• 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
CONSTRUCT
• Social constructs -- by-products of countless human choices rather than laws resulting from divine will, nature, OR ANY OTHER
EXPLANATION THAT PURPORTS OTHERWISE

• Economic & social arrangements shape knowledge
• Ideology and knowledge
– Social structure/stratification : power
• Administrative apparatus, forms of governance and knowledge
• Concepts we use to think with reflect social organization of society
• Social constructions

• Kuhn shows scientific paradigms as assumptions about the social world & reality often grounded more in practice than in theory
• Facts & Fictions
– facts are things done
– fiction is about action yet implicated in a dialectic of the “true” (natural) & the “counterfeit” (artifactual)
– the act of fashioning
• Facts & fiction -- embedded in social forms & practices
• entangled within interpretation & language

• Thomas Kuhn (PhD Harvard physics)
• science does not progress via a linear accumulation of new knowledge
• periodic revolutions: "paradigm shifts"
• anomalous results build up, science reaches a crisis, at which point a new paradigm
• it is not possible to understand one paradigm through the conceptual framework and terminology of another rival paradigm (relativism)
• theory choice is fundamentally irrational: if rival theories cannot be directly compared, then one cannot make a rational choice as to which one is better
• criteria admittedly determine theory choice, they are imprecise in practice and relative to individual scientists

• Donna Haraway -- story of scientific progress
(primatology)
• From misty sight prone to invention to sharp eyed quantitative knowledge rooted in experiment
• Stories with a particular aesthetic (realism) & a particular politics (progress)
• Nature is constructed & reconstructed in the bodies
& lives of 3rd world animals serving as surrogates for man
• Stories of race, gender, class, romance, Judeo-
Christian science

• Catherine Lutz -- gender & the formation of the canons of anthro
• Through the designation of particular works as theoretical
• Masculinizing of theory -- raced & classed
• historical processes by which subordinate groups are allowed access to writing
• theory as male writing -- patriarchy, patriline, author, theory

• Knowledge – systematic, diagnostic, neutral, objective, analytic, clarity, facts, useful
– Positive image
• Ideology – justificatory, defensive of belief & values, biased, emotive, political, murky/cloudy, caught up in life situations
• Both are concerned with the definitoon of a problem situation
• Both are responses to felt lack of needed information

Knowledge and Ideology as Cultural Systems
• Both are critical and imaginative works
– Symbolic structures
• Differing symbolic strategies for encompassing situations
• Science names situations with an attitude of disinterestedness
• Ideology names a situation with an attitude of commitment
– Stylistic differences
• Different enterprises but not unrelated

Knowledge is a Social Product
• actors interacting together form, over time,
typifications or mental representations of each other's actions
• typifications eventually become habitualized into reciprocal roles played by the actors in relation to each other
• reciprocal roles become routinized, the typified reciprocal interactions are said to be institutionalized.
• process of institutionalization, meaning is embedded and institutionalized into individuals and society
• knowledge and people's conception of (and therefore belief regarding) what reality 'is' becomes embedded into the institutional fabric and structure of society
• social reality is therefore said to be socially constructed

• F. Nietzsche – “knowledge works as a tool of power”
• M. Foucault – knowledge/power
– Power is based on knowledge and makes use of knowledge
– power reproduces knowledge by shaping it in accordance with its anonymous intentions
– Power (re-) creates its own fields of exercise through knowledge

• ways of constituting knowledge, together with the social practices, forms of subjectivity and power relations which inhere in such knowledges and relations between them
• a form of power that circulates in the social field and can attach to strategies of domination as well as those of resistance
• questions of how some discourses have shaped and created meaning systems that have gained the status and currency of 'truth', and dominate how we define and organize both ourselves and our social world

• 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.

• 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 genesis
• Individual language users operate within a system of meaning that is given to them from outside
• Meaning is therefore not fully under the control of the individual language user

• Medicine is a set of categories that filters and constructs experience
• Medicine produces its own objects and subjects (subjectivity & subject positions)
– i.e. body mind dualism – nature is separate from society

• 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)
– Is it a disease or political issue– various interpretations
• Alzheimer’s, hypertension, dyslexia, etc.
– Masturbatory insanity, hysteria

• Demographic transition & health transition
• Story of the irony of progress (Rousseau)
• Story of the modern (Rousseau)
• 19 th century evolutionary paradigms of social and cultural evolution and social development
• Modern, modernity, modernization
• Important categories
– “tradition” & “modern”

The Irony of Progress
• Negative impact of progress
• Degeneration into social inequality
• Harsh impact of private property, agriculture, mechanical arts
• Humans can exploit humans
Jean-Jacques Rousseau
Philosopher
1712 - 1778

• Jared Diamond
• a society can "choose to fail."
• Collapse
• climate change
• hostile neighbors
• trade partners
• society's response to its environmental problems.

Modernity & the Discourse of Irony
• Émile Durkheim
– Anomie
• Karl Marx
– Alienation
• Charles Dickens
– Ugly social truths of modern life
• Dystopia or anti-utopia

• Marshall Berman
• To be modern, I said, is to experience personal and social life as a maelstrom, to find one's world and oneself in perpetual disintegration and renewal, trouble and anguish, ambiguity and contradiction: to be part of a universe in which all that is solid melts into air. To be a modernist is to make oneself somehow at home in the maelstrom, to make its rhythms one’s own, to move within its currents in search of the forms of reality, of beauty, of freedom, of justice, that its fervid and
perilous flow allows.(All That Is Solid Melts Into Air, The
Experience of Modernity, 1988: 345-346)

Epidemiological/Health Transitions
• complex change in patterns of health and disease
• the interactions between these patterns and the demographic, economic, and sociological determinants and consequences.

• pestilence and famine
• receding pandemics
• degenerative and man-made diseases

Life Expectancies as Measure of Health
Transitions

From Infectious to Chronic Diseases

1900
1.
Influenza and pneumonia
2.
Tuberculosis
3.
Gastritis
4.
Diseases of the Heart
5.
Cerebrovascular Disease
6.
Chronic Nephritis
7.
Accidents
8.
Cancer
9.
Certain diseases of infancy
10. Diptheria
1998
1.
Heart Diseases (31.4% )
2.
Cancer
(23.3%)
3.
Cerebrovascular diseases (6.9%)
4.
Pulmonary disease
(4.7%)
5.
Accidents (4.1%)
6.
Pneumonia and Influenza
(3.7%)
7.
Diabetes
(2.7%)
8.
Suicide (1.3%)
9.
Diseases of Arteries
(1.2%)
10. Nephritis (1.1%)

Developed countries
1.
IHD (arteries) 22.6%
2.
CVD (heart/stroke) 13.7%
3.
Lung Ca. 4.5%
4.
Respiratory infections 3.7%
5.
Pulmonary Disease 3.1%
6.
Colon Ca 2.6%
7.
Stomach Ca 1.9%
8.
Self-inflicted injuries 1.9%
9.
Diabetes 1.7%
10. Breast Ca 1.6%
Developing countries
1. IHD 9.1%
2. CVD 8.0%
3. Respiratory infections 7.7%
4. HIV/AIDS 6.9%
5. Perinatal conditions 5.6%
6. Pulmonary disease 5%
7. Diarrhoeal diseases 4.9%
8. Tuberculosis 3.7%
9. Malaria 2.6%
10. Road accidents 2.5%
Beaglehole and Yach. Lancet 2003

Demographic Transitions and Health
Transitions
• Decreased fertility rates
• Decreased infant mortality rates
• Increased life expectancies at birth
• Reflect shifts in social and economic patterns
• Changes in health conditions
• Changes in health care

Population and demographic changes

Human Determinants of Transitions
• technological change
• alterations in the environment
• alterations in food type, availability, production, preparation, and consumption
• alterations in patterns of energy expenditure
• interplay of environmental factors and the genetic pool of a community

Two Examples of Interplay of Human
Determinants of Health
• Malaria & Sickle Cell Anemia
• Type 2 Diabetes & Chronic Diseases

Epistemological Framework of
Epidemiological Transitions

MULTIPLE EPIDEMIOLOGIC
TRANSITIONS
• recent resurgence of infectious disease mortality marks a third epidemiologic transition
• characterized by newly emerging, reemerging, and antibiotic resistant pathogens in the context of an accelerated globalization of human disease ecologies

Human Determinants of Transitions
REDUX
• technological change
• alterations in the environment
• alterations in food type, availability, production, preparation, and consumption
• alterations in patterns of energy expenditure
• interplay of environmental factors and the genetic pool of a community
• Social inequality? Where is it?

“SOCIAL FORCES AND PROCESSES
EMBODIED AS BIOLOGICAL EVENTS”
THE CRITICAL PERSPECTIVE
• Paul Farmer:
• “Inequality itself constitutes our modern plague – inequality is a pathogenic force”
• “Social inequalities often determine both the distribution of modern plagues and clinical outcomes among the afflicted”

Life Expectancy & Ethnicity in the US

Canadian First Nations & Aboriginal
Peoples
• serious health-related challenges
– high rates of chronic and contagious diseases and shorter life expectancy
• Compared to the general Canadian population
– Heart disease is 1.5 times higher;
– Type 2 diabetes is 3 to 5 times higher
– Tuberculosis infection rates are 8 to 10 times higher.
– 15 per cent of new HIV and AIDS infections occur in Aboriginal people.

• Overcrowded housing is associated with an increased risk of tuberculosis in a community

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.

First Nations: Non-Medical Determinants of Health
• only 56.9% of homes were considered adequate in 1999--00.
• only 33.6% of communities had at least 90% of their homes connected to a community sewage disposal system.
• In 1999, 65 First Nations and Inuit communities were under a boil water advisory for varying lengths of time
– communicable diseases such as giardiasis and shigellosis (both acute infectious diseases characterized by diarrhea, fever and nausea) can be traced to poor water quality

First Nations: Education

• A world-system is a social system
– one that has boundaries, structures, member groups, rules of legitimation, and coherence.
• made up of the conflicting forces which hold it together by tension and tear it apart as each group seeks eternally to remold it to its advantage.
• a life-span over which its characteristics change in some respects and remain stable in others.
• its structures -- at different times strong or weak in terms of the internal logic of its functioning.

Indonesia: From an Ethnographic Point of View
• Pembangunan – development, lit. “to wake up,” “to structure/form,” “to rise, “to model”
• Suharto’s New Order – pembangunan government
• 1990s – epi/health transition
– Cultural critique

Medical Pluralism, Modernity, &
Health Transitions

Healing the Modern in Indonesia
• a theory, a livelihood, or a health condition conjoined in expected and unexpected ways that sometimes are not easily contained by a globalizing “regime of modernity”
• process of global integration, a process coined as modernity, producing a “unified history of the world” that shapes “meanings and values as they are actively lived and felt” into now transnationally, globally shared “structures of feeling”
– All over progress?

Local & Global: The Irony of Progress