented RO1’s 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.
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Social Theory and Global Health
 How can we apply these ideas to
contemporary problems? (one of the
objectives of this course)
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Social Theory, Political
Economy, and Global Health
 What is political economy?
 How does political economy relate to the
social theories we are exploring in this
course?
 What is moral economy?
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