Perspectives The art of medicine Four social theories for global health Global health, many would agree, is more a bunch of to be routinely evaluated for unintended consequences problems than a discipline. As such it lacks theories that that might lead to the modification of programmes can generalise findings-through an iterative process and even, if the consequences are serious enough, their of knowledge construction, empirical testing, critique, termination. This theory would seem to be the social new generalisation, and so on-into durable intellectual science equivalent of medicines"frst, do no harm", but frameworks that can be applied not only to distinctive it goes beyond that ancient saw to reason that every health problems, but to different contexts and future action can have unintended effects and also that certain scenarios. This lack may or may not have slowed progress of those may not necessarily be harmful. Global health in developing and implementing programmes, but it filled with illustrations of unintended and often harmful urely has limited the education of practitioners and consequences of programmes, such as those following the emergence of an intellectually robust field. There coercive vaccination during the smallpox eradication is no contradiction between global health being both campaigns in India, which led to individual and community evidence-based and theory-oriented. After all, this is what resistance to later vaccination campaigns. An unintended characterises the social sciences and natural sciences, consequence of Chinas one child per family population he academic platform for global health, even if the profession of medicine, another core Second, is the social construction of reality, as introduced component, has not been a theory-rich field by Peter Berger and Thomas Luckmann in the 1960s, t During the past 2 years, I had the privilege of teaching a has become foundational in the social sciences. This theory course on global health to Harvard undergraduates with my holds that the real world, no matter its material basis, is olleagues Jim Kim, Paul Farmer, Anne Becker, and Salmaan also made over into socially and culturally legitimated Keshavjee. We started off with several social theories that ideas, practices, and things. Hence the spread of the HinI we used to make more general sense of individual case influenza virus is made over globally into the sociall studies in global health implementation, but we ultimately threatening and culturally fearful swine flu epidemic; cancer honed our exploration down to four key social theories. takes on the meaning as the dread disease in the USA in The first social theory of global health is the unintended the early 20th century; mental illness is stigmatised by the consequences of purposive(or social) action. Introduced social construction of non-persons in China; a formerly by the sociologist Robert Merton, this theory holds that all authoritarian physician-patient relationship becomes of which can be foreseen and prevented, whereas others medications take on a social lite stations change: and social interventions have unintended consequences, some increasingly egalitarian as cultural expe ir own via informal cannot be predicted. Therefore, all social action needs networks and social marketing. Abortion becomes highly contentious in the USa but not in Japan, just as brain death becomes highly contentious in Japan but not in the USA Global health problems and programmes can(and at times do) take on culturally distinctive significance in different local settings. This leads to a tension between global policies and local reality that is foundational to medical and ublic health practice. A corollary of the social construction of reality is that each local world-a neighbourhood, a The printed journal illage, a hospital, a network of practitioners/researchers- realises values that amount to a local moral context that includes an image merely nfluences the behaviour of its members. For global health the implication is that those local moral worlds can affect for illustration everything from smoking cessation interventions to HIv/ AIDS prevention and treatment The third social theory is that of social suffering, which vides a framework that holds four potentially useful lications for global health. First, that socioeconomic and sociopolitical forces can at times cause disease, as is the case with the structural violence of deep poverty creating the conditions for tuberculosis to flourish and www.thelancet.comVol375maY1,2010
Perspectives 1518 www.thelancet.com Vol 375 May 1, 2010 Global health, many would agree, is more a bunch of problems than a discipline. As such it lacks theories that can generalise fi ndings—through an iterative process of knowledge construction, empirical testing, critique, new generalisation, and so on—into durable intellectual frameworks that can be applied not only to distinctive health problems, but to diff erent contexts and future scenarios. This lack may or may not have slowed progress in developing and implementing programmes, but it surely has limited the education of practitioners and the emergence of an intellectually robust fi eld. There is no contradiction between global health being both evidence-based and theory-oriented. After all, this is what characterises the social sciences and natural sciences, which together create the academic platform for global health, even if the profession of medicine, another core component, has not been a theory-rich fi eld. During the past 2 years, I had the privilege of teaching a course on global health to Harvard undergraduates with my colleagues Jim Kim, Paul Farmer, Anne Becker, and Salmaan Keshavjee. We started off with several social theories that we used to make more general sense of individual case studies in global health implementation, but we ultimately honed our exploration down to four key social theories. The fi rst social theory of global health is the unintended consequences of purposive (or social) action. Introduced by the sociologist Robert Merton, this theory holds that all social interventions have unintended consequences, some of which can be foreseen and prevented, whereas others cannot be predicted. Therefore, all social action needs to be routinely evaluated for unintended consequences that might lead to the modifi cation of programmes, and even, if the consequences are serious enough, their termination. This theory would seem to be the social science equivalent of medicine’s “fi rst, do no harm”, but it goes beyond that ancient saw to reason that every action can have unintended eff ects and also that certain of those may not necessarily be harmful. Global health is fi lled with illustrations of unintended and often harmful consequences of programmes, such as those following coercive vaccination during the smallpox eradication campaigns in India, which led to individual and community resistance to later vaccination campaigns. An unintended consequence of China’s one child per family population control policy is the sexual revolution it created. Second, is the social construction of reality, as introduced by Peter Berger and Thomas Luckmann in the 1960s, that has become foundational in the social sciences. This theory holds that the real world, no matter its material basis, is also made over into socially and culturally legitimated ideas, practices, and things. Hence the spread of the H1N1 infl uenza virus is made over globally into the socially threatening and culturally fearful swine fl u epidemic; cancer takes on the meaning as the dread disease in the USA in the early 20th century; mental illness is stigmatised by the social construction of non-persons in China; a formerly authoritarian physician–patient relationship becomes increasingly egalitarian as cultural expectations change; and medications take on a social life of their own via informal networks and social marketing. Abortion becomes highly contentious in the USA but not in Japan, just as brain death becomes highly contentious in Japan but not in the USA. Global health problems and programmes can (and at times do) take on culturally distinctive signifi cance in diff erent local settings. This leads to a tension between global policies and local reality that is foundational to medical and public health practice. A corollary of the social construction of reality is that each local world—a neighbourhood, a village, a hospital, a network of practitioners/researchers— realises values that amount to a local moral context that infl uences the behaviour of its members. For global health, the implication is that those local moral worlds can aff ect everything from smoking cessation interventions to HIV/ AIDS prevention and treatment programmes. The third social theory is that of social suff ering, which provides a framework that holds four potentially useful implications for global health. First, that socioeconomic and sociopolitical forces can at times cause disease, as is the case with the structural violence of deep poverty creating the conditions for tuberculosis to fl ourish and The art of medicine Four social theories for global health Reuters The printed journal includes an image merely for illustration
erspectives for antibiotic resistance to develop. Second, that social funded ostensibly to improve transportation to clinics, institutions, such as health-care bureaucracies, that are whereas the government's deep motive was being able to worse. Examples of this are hospital-based medical errors political purposes. The UN system and it ntry to another for developed to respond to suffering can make suffering move the Army from one part of the co or the failure of the US Veterans Administration clinics individual nation-states frequently govern via biopower so to adequately diagnose and treat the psychiatric trauma that global health programmes can come to serve ulterior among soldiers returning from the current wars in raq and purposes. In post-conflict states like Liberia and Sierra Afghanistan. Third, social suffering conveys the idea that Leone, governance is dominated by the UN system agencies the pain and suffering of a disorder is not limited to the and non-governmental organisations(NGOs)that exert individual sufferer, but extends at times to the family and political and social control via programmes focused on social network, as is the case when Alzheimers disease has the management and rehabilitation of trauma. Biopower created such serious cognitive impairment in the patient becomes an increasingly important issue as global health that he or she expresses no discomfort while the adult programmes are scaled up by nation-states children experience deep loss and frustration For global These four theories, and their derivatives, do not health programmes, the implication is that the family exhaust the social theories that are potentially salient and network may also be in need of health interventions for global health. among other influential theories are and are often influential in help seeking and adherence. for example, those of the great German sociologist Finally, the theory of social suffering collapses the historical Max Weber on bureaucratic rationality and the predicament distinction between what is a health problem and what is of institutionalising charismatic leadership. Weber's ideas a social problem, by framing conditions that are both and are directly pertinent to understand how bureaucracies are that require both health and social policies, such as in urban indifferent as they become implementation bottlenecks slums and shantytowns where poverty, broken families, for global health programmes and international and local and a high risk of violence are also the settings where NGOs falter after their founders depart, respectively. And, depression, suicide, post-traumatic stress disorder, and of course, all of these theories have their limitations and drug misuse cluster. Although there are clearly occasions potential misuses that need to be taught along with their Further reading when health policy and social policy have different targets, appropriate uses Abramowitz. Kleinman A and the political may often be inseparable Fourth, we draw on the concept of biopower, a term case studies in order to generalise knowledge and to Health and Psychosocial support ined by Michel Foucault to model the way political develop a more systematic critical reflection on global Intervention 2008: 6: 219-27. governance increasingly exerted its effects via the control health problems and programmes as a complement to Berger P, Luckmann T. The social of bodies and populations. Social statistics in Europe grew epidemiological, health services, policy, and ethical studies. construction of reality.Garden out of the state 's efforts to enumerate populations for Social theories have a place in medicine as well as in global City. Anchor Books 1967. purposes of social control, albeit that effort also had health- health And one of the pedagogic responsibilities of medical Berkeley. University of Califomia relevant consequences. Other examples include the way humanities and social science programmes must be Press, 2005 that during the era of radical collectivisation under Maoist introduce students to intellectual frameworks that lead to Ferguson ) The anti-politics policies in China in the 1960s and 1970s, the population both a deeper critical reflection on disease and caregiving machine:"development" cycles on the doors of their homes as a means of surveillance and medicalisation are proven examples, but the potential Minnesota nes sapor control policy led to local cadres requiring village women in and new tools to improve practice. Clinically relevant depoliticization an of the post-Chemobyl disaster situation in the Ukraine. used theories simply to attack medicine, not to improve Penguin, s0 ondon ntroduced the term biological citizenship to make sense is still much larger. Sadly, social scientists have at times sexuality part t victims of radiation exposure, a much greater number of bit as damaging as the profession of medicine s failure to university es, 00 orbiters. gh radiation scientists certified only a few hundred medical practice. That is a failure of social trauma as deserving of compensation from a caring state make social theory another instrument of improving b y yxa. 9g ifom 3M,eds. eople claimed disability from the accident, and in the seriously engage with social theories. The time has long process, a new identity: citizens biologically defined by this since come to supersede this untenable situation and to Social suffering. Berkeley: that exerts the power of governance via the welfare rolls. and reforming health care In his powerful ethnography of failed development Merton RK. The unanticipated onsequences of purposive social projects in the 1970s and 1980s in Lesotho-one of the Arthur Kleinman action. Am Sociological Rev 1936; world's poorest countries-James Ferguson showed that Harvard University, Department of Anthropology, Cambride 1:894904 the government used biopower to deal with intemational MAO2138, USA agencies like the World Bank by prioritising road building, kleinman@wjh. harvard.edu Press. 200 www.thelancetcomVol375May1,2010
Perspectives www.thelancet.com Vol 375 May 1, 2010 1519 for antibiotic resistance to develop. Second, that social institutions, such as health-care bureaucracies, that are developed to respond to suff ering can make suff ering worse. Examples of this are hospital-based medical errors or the failure of the US Veterans Administration clinics to adequately diagnose and treat the psychiatric trauma among soldiers returning from the current wars in Iraq and Afghanistan. Third, social suff ering conveys the idea that the pain and suff ering of a disorder is not limited to the individual suff erer, but extends at times to the family and social network, as is the case when Alzheimer’s disease has created such serious cognitive impairment in the patient that he or she expresses no discomfort while the adult children experience deep loss and frustration. For global health programmes, the implication is that the family and network may also be in need of health interventions and are often infl uential in help seeking and adherence. Finally, the theory of social suff ering collapses the historical distinction between what is a health problem and what is a social problem, by framing conditions that are both and that require both health and social policies, such as in urban slums and shantytowns where poverty, broken families, and a high risk of violence are also the settings where depression, suicide, post-traumatic stress disorder, and drug misuse cluster. Although there are clearly occasions when health policy and social policy have diff erent targets, in the poorest of communities the medical, the economic, and the political may often be inseparable. Fourth, we draw on the concept of biopower, a term coined by Michel Foucault to model the way political governance increasingly exerted its eff ects via the control of bodies and populations. Social statistics in Europe grew out of the state’s eff orts to enumerate populations for purposes of social control, albeit that eff ort also had healthrelevant consequences. Other examples include the way that during the era of radical collectivisation under Maoist policies in China in the 1960s and 1970s, the population control policy led to local cadres requiring village women in their reproductive years to post the dates of their menstrual cycles on the doors of their homes as a means of surveillance and birth control. Working with this theory, Adriana Petryna introduced the term biological citizenship to make sense of the post-Chernobyl disaster situation in the Ukraine. Although radiation scientists certifi ed only a few hundred victims of radiation exposure, a much greater number of people claimed disability from the accident, and in the process, a new identity: citizens biologically defi ned by this trauma as deserving of compensation from a caring state that exerts the power of governance via the welfare rolls. In his powerful ethnography of failed development projects in the 1970s and 1980s in Lesotho—one of the world’s poorest countries—James Ferguson showed that the government used biopower to deal with international agencies like the World Bank by prioritising road building, funded ostensibly to improve transportation to clinics, whereas the government’s deep motive was being able to move the Army from one part of the country to another for political purposes. The UN system and its agencies as well as individual nation-states frequently govern via biopower so that global health programmes can come to serve ulterior purposes. In post-confl ict states like Liberia and Sierra Leone, governance is dominated by the UN system agencies and non-governmental organisations (NGOs) that exert political and social control via programmes focused on the management and rehabilitation of trauma. Biopower becomes an increasingly important issue as global health programmes are scaled up by nation-states. These four theories, and their derivatives, do not exhaust the social theories that are potentially salient for global health. Among other infl uential theories are, for example, those of the great German sociologist Max Weber on bureaucratic rationality and the predicament of institutionalising charismatic leadership. Weber’s ideas are directly pertinent to understand how bureaucracies are indiff erent as they become implementation bottlenecks for global health programmes and international and local NGOs falter after their founders depart, respectively. And, of course, all of these theories have their limitations and potential misuses that need to be taught along with their appropriate uses. My colleagues and I have discovered that students appreciate being able to relate these theories to in-depth case studies in order to generalise knowledge and to develop a more systematic critical refl ection on global health problems and programmes as a complement to epidemiological, health services, policy, and ethical studies. Social theories have a place in medicine as well as in global health. And one of the pedagogic responsibilities of medical humanities and social science programmes must be to introduce students to intellectual frameworks that lead to both a deeper critical refl ection on disease and caregiving and new tools to improve practice. Clinically relevant theories, such as illness behaviour, explanatory models, and medicalisation are proven examples, but the potential range of social theories appropriate for medical practice is still much larger. Sadly, social scientists have at times used theories simply to attack medicine, not to improve medical practice. That is a failure of social science every bit as damaging as the profession of medicine’s failure to seriously engage with social theories. The time has long since come to supersede this untenable situation and to make social theory another instrument of improving health and reforming health care. Arthur Kleinman Harvard University, Department of Anthropology, Cambridge, MA 02138, USA kleinman@wjh.harvard.edu Further reading Abramowitz S, Kleinman A. Humanitarian intervention and cultural translation: a review of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Intervention 2008; 6: 219–27. Berger P, Luckmann T. The social construction of reality. Garden City: Anchor Books, 1967. Farmer P. Pathologies of power. Berkeley: University of California Press, 2005. Ferguson J. The anti-politics machine: “development”, depoliticization, and bureaucratic power in Lesotho. Minneapolis: University of Minnesota Press, 1994. Foucault M. The history of sexuality, part V. London: Penguin, 1990. Kleinman A. What really matters. New York and Oxford: Oxford University Press, 2006. Kleinman A, Das V, Lock M, eds. Social suff ering. Berkeley: University of California Press, 1997. Merton RK. The unanticipated consequences of purposive social action. Am Sociological Rev 1936; 1: 894–904. Petryna A. Life exposed. Princeton: Princeton University Press, 2002
