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.comVol375maY1,2010Perspectives 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