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.thelancetcomVol375May1,2010Perspectives 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 health￾relevant 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