Medicalization



Medicalization1ncIncreases in coverage increase our propensity to treat social problems technologicallyMaturo 12 (US National Library of Medicine. National Institutes of Health. Antonio Maturo, Ph.D. in Sociology. “Medicalization: Current Concept and Future Directions in a Bionic Society”) Consumers are a factor of medicalization because health is increasingly becoming, and has become, a commodity. People are increasingly using medical terminology in order to analyze their own health influenced from watching TV and browsing the internet. Also, advertisements encourage people to consider health needs that otherwise they would not have thought about. New social representations of health and illness are emerging, for instance, the representations of idealized beauty and the parallel “treatments” of cosmetic surgery. The body is increasingly considered as a “text” through which people may transmit signals and information. Technology Technology is a driving factor of medicalization for many reasons. First, new diagnostic tools mean more chances to discover illnesses. Yet, often the risk factors are considered as pathological and therefore treated. Sometimes, the “discovery” of new diseases is done by pharmaceutical firms which also have the “right” treatment (‘disease mongering’). Managed care Managed care is also a force of medicalization. For instance, considering depression as a condition caused by a chemical imbalance legitimates a treatment based on pills rather than on expensive psychotherapy. On these bases, social problems are transformed into medical ones. In the US, according to Conrad: It seems likely that physicians prescribe pharmaceutical treatment for psychiatric disorders knowing that these are the types of medical interventions covered under managed care plans, accelerating psychotropic treatments for human problems. In the US, in 1997, laws regulating pharmaceutical advertisement became less restrictive which resulted in the expenditure for prescription drugs ads to increase four times between 1998 and 2007. The increase in advertising has also strongly stimulated disease mongering, which is the “invention of illnesses.” A commonly used strategy in the advertisement for drugs is the overstatement of the risks of certain situations which mislead consumers. People are increasingly encouraged to discover some diseases through a self-diagnosis based on a check-list. In the debate on medicalization, a new topic has emerged in the last years: the opportunity of using biotechnology – mainly drugs – not to treat pathology, but to enhance normal conditions. Human enhancement can be defined as the use of biomedical technology to improve (physical, cognitive, emotional or social) performance on a human being who does not need any cure. Human enhancement is part of the concept of biomedicalization proposed by Clarke and Shim. Biomedicalization differs from the concept of medicalization because it takes into consideration the aspect of human enhancement and also the role of pharmaceuticalization in contemporary society. Indeed, the topic of human enhancement has everything to do with the shift of medicine, or a section of it, from the treatment of pathologies to the optimization and possibility of going beyond normality: better than well. Some examples of human enhancement are: prosthetic limbs, cosmetic surgery, and emotional and cognitive enhancement through pharmaceuticals. The line between the medicalization of pathologies and the enhancement of normality is blurred, as there are actions carried out at the borders that do not fall into either category. Moreover, it is likely that the enhanceable of today becomes the pathological of tomorrow, which brings about an ever-broader area in which biomedical interventions are required. The World Health Organization definition's of health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” has been often criticized because it proposes an extremely wide and ambitious concept of health. An edenic idea of health! Instead, it seems that today these three dimensions – body, psyche and society – are fully involved in the medicalization process. Moreover, health should be considered more as a “process”, than a state. A process in which “physical, mental and social well-being” is constructed, maintained and rebuilt. An asyntotic process without an end – as biocorporations and advertising know very well. As already stated, the expansion of medical categories into social spheres, which were not previously “read” medically, may play a reassuring role. For example, if we think that boisterous children are sick and have neurological problems and chemical imbalances, we allow ourselves to avoid looking at social problems like unemployment, social cohesion in ghettos and integration of the immigrants. A pill which works on serotonin levels is easy to prescribe, and is cheaper and “cleaner” than any social policy. Another example of medical colonization can be seen in food. In supermarkets, shelves of health foods are constantly growing. Food is increasingly advertised, packed and branded in ways which connect it to medical contexts. We have probiotic yoghurt which reduces the risk of ictus, blueberry drinks which improve our vision, and mineral waters which “purify”. To sum up, the bionic society can be described by at least three intertwining forces: A strong emphasis on health as considered by its chemical, neurological and genetic dimensions; The extension of medical ways of thinking (not only medical treatments) in areas which were not medicalized previously – or were only partially medicalized – like prevention, cosmetic, nutrition; A growing pharmaceuticalization which questions the borders between normality, pathology and enhancement, and therefore also between nature and nurture. In the near future, it seems that a bionic healthscape could lead to the transformation of social problems into medical problems of the single individual, therefore de-responsabilizing political and social institutions. On the other side, the emphasis on genetics and neurological dimensions might foster fatalism and passivity, leading to the deresponsabilization of the individuals for their health choices. All of this happening in a context where the lines between natural and artificial, normal and pathological, treatment and enhancement, are increasingly blurred.LinksTop-LevelMedicine’s epistemic authority has the ability to shape the way the world interprets our experiences enabling the oppressive socialization into productive capitalist conformity with their “magic pill” that can fix their “sicknessWardope 14 (Alistair Wardrope, Psychosomatic Medicine, Neurology, Philosophy of Science, “Medicalization and epistemic injustice”, Med Health Care and Philos, 11/09/2014, pg 341-342, Rawle)Illich, however, reserves his most vociferous condemnation for a more subtle but pervasive kind of harm, a ‘‘structurally health-denying effect’’ that he labels ‘‘medical Nemesis’’ (Illich 1977). This Nemesis is the social-constructive power of the medicalized frame, the ability to shape the collective conceptual resources through which we interpret and understand our experiences. Medicalization, Illich contends, is able to transform these resources such that we view more and more of our lives through the lens of medical discourse. Many have since echoed (in more or less restrained form) Illich’s critique. Psychiatric medicine has been a particular target for such critics, a recent resurgence in such concerns coinciding with the publication of the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The worries are familiar: depression pathologises sadness, alienation and melancholy, better understood as legitimate, if not necessary reactions to human experience and social injustice; ADHD recasts childhood exuberance as biological dysfunction, enabling the oppressive socialisation of children into productive capitalist conformity; and so on (Elliott 1998; Rose 2013; Kriss 2013; Fraser 2013; Self 2013). Similar concerns also pervade somatic medicine; women’s health and health promotion have served as particular foci for authors concerned with how the authority of medical discourse produces a ‘‘medicalized subjectivity’’, transforming and constraining agents’ self-understanding, and prescribing what reasons are deemed legitimate in determining how to live our lives (Morgan 1998; Verweij 1999; Kukla 2005). Contrasted with the more concrete individual, social or political harms envisioned by some critics of medicalization, the damage wrought by the medical Nemesis is at once less immediate and far deeper. It is a deprivation of the means to understand and communicate one’s social experience and situate it within understandings of one’s life and environment. The critique holds that aspects of medicalized phenomena that are distorted or not present when viewed through a medical lens are thereby rendered inexpressible. Cast in this light, the harm of medicalization has a decidedly epistemic tone—one of distortion of the collective hermeneutic resources by which we are able to interpret and share our experiences, and reason about and justify our decisions to one another. Understood in these terms, medicalization appears to comprise what Fricker (2007) calls a hermeneutical injustice. Fricker uses the term hermeneutical injustice to denote one of two forms of epistemic injustice, harms in which ‘‘the subject is wronged in her capacity as a knower’’ (2007, 44). Hermeneutical injustice is ‘‘the injustice of having some significant area of one’s social experience obscured from collective understanding owing to hermeneutical marginalization’’ (2007, 158). It is just this sort of claim that is made by medicalization’s critics; that medicine’s epistemic authority eclipses all other understandings in our collective hermeneutical resources. The melancholic cannot convey a painful, but vital, sense of existential alienation or a repulsed reaction to social injustice if these experiences are conceptualised simply as ‘low mood’ and ‘anhedonia’ on a diagnostic checklist. The bored, discontented, or exuberant child is unable to interpret his restlessness as anything other than a sickness demanding ‘‘magic pills which make me into a good boy and makes everybody like me’’ (Rose 2013). And immersion into practices of medicalized self-surveillance and self-discipline constrains the multiplicity of values and paths through life available to us, reducing the diversity of substantive conceptions of human flourishing to one pre-con- figured choice between the ‘responsible’, ‘healthy’ option and ‘irresponsible’, ‘selfish’ alternatives (Verweij 1999; Kukla 2005).We live in a society marked by the medicalization of death; this makes health care a monolithic world religion where humans are reduced to the objects of medical institutionsSmith 03 (Richard, Editor for The British Medical Journal, “Limits to medicine. Medical nemesis: the expropriation of health” Journal of Epidemiology and Community Health, pg. 928, Dec 2003,) JohnsonSocial iatrogenesis results from the medicalisation of life. More and more of life's problems are seen as amenable to medical intervention. Pharmaceutical companies develop expensive treatments for non-diseases. Health care consumes an ever-growing proportion of the budget. In 1975 the United States spent $95 billion on health care, 8.4% of its gross national product, lllich noted, from 4.5% in 1962. In 2001 it was $1424 billion, 14% of GNP. Predictions published this month suggest it will be $2815 billion, 17% of GNP by 2011. Can this be sensible? Worse than all of this for lllich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. "A society's image of death," argues lllich, "reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness." For lllich ours is a morbid society, where "through the medicalisation of death, health care has become a mono lithic world religion...Society, acting through the medical system, decides when and after what indignities and mutilations he [the patient] shall die...Health, or the autonomous power to cope, has been expropriated down to the last breath." Dying has become the ultimate form of consumer resistance. lllich's book is more polemic than analysis and should be read as such. The rhetoric is intoxicating, and I can see why lllich captured my soul all those years ago. lllich was a Catholic priest before he became a critic of industrial society, and the story he tells reeks of "the fall of man." Romantically, lllich seems to hanker after "the noble savage," and most readers of his book will never have known such a person and may be sceptical that he has ever existed. Much of life before modern medicine looked nasty, brutish, and short, and have not most people offered the choice opted for the comforts of modern medicine? It's the ultimate book reviewer's cliche to say that every doctor and medical student should read this book, but those who haven't have missed something important. When sick I want to be cared for by doctors who every day doubt the value and wisdom of what they do, and this book will help make such doctors.The “medical perspective” obscures the social causes of the challenges people face, consequently reinforcing bigoted discourses and justifying social controlConrad and Barker 2010 [Peter Conrad and Kristin Barker, The Social Construction of Illness: Key Insights and Policy Implications, Journal of Health and Social Behavior 51(S) S67 –S79, DOI: 10.1177/0022146510383495] Peter Conrad is a professor of social science at Brandeis University. Kristin Barker is an associate professor of sociology at the University of New Mexico.By acknowledging that medical knowledge about disease and illness is constructed by socially situated claims-makers and other interested parties, we can bring greater critical awareness to the policy-making process. After all, any policy response to a problem is determined by how the problem is defined or framed in the first place. For example, how do we approach the problem of health disparities between racial and ethnic groups? When the solution is to mandate that federally funded clinical studies include individuals from underrepresented subgroups, we inadvertently cast the problem as rooted in biological differences between racial and ethnic groups and downplay the role of socially structured inequalities (Epstein 2007). Likewise, when we define alcoholism as a disease, the dominant approach is to treat the individual alcoholic, rather than examine the social factors contributing to alcohol abuse or the role of the alcohol industry in alcohol promotion. When medical perspectives increasingly define obesity as an illness (rather than a risk factor for diseases such as diabetes, cardiovascular disease, etc.), policies focus on solutions such as gastric bypass surgeries, rather than examining the role of product promotion by the food industry or the availability of healthy foods in neighborhoods with high rates of obesity.2 Warnings about the risks of fetal alcohol syndrome effectively blame individual women and deflect attention away from the well-established links among class, race, and birth outcomes (Armstrong 2003). Framing anger in women as evidence of the disease PMS, to be treated with antidepressants, trivializes the impact of gender inequality on women’s daily lives. And when difficulties in children’s attention and behavior get defined as attention deficit hyperactivity disorder (ADHD), school policies increasingly encourage the use of medication and special accommodations for learning disabled students; yet these responses fail to address the social and nonmedical causes of children’s classroom inattention or agitation, such as increasing class size or the termination of physical education programs (Conrad 1975). In each case, and many others, the process by which human problems become medicalized in the first place is largely ignored in creating policy toward these issues. A social constructionist approach provides a means of understanding how such problems come to be defined in medical terms and how this translates into public policy (see Gusfield 1981). As the above examples attest, medicalized constructions can also be strongly evaluative (i.e., they suggest how people ought to behave) and result in policies that authorize social control.Medicalization of “non-threatening” conditions unsubtly shapes the relationship with ourselvesDuster 2007 [Troy, professor at New York University, “Medicalisation of race,” The Lancet 369.9562 (07)60320-1]Medicalisation implies passivity on the part of the medicalised. One example is when people claim that disease-awareness campaigns persuade potential cust- omers to “recode” their unease and dissatisfaction in the form of a diagnostic category to extend the market for pharmaceutical products and the remit of medical prac- titioners. With notable exceptions (children, prisoners, people deemed mentally ill and admitted to hospital under compulsion), doctors do not force diagnostic labels on resistant individuals. And although drug companies use techniques of modern marketing, they do not seek to dupe an essentially submissive audience. Marketing techniques, since the 1950s, have not regarded the consumer as a passive object to be manipulated by advertisers, but as someone to be known in detail, whose needs are to be charted, for whom consumption was an activity bound into a form of life that must be understood.4 Marketing does not so much invent false needs, as suggested by cultural critics, but rather seeks to understand the desires of potential consumers, to affiliate those with their products, and to link these with the habits needed to use those products. It is this process of mutual construction, the intertwining of products, expectations, ethics and forms of life, that we observe in the development and spread of psychiatric drugs such as those for depression. This process is not a brute attempt to impose a way of recoding miseries, but the creation of delicate affiliations between subjective hopes and dissatisfactions and the alleged capacities of the drug. Such a medicalisation of sadness can occur only within a political economy of subjectification, a public habitat of images of the good life for identification, a plurality of pedagogies of everyday existence, which display, in meticulous if banal detail, the ways of conducting oneself that make possible a life that is personally pleasurable and socially acceptable. In engaging with these formulae in inventive ways, individuals play their own part in the spread of the diagnosis of depression and shaping new conceptions of the self. Thus, beyond medicalisation, medicine has shaped our ethical regimes, our relations with ourselves, our judgments of the kinds of people we want to be, and the lives we want to lead. But if medicine has been fully engaged in making us the kinds of people we have become, this is not in itself grounds for critique. Critical evaluation of these heterogeneous developments is essential. But we need more refined conceptual methods and criteria of judgment to assess the costs and benefits of our thoroughly medical form of life—and of those that offer themselves as alternatives.The medicalization of social problems creates dependence on authoritarian market regimesMangosing 14 (Daryl Mangosing, Tufts University, Public Health. “The Medicalization of Human Conditions and Health Care: A Public Health Perspective.” Academia.edu and )"Public Health" focuses on the upstream causes of poor health, particularly those related to social and environmental factors that impact health status. However, biomedical advances in the last century have shifted the public's health to another aspect of care: individual causes and manifestations of illness and disease. This transition has led to what we call medicalization or “the process by which previously nonmedical problems become defined and treated as medical problems.” The medicalization of human conditions releases a ripple of effects, one being whether a consumer of health care recognizes a health problem that needs to be medically addressed. These problems are generally the result of failures in biology, hygiene, and behaviors, and they are resolved through biomedical treatments delivered by providers. If such is the case, two significant questions surrounding health care arise: what is the relationship between medicalization and health care spending and health policy, and is the medicalization of human conditions generally justified at the public health level? The answers to these questions, as we shall see, warrant implicative actions that shift the direction of public health interventions to a more social, community-based effort in attacking the heart of poor health. Put simply, we have to translate the knowledge gained and lessons learned from medicalization of human conditions into preventive measures that go beyond what we may think is beneficial for health not just at the individual-level but ultimately at the population-level. Individual problems of ill health have attracted the attention of money and manpower, lending to increasing concerns of medicalization driving up health care costs in the U.S. It is essential then that we take a further look into these estimations. For example, a study that estimated medical spending in the U.S. of identified medicalized conditions generated the following sum: $77.1 billion or 3.9% of total domestic expenditures on health care costs. Although it is a relatively minor portion of national health care expenditures, such an amount implies a substantial cost to private and public sectors as well as consumers. Whether this spending is inappropriate depends on the economic, social, and political dimensions of health care. Conversely, one can look to managed care, a major type of health insurance, as another major driver of U.S. health care. Conditions that are covered by health insurance fuel medicalization whereas the lack of coverage may slow it down; for example, Medicare and other medical insurance plans decided to consider obesity a reimbursable illness while some insurance plans do not cover certain conditions such as infertility. Furthermore, the only way to get human services paid for/reimbursed is to define a condition as a medical problem, thereby creating an incentive to medicalize more problems. The medicalization of human conditions therefore influences health care spending indefinitely, with increasing costs yielding unknown results. Policymakers have focused on increasing financial and geographic access to personal health services because of the assumption that health status problems are fixed by medical care. As the health problems of vulnerable populations became more medicalized, public policy started expanding access to individualized medical care. This approach may broadly help to achieve some public health goals, but key social and economic causes of health vulnerability and disparities lose attention. For instance, Medicaid provides a funding umbrella through which states finance expanded services and social supports that extend beyond medical treatment but services only become available or accessible after an individual is diagnosed with the health problem. On top of health care spending, the political drivers behind it have relied on medicalization to address health vulnerabilities by increasing access, but again, policy may lose sight of the root of the problem. When looking at patterns of health, patient/doctor ratios, the availability of tools for the job, and numbers of hospital beds may bear little relation to improvements in public health, and even disease and disability continues to directly result from medical intervention. Medicalization can also negatively affect how populations manage health problems in the following ways: the creation of ill-informed demand, enforcement of the belief that one has to spend more on medical services to secure a healthier population, and dependence on a system for medical help from womb to grave. Disease prevention then looks like a reliance on authoritative systems that give insufficient consideration for empowering people themselves to take responsibility for their health, giving people no choice but to support the system. The medicalization of human conditions have spurred the “individualization of social problems,” making social or environmental interventions either ignored or secondary and reinforces technical fixes for complex problems. One complex problem in which medicalization may be at odds with public health is alcoholism: is it truly a disease or is it just deviant social behavior? Not a single cause of alcoholism has been established or likely will be as patterns of alcohol abuse vary individually and are influenced by social structure and external events. Another surprising proposition is that prevention itself has become a key driver of over-medicalization. Certain diseases and conditions have a long lead-time, leading people to opt for treatment that possibly lengthens their “disease survival” without lengthening their lifespan. If screening was not enough to halt disease progression, physicians may intervene earlier or screen for “pre-disease” (e.g. pre-hypertension) that may or may not pay dividends in the end. In all truthfulness nonetheless, the medicalization of certain conditions and behaviors may surely benefit certain individuals more so than others. These others then unfortunately miss the intended benefits. In summary, several conclusions can be inferred from what we know regarding medicalization and its effect on health care: medicalization influences health care spending indefinitely, policy has focused on increasing health access, prevention may have promoted reliance on authoritative systems, and medicalization may benefit some more than others. What remains common among these assumptions is the neutral yield of both benefits and losses, thereby calling for further research and analysis of such data. However, the implication raised here is to return to the public health view of upstream causes of health. This means policy action in income security, education, housing, nutrition/food security, and the environment to improve health among all populations, especially among socially disadvantaged groups. Accompanying this step is the transition from medicalization to “healthization” – lifestyle and behavioral causes and interventions – turning health into the moral rather than the moral into health. Doing so creates efficacious communities and stronger families, which serve as mediating institutions that can screen out the individual and social effects of disease. Put simply, the key could be a form of strong community self-help. The medicalization of human conditions is not an inherently negative asset of health care, but rather, it is a way for us improve our understanding of disease processes so that we may delve into deeper solutions that attack the root of the problem. In this case, the starting point is the holistic, societal unit of the individual: the community.Instead of increasing access to pharmaceuticals and other quick fix solutions, the health system should reevaluate the socioeconomic issues increasing health risks in low income populationsVan Dijk et al, 2016. (Wieteke van Dijk, Celsus Academy for Sustainable Healthcare, Marjan J. Faber, Senior Research Fellow in Patient Participation for Quality Improvement in Health Care at Radboud University Medical Center, Marit A.C. Tanke, University of Groningen, Patrick P.T. Jeurissen, Radboud University Medical Centre, and Gert P. Westert, Radboud University, “Medicalisation and Overdiagnosis: What Society Does to Medicine.” International Journal of Health Policy and Management, ) PMWhen discussing over diagnosis and its consequences the underlying assumption seems to be that diagnosing is an objective and strictly medical procedure, which physicians would accomplish beautifully if they would only have the perfect knowledge. Besides the conceptual omissions in this interpretation of overdiagnosis,13 it is also untrue: disease and illness are not merely given biological facts but social constructions as well.14,15 The discussion whether disease can be defined entire value-free or is unavoidably value-laden remains unsettled, although all agree that values do have a role in the perception of disease.16 Societal actors such as governmental agencies can press their values on the health system by policy-making or prioritising certain diseases or treatments. An example of how ‘disease’ is more complex than a biological fact is the current scare for and treatment of hypertension. Firstly, this condition is in itself nothing more than a diagnosis based on a cut-off point. In the end, this diagnosis solely serves to identify a risk factor for cardiovascular conditions, such as heart attack and stroke.10,17 Secondly, in the focus on lowering this risk with pharmaceutical treatment we may overlook that hypertension is one of several risk factors, and, even more important, can be lowered or prevented with lifestyle change.18 By looking at hypertension from a purely medical view, other risk factors such as an unhealthy diet, obesity, and physical inactivity are easily overlooked. Furthermore, these risk factors are strongly related to socio- economic determinants such as education and occupation, with the result that those that lose out economically are also losing out healthwise. Focussing on pharmaceutical quick- fixes instead of addressing the underlying socio-economic problems possibly leads to more inequality, both globally19 and nationally. As Conrad and Barker put it: “it seems that we have a social predilection toward treating human problems as individual or clinical – whether it is obesity, substance abuse, learning difficulties, aging, or alcoholism- rather than addressing the underlying causes for complex social problems and human suffering.”15 This does not mean that medicalising a situation rules out simultaneous action on its social and political determinants. Physicians can be amongst the most passionate proponents of societal change for some of the medical problems they face in their practices, such as stricter regulations for tobacco industry, sugar-taxes on beverages and calls for obesity prevention.20-22 Nonetheless, by our tendency to seek medical solutions for social problems, we medicalise social issues such as inequality, deviance and abnormality and locate the sources and solution of these problems increasingly on the individual level.15 AccessNational health care is merely an extension of the seemingly benevolent liberal biopolitical mission to render the populace productive.Nye 3 (Robert A. Nye, “THE EVOLUTION OF THE CONCEPT OF MEDICALIZATION IN THE LATE TWENTIETH CENTURY,” Journal of History of the Behavioral Sciences, Vol. 39(2), p. 118-120)The essay entitled “The Politics of Health in the Eighteenth Century” appeared in 1976; here Foucault attempted a more coherent synthesis of the phenomenon. He rejected the notion that medicalization proceeded through “vertical” state initiatives, preferring to see medical interventions emerging at a “multitude of sites in the social body of health.” However, he still occasionally referred in this essay to the state as a kind of unity and attributed to doctors a willful desire to impose “authoritarian medical interventions and controls” (Foucault, 1980, pp. 166 – 82). However, it is in this essay, as in Surveiller et Punir, which appeared the previous year, that Foucault also began to decenter the notion of medical power, locating it in the rules of disciplinary discourses that work on the bodies of individuals, and in particular on children as objects of a kind of reproductive hygiene of families (Foucault, 1980, pp. 172 – 175). By the late 1970s Foucault had incorporated the notion of “governmentality” into his concept of how the modern state ruled the “social body.” In his important 1978 lecture on the arts of government, Foucault abandoned the notion of an essentialized and willful state in favor of a conception of governance that was not based on a juridical notion of sovereignty acting on citizens, but on a set of practices that operated on bodies and on families as reproductive units, while making use of the mechanisms of political economy to motivate and police the population. Medical practitioners were no longer, in his thinking, enforcers or servants of the state but experts in the service of a discourse that, as Foucault put it, was already “in some sense immanent in the population.” The aim of governance was thus “the welfare of the population, the improvement of its condition, the increase of its wealth, longevity, health, etc.,” that tactically reconciles, in the mode of liberal politics, the interests of each with the interest of all (Foucault, 1991, p. 100). According to Colin Gordon, this move was Foucault’s acknowledgment that the welfare state was a product of both a police function and of liberalism, permitting power to individualize and totalize at once (Gordon, 1991, pp. 3 – 14). In the end, Foucault proved to be far more interested in a kind of modern biopolitical power that relied on autonomous citizens who embraced their social duties as individuals than in despotic power that ruled by force alone. Foucault and his students and colleagues, Jacques Donzalot, Giovanna Procacci, Pasquale Pasquino, and others have tried to show how the liberal welfare state intervened more effectively in the lives of citizens when it was believed to be doing so in the name of some statistical or hygienic “truth,” or in defense of the health of the whole social body. Citizens, Procacci has argued, will resist vigorously the imposition or justification of legal inequality but endure or even promote an identity of difference (or otherness) in the name of health (Procacci, 1991, pp. 158 – 159). As Foucault argued in another 1978 essay, “About the Concept of the Dangerous Individual,” the security of the whole and the health of the social body were also advanced by the development in 19th century psychiatry and legal medicine of the concept of the “dangerous individual,” whose civil rights could be abridged in the name of a higher collective principle and with a medical judgment (Foucault, 2000, 178 – 200; Pasquino, 1991, pp. 235 – 250). Finally, taking their cue again from Foucault, a number of writers have attempted to demonstrate how the statistical aspects of medical policing in the modern liberal welfare state have produced a social concept of health that, by individualizing the notion of risk factors, deepens and expands the sway of medicalization. Francois Ewald, Daniel Defert, Alan Petersen, and many others have argued that the modern welfare state has adopted the collective risk calculus of insurance companies in attempting to assess the dangers and the costs of occupations, diet, recreation, and behavior that cause individuals, in certain predictable ways, to be a charge upon the state (Defert, 1991; Ewald, 1991; Petersen, 1997). Through education and the promotion of notions of individual responsibility for health, something like Foucault’s important concept of “technologies of the self” has been harnassed in neo-liberal policies to cost-effective programs of preventive medicine and health “maintenance” (Lupton, 1999; Wilkinson, 2001, pp. 91 – 99). As many scholars have observed, the concept of risk has evolved from an eighteenth century application of the probabilities of “good” as against “bad” investments in business ventures or insurance coverage to modern, fearful assessments of environmental hazards, or, as Mary Douglas has put it, we have moved from a probablistic calculus of chance to a politics of risk as danger (Douglas, 1992, pp. 22 – 25) The attempt by early nineteenth-century health reformers like Edwin Chadwick and Florence Nightingale and Louis-Rene? Villerme? to identify and eradicate the underlying causes of infectious disease was an important step in this evolution (Freedgood, 2000, pp. 42 – 73). The early hygienists like Chadwick invoked government intervention but not to the extent of disturbing the laws of political economy (Coleman, 1982). They preferred a more remote surveillance, fact-gathering, and regulation that left responsibility with local officials and individuals, although they dreamed of discovering the natural laws that would yield up the mechanisms and guarantee mastery of both disease and deviance. The combination of piecemeal, market-driven solutions and uncertainty about the natural laws of health has shifted our contemporary attention from the nineteenth-century preoccupation with pathogens and bodies that could be confined, segregated, or cured to the individual cultivation of a healthy body that is exalted as an ideal (Armstrong, 1995; Gastaldo, 1997, pp. 113 – 118). We still gather statistics, engage in medical surveillance, and promote health education, but we have given up the hygienist’s dream of isolating and eradicating disease for a model of individual responsibility. The irony of this development is that the goal of a perfectly healthy population— bodies that are “natural” and unmedicalized— can only be achieved by the individual internalization of a totally medicalized view of life. As Jennifer Harding has written, “. . . owing to the medicalization of life generally and the promulgation of medical statements about symptoms and diseases and their treatments, in the clinic and in the media, as news and entertainment, it is hard to isolate examples of medicalization from its absences . . .” (Harding, 1997, p. 145). Although the burden of responsibility for health in this new schema rests with individuals, who are encouraged endlessly to assess the risks of particular behaviors and to make their bodies into self-directed enterprises for maintaining health and fitness, aggressive government intervention is not ruled out when particular crises in public health arise. If anything, as Robert Castel has argued, the new health doctrine of risk prevention potentially expands the occasions for intervention: “Not just those dangers that lie hidden away inside the subject, consequences of his or her weakness of will, irrational desires or unpredictable liberty, but also the exogenous dangers, the exterior hazards and temptations from which the subject has not learnt to defend himself or herself, alcohol, tobacco, bad eating habits, road accidents, various kinds of negligence, pollutions, etc.” (Castel, 1991, p. 289).Medicalization gained prominence as a means of increasing national productivity by justifying the eradication of otherness. Nye 3 (Robert A. Nye, “THE EVOLUTION OF THE CONCEPT OF MEDICALIZATION IN THE LATE TWENTIETH CENTURY,” Journal of History of the Behavioral Sciences, Vol. 39(2), p. 121-123)Thus it is far from clear that any direct relationship may be drawn between the process of medical professionalization and the growth of either a medical model of health or a medical regime allied to state power. Instead, the development of greater medical cooperation with the nation state and the emergence of a national medical perspective of health and power proceeded by fits and starts, and differentially. As Abram de Swaan has written, the incorporation of medical knowledge and power into the modern state was a “reluctant imperialism.” As he says, “. . . , the establishment of a medical regime was not the achievement of a determined iron cohort of medical men, but on the contrary, the unintended effect of social conflicts in which doctors became involved, apparently had solutions to offer, and again and again were allotted new managerial functions” (de Swaan, 1988, pp. 238 – 244; de Swaan, 1990, p. 29). In addition, it has been argued recently that hospitals and asylums were prized by medical specialists for the opportunities they offered for scientific research, specialized credentials, and access to a well-paying clientele. Aiding and abetting the state in the growth of carceral regimes that segregated the deviant or marginal seems to have been far less important a motive than that of adding to scientific knowledge and practice that would redound to individual practitioners and to the independence and status of medicine as a whole (Bleker, 1997; Lawrence, 1996; Loudon, 1986). Scientific medicine, it would appear, and the continued rise in medical educational standards, was very much a product of the competitive dynamics of the profession, the ambitions and realism of young doctors, and of efforts to enhance the prestige, if not yet the efficacy, of the medical profession (McClelland, 1997; Solomon-Bayet, 1986). However, reluctant or not, medical professionals were gradually drawn into the web of the welfare state where they played increasingly important roles in administering health related programs. Perhaps more importantly, the medical concepts of pathology and norm became an important part of the cultural and political outlook of nationalist politics at the end of the nineteenth century. Doctors may have invented these notions and suggested their relevance to the analysis of social problems, but they became enormously popular with intellectuals, social scientists, and politicians, thanks, in no small measure, to the growing prestige of scientific medicine. It was the progress in the medicalization of modern society that followed these “second wave” developments that eroded the civil liberties and individual rights of citizens in the modern welfare state, and in the most horrific twentieth-century expressions, took the lives of the least fortunate of them. Many historians agree that the growth of a biomedical outlook on the management of populations resembles the picture painted by Foucault’s notion of the practices of governmentality. The first health legislation seems to have been inspired by political interest in greater national efficiency and productivity rather than by a desire for social justice. The aim of much European national health insurance legislation, maternal health care, and disability insurance in the period 1870 – 1914 was the elimination of lost days of labor and the provision of larger, more productive populations. However, by degrees, as a greater share of the population came under some form of coverage, individuals saw doctors more and more frequently and came to equate medical care and health with other basic needs. The population dearth in France, the fears of an “inefficient” population in Britain, and the labor shortage in a booming economy in Germany contributed in each country to the view that, as Alfons Labisch has argued for the German case, “. . . health became a value accepted by all social groups— by the high officials, politicians, industrialists, military officers, and finally by the individuals themselves. This development led to the general acceptance of the good ‘health’ of a society as a goal of political, social, and individual action” (Accampo, Fuchs, & Stewert, 1995; Labisch, 1997, p. 53). Medicalization, in short, entered the political field indirectly, as an aspect of the desire to obtain larger, more efficient, and productive populations in an era of fierce nation – state competitiveness. Certainly, Rudolf Virchow’s remark that “Medicine is a social science and policy is nothing else but medicine on a large scale” is testimony to the ambition of the medical outlook toward the end of the nineteenth century and the extent to which biomedical concepts undergirded social theory and policy throughout Europe (Labisch, 1992, pp. 94 – 96). Biomedical ideas were joined with concepts drawn from the life sciences to produce a wide array of theories about race and “Darwinian” race struggle in modern Europe, and about the “degeneration” of populations, including the dysgenic and eugenic ways these might be improved. Medical professionals often took important positions in the organizational efforts to advance and popularize these ideas, but, as Richard Evans has reminded us for the German example, practitioners were also deeply influenced in these commitments by their status as members of a bourgeoisie for whom order was a fetish, and, who like bourgeois everywhere, generally despised filth and disorder (Evans, 1997, p. 78). In the task of documenting the impact and the penetration of medicalization in the growing welfare state, historians have often oversimplified the complex historical relationship that this biomedical perspective has had with liberalism and juridical concepts of the free individual. There is no doubting that governmental preoccupation with national health encouraged a rearticulation of the notion of the citizen into an organic being conceptually inseparable from his or her family, neighborhood, or society in general. The growth of local and national medical inspectorates and the hygienic regulation of housing, water, and air permitted abridgments of individual rights and property in the name of a higher social good. This had always been true in plague time, but such measures were regularized in Europe throughout the last half of the nineteenth century. In France, at the moment of Republicanism’s triumph, medically staffed hygiene commissions were empowered to remove contagious individuals, quarantine families, and destroy infected property. In the language of one directive, Commission delegates must be concerned, above all “with the illness in general, [and] the preservation of the neighbors by all the means that hygiene and experience provide . . .” [quoted in Aisenberg (1999, p. 168)]. As Richard Evans has chronicled, liberal Hamburg resisted such regulations in the name of liberty and was visited by the worst cholera epidemic in many decades in 1892 (Evans, 1987). The displacement of individual rights by collective obligations occurred perhaps most dramatically in the domain of penology. The transformation of the criminal justice system, and the prison in particular, from making assessments of guilt or innocence, to making medical judgments of dangerousness or curability has been generally supported by recent scholarship, with the caveat that Michel Foucault’s own timetable for these developments anticipated their actual implementation by 75 years or more. Stephen Watson, David Garland, and Joe Sim in Britain; Laurent Mucchielli, Jacques-Guy Petit, and many others in France; and Dirk Blasius in Germany have engaged the Foucauldian model in recent years with varying degrees of support and criticism (Blasius, 1989; Garland, 1985; Lenoir, 1996; Mucchielli, 1994; Sim, 1990; Watson, 1994). Most agree that the principle of the individualization of punishment, designed in the 1880s and 1890s to fit each criminal’s particular depravity, has been generally implemented in sentencing procedures, prison regimes, and parole criteria throughout the West. In our own time in the United States, a wholly medicopsychiatric evaluation of sex criminals virtually sets aside any consideration of civil rights or expiatory punishment in the name of community security.Demands for expanding health care rely on high expectations about what it ought to be able to accomplish and to prevent, furthering the medicalization of deviance. We are going to get more and more diseases, since our expectations of health care are going to become more expansive.Fox 77 (Renee C. Fox, PhD, “The Medicalization and Demedicalization of American Society,” Daedalus, Vol. 106, No. 1, Doing Better and Feeling Worse: Health in the UnitedStates (Winter, 1977), p. 10-12, The MIT Press)One indication of the scope that the "health-illness-medicine complex" has acquired in American society is the diffuse definition of health that has increasingly come to be advocated: "a state of complete physical, mental, and social well-being," to borrow the World Health Organization's phrase. This conception of health extends beyond biological and psychological phenomena relevant to the functioning, equilibrium, and fulfillment of individuals, to include social and cultural conditions of communal as well as personal import. Such an inclusive perspective on health is reflected in the range of difficulties that persons now bring to physicians for their consideration and help. As Leon Kass picturesquely phrased it: All kinds of problems now roll to the doctor's door, from sagging anatomies to suicides, from unwanted childlessness to unwanted pregnancy, from marital difficulties to learning difficulties, from genetic counseling to drug addiction, from laziness to crime. . . .3 A new term has even been coined by medical practitioners to refer to those clients who seem to have some legitimate need of their therapeutic services, but who technically cannot be considered to be ill. With discernible ambivalence, such persons are often called "the worried well." Accompanying the increasingly comprehensive idea of what constitutes health and what is appropriate for medical professionals to deal with is the growing conviction that health and health care are rights rather than privileges, signs of grace, or lucky, chance happenings. In turn, these developments are connected with higher expectations on the part of the public about what medicine ideally ought to be able to accomplish and to prevent. To some extent, for example, the rise in the number of malpractice suits in the United States seems not only to be a reaction to the errors and abuses that physicians can commit, but also a reflection of the degree to which the profession is being held personally responsible for the scientific and technical uncertainties and limitations of their discipline. The vision of an iatrogenesis-free furthering of health, which social critics such as Illich hold forth, is also an indicator of such rising expectations. One significant form that the process of medicalization has taken is the increase in the numbers and kinds of attitudes and behaviors that have come to be defined as illnesses and treatment of which is regarded as belonging within the jurisdiction of medicine and its practitioners. In an earlier, more religiously oriented era of a modern Western society like our own, some of these same kinds of attitudes and behaviors were considered sinful rather than sick, and they fell under the aegis of religious authorities for a different kind of diagnosis, treatment, and control. In a more secular, but less scientifically and medically oriented, stage of the society than the current one, certain of these ways of thinking, feeling, and behaving were viewed and dealt with as criminal. Although sin, crime, and sickness are riot related in a simple, invariant way, there has been a general tendency in the society to move from sin to crime to sickness in categorizing a number of aberrant or deviant states to the degree that the concept of the "medicalization of deviance" has taken root in social-science writings. The sin-to crime-to-sickness evolution has been most apparent with respect to the conditions that are now considered to be mental illnesses, or associated with serious psychological and/or social disturbances.4 These include, for example, states of hallucination and delusion that once would have been interpreted as signs of possession by the Devil, certain forms of physical violence, such as the type of child abuse that results in what is termed the "battered child syndrome," the set of behaviors in children which are alternatively called hyperactivity, hyperkinesis, or minimal brain dysfunction, and so-called addictive disorders, such as alcoholism, drug addiction, compulsive over eating, and compulsive gambling. This "continuing process of divestment"5 away from sin and crime as categories for abnormality, dysfunction, and deviance and toward illness as the explanatory concept has entailed what Peter Sedgwick calls "the progressive annexation of not illness into illness." "The future belongs to illness," he proclaims, predicting that "we ... are going to get more and more diseases, since our expectations of health are going to become more expansive and sophisticated."6 If we include into what is considered to be sickness or, at least, non-health in the United States, disorders manifested by subjective symptoms which are not brought to the medical profession for diagnosis and treatment, but which do not differ significantly from those that are, then almost everyone in the society can be regarded as in some way "sick." At least two . . . studies have noted that as much as 90 percent of their apparently healthy sample had some physical aberration or clinical disorder. ... It seems that the more intensive the investigation, the higher the prevalence of clinically serious but previously undiagnosed and untreated disorders. Such data as these give an unexpected statistical picture of illness. Instead of it being a relatively infrequent or abnormal phenomenon, the empirical reality may be that illness, defined as the presence of clinically serious symptoms, is the statistical norm.1 Such a global conception of illness acutely raises the question of the extent to which illness is an objective reality, a subjective state, or a societal construct that exists chiefly in the minds of its social "beholders," a question that will be considered in greater detail below. The great "power" that the American medical profession, particularly the physician, is assumed to possess and jealously and effectively to guard is another component of the society's medicalization. In the many allusions to this medical "power" that are currently made, the organized "autonomy" and "dominance" of the profession are frequently cited, and, in some of the more critical statements about the physician, these attributes are described as constituting a virtual "monopoly" or "expropriation" of health and illness. The "mystique" that surrounds the medical profession is part of what is felt to be its power: a mystique that is not only spontaneously conferred on its practitioners by the public but, as some observers contend, is also cultivated by physicians themselves through their claim that they command knowledge and skills that are too esoteric to be freely and fully shared with lay persons. However, it is to the biotechnological capacities of modern medicine that its greatest power is usually attributed: both its huge battery of established drugs and procedures and its new and continually increasing medical and surgical techniques. Among the actual or incipient developments that are most frequently mentioned are the implantation of cadaveric, live, or mechanical organs, genetic and other micro cellular forms of "engineering," and in vitro fertilization, as well as various chemical, surgical, and psychophysiological methods of thought and behavior control. The potentials of medicine not only to prevent and to heal, but also to subjugate, modify, and harm are implicated in such references. The current focus on expanding health creates a never ending cycle of lack of access to health care and increased vulnerability by reducing states of unhealthiness to individual choices and responsibilitiesLantz et al., 2007 (Paula M. Lantz, Associate Dean for Academic Affairs and a professor of public policy at the Ford School with a masters in Epidemiology and PhD in Social Demography, Richard L. Lichtenstein, Professor of Health Management and Policy with a M.P.H. and Ph.D. from the University of Michigan in medical care organization and a B.S. from Cornell University in industrial and labor relations, Harold A. Pollack, Professor at The University of Chicago School of Social Service Administration, “Health Policy Approaches To Population Health: The Limits Of Medicalization”, Health Affairs, ) PMA century ago, policy interventions addressing health vulnerability often reflected a broad view of the causes of vulnerability and the conditions that needed to be addressed through public action. The specific etiology of most illnesses and diseases was poorly understood. However, given the large and obvious statistical association between poverty and illness, health status vulnerability was readily seen as a consequence of socioeconomic vulnerability.3 As a result, public health activities in the late nineteenth and early twentieth centuries focused on “upstream” causes of poor health, including poor sanitation, overcrowded and squalid housing conditions, work-related hazards, food security, and nutrition.4 Interventions in these realms are believed responsible for sharp mortality declines across age groups in the United States.5 Concurrent with these public health improvements, a sea change was under way in biomedical science, with an increasing focus on individual causes and manifestations of illness and disease. This increasingly individualized perspective fostered a tendency to medicalize health and illness.6 Irving Zola defines medicalization as the expansion of medicine as an institution and the use of a medical lens to view human processes and behavior.7 A medicalized perspective tends to define health problems as the result of individual failures of biology, hygiene, and behavior, with the implicit or explicit belief that the primary strategy for addressing these problems is through biomedical treatments delivered to individuals by physicians and other providers.8 Multiple economic, social, and political factors fueled the growth and dominance of individualistic, medicalized perspectives regarding public health, although a detailed analysis of this topic is outside of the scope of this essay.9 Michael Katz argues that individualized accounts of illness and vulnerability strongly resonated with Americans’ historic ambivalence toward disadvantaged individuals and groups, with accompanying moral and ideological distinctions between citizens deemed worthy and unworthy of assistance.10 As health status and health vulnerability became more medicalized throughout the twentieth century, discourse and decisions regarding policy priorities changed as well. Given an increasingly medicalized view of health vulnerability, public policy became focused on expanding access to individualized medical care.11 The federal government was providing personal health services to certain populations (such as merchant seamen and Native Americans) before 1900. However, as the problems of vulnerable populations became more medicalized, policies and initiatives focusing on health care access proliferated across populations and across a range of pertinent medical services. Given this policy emphasis on medical care, a piecemeal, categorical, and separatist approach to providing health care services to vulnerable populations emerged. Throughout the twentieth century, the making and buying of health care services through government policy created facilities, systems, providers, financing arrangements, and bureaucracies that exist outside the mainstream health care delivery system and operate specifically for vulnerable populations. Examples abound, including community and migrant health centers, Title X family planning clinics, local public health clinics, Medicaid managed care, Medicaid expansions for pregnant women, the National Breast and Cervical Cancer Early Detection Program, and the State Children’s Health Insurance Program (SCHIP).Reducing questions of health status to questions concerning access to health care erases the way in which socioeconomic conditions create health vulnerability in the first placeLantz et al., 2007 (Paula M. Lantz, Associate Dean for Academic Affairs and a professor of public policy at the Ford School with a masters in Epidemiology and PhD in Social Demography, Richard L. Lichtenstein, Professor of Health Management and Policy with a M.P.H. and Ph.D. from the University of Michigan in medical care organization and a B.S. from Cornell University in industrial and labor relations, Harold A. Pollack, Professor at The University of Chicago School of Social Service Administration, “Health Policy Approaches To Population Health: The Limits Of Medicalization”, Health Affairs, ) PMMaterial deprivation, social marginalization, and psychosocial stressors get “under the skin” in many ways that provide a biological basis for health vulnerability.1 As argued by Alice Furumoto-Dawson and colleagues, negative conditions in early life are especially critical, for these exposures can interact with developmental gene expression and, in turn, can influence adult health through multiple mechanisms and pathways, including hor- monal, neurological, and immune system dysfunction.2 Their paper calls for community- based policy responses that will improve neighborhood social environments for children and that will reduce marginalization, discrimination, and other forms of psycho- social stress over the life course. Such arguments reinforce a critical yet of- ten neglected lesson for health policymakers: For policy responses to health vulnerability and population health disparities to be effective, they must extend beyond the provision of medical care. In this essay we offer the perspective that U.S. health policy has become too focused on medical care as the primary policy lever. Along with an increasingly medicalized view of population health and health vulnerability has come a policy focus on the narrow is- sue of improving access to personal health ser- vices. The overarching goal of improving health status has become displaced by the more immediate goal of increasing access to health care services. As a result, we have a fragmented and beleaguered health care safety net, and insufficient policy attention is being paid to socioeconomic conditions that give rise to health vulnerability in the first place.Health insurance schemes coopt payment and taxation into direct medical services which trade off with community approaches to health status improvementLantz 07 (Health Affairs, Ph.D. Associate Dean for Research and Policy Engagement. Professor of Public Policy. Professor of Health Management and Policy. “Health Policy Approaches To Population Health: The Limits Of Medicalization.”)Current public policy responses to health vulnerability focus primarily (although not exclusively) on the procurement of medical care services, with a reduction in access barriers proffered as the central benchmark for success. Although policies that address financial and geographic barriers to health care bring important services to populations in need, many such policies establish and reinforce a two-tier “safety-net” system in which vulnerable populations primarily go to separate institutions or providers for their health care. These separate programs are viewed as necessary as a result of the dominant system’s failure to provide adequate access for those who are marginalized and vulnerable. These programs, however, are not well funded, and the services provided are neither adequately paid for nor completely covered. This leaves safety-net providers and programs plagued by financial pressures and often unable to deliver high-quality medical care to the populations they serve. A second, less noticed consequence of medicalized perspectives is a conflation between health status disparities and health care disparities. Medicalization encourages the view that one can solve socioeconomic and racial/ethnic health status disparities through initiatives and policies that reduce disparities in health care access, use, and quality. This conflation, for example, can be seen in some aspects of the Health Disparities Research Plan of the National Institutes of Health (NIH) and also in the National Action Agenda of the Department of Health and Human Services (HHS) Office of Minority Health. In turn, when health vulnerability and disparities are medicalized, health care access becomes overvalued and overemphasized as the most promising policy path. It is also an easier path, politically, than are fundamental social and economic reforms. The result is our current situation, in which an estimated 95 percent of U.S. health services spending goes toward direct medical services, and only 5 percent is invested in population or community approaches for prevention and health status improvement. Medicalized framing of health vulnerability can be an effective strategy to defend policy benefits/transfers to the disadvantaged by sidestepping social and political debates over the deservingness or worthiness of vulnerable populations. The Supplemental Security Income and Social Security Disability Insurance programs are examples of how a medicalized approach to complex social problems can bring valuable income support and other benefits to people living with disabilities. Similarly, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides housing and social services that extend beyond the domain of medical care to people living with HIV and AIDS. In addition, Medicaid provides a funding umbrella under which many states finance expanded services and social supports that extend beyond medical treatment and care. Nonetheless, these types of social services and interventions tend to become available only after a person is diagnosed as sick or disabled, and they focus on individuals and families rather than on the social and economic conditions of communities that are the fundamental drivers of poor health over the life course.National health insurance is not just an economic or medical issue—it is also an ethical and social issueFox 77 (Renee C. Fox, PhD, “The Medicalization and Demedicalization of American Society,” Daedalus, Vol. 106, No. 1, Doing Better and Feeling Worse: Health in the UnitedStates (Winter, 1977), p. 12-13, The MIT Press)The high and rapidly growing cost of medical and health care is still another measure of increased medicalization. In 1975, Americans spent $547 per person for health care and related activities such as medical education and research. This represented 8.3 per cent of the GNP. In 1950, 4.6 per cent and in 1970, 7.2 per cent of the GNP was spent. From 1963 to the present, health expenditures have risen at a rate exceeding 10 per cent annually while the rest of the economy as reflected in the GNP has been growing at a rate between 6 and 7 per cent. In addition to allocating an ever increasing proportion of society's economic resources for health care, greater amounts of political and legal energy are also being invested in health, illness, and medical concerns. The pros and cons of national health insurance, which continue to be vigorously debated in various arenas, are as much political, ideological, and legal issues, as they are economic ones. The volume of legislation relevant to health care has grown impressively. In 1974, for example, more than 1,300 health-care bills were introduced in the Congress, and more than 900 such bills in the state legislature in New York alone. The health subcommittees of the Senate and the House of Representatives are particularly active, and they have become prestigious as well. Furthermore, partly as a consequence of various congressional investigations and hearings, the federal government is now significantly involved in bioethical questions (especially those bearing on human experimentation) in addition to their more traditional interests in medical economic and health-care delivery problems. During the past few years, a number of medico-legal decisions have been made that are of far-reaching cultural importance, affecting the society's fundamental conceptions of life, death, the body, individuality, and humanity. These include: the Supreme Court's decisions in favor of the legal right of women to decide upon and undergo abortion; the Court's ruling against the involuntary, purely custodial confinement of untreated, mentally ill persons; the Uniform Anatomical Gift Act, adopted in fifty-one jurisdictions, which permits persons to donate all or parts of their bodies to be used for medical purposes after their death; death statutes passed in various states which add the new, "irreversible coma" criterion of "brain death" to the traditional criteria for pronouncing death, based on the cessation of respiratory and cardiac function; and, in the case of Karen Ann Quinlan, the New Jersey Supreme Court's extension of "the individual's right of privacy" to encompass a patient's decision to decline or terminate life-saving treatment, under certain circumstances. One other, quite different, way in which medical phenomena have acquired central importance in the legal system is through the dramatic escalation of malpractice suits against physicians. An estimated 20,000 or more malpractice claims are brought against doctors each year, and the number seems to be rising steadily. In New York, for example, the number of suits filed against physicians rose from 564 in 1970 to 1,200 in 1974; in the past decade, the average award for a malpractice claim grew from $6,000 to $23,400, with far more very large awards being made than in the past.8 Increasing preoccupation with bioethical issues seems also to be a concomitant of the medicalization process. Basic societal questions concerning values, beliefs, and meaning are being debated principally in terms of the dilemmas and dangers associated with biomedical advances. Consideration of particular medical developments such as genetic engineering, life-support systems, birth technology, organ implants, and population and behavior control have opened up far-reaching ethical and existential concerns. Problems of life, death, chance, "necessity," scarcity, equity, individuality, community, the "gift relationship," and the "heroic" world view are being widely discussed in medical, scientific, political, legal, journalistic, philosophical, and religious circles. A bioethics "subculture" with certain characteristics of a social movement has crystallized around such issues. The unprecedented number of young people who are attempting to embark on medical careers is also contributing to the medicalization process. In this country, on the average, more than three persons apply for each medical-school place available to entering first-year students, and there is as yet no sign of a leveling off. Paradoxically, this is happening during a period when medicine and the medical profession are being subjected to increased scrutiny and criticism.Market based systems have recommodified (i.e. over medicalized) the welfare state which hampers access to healthcare for low income groups.Farrants et al 16 (Kristin, PhD health studies @Durham University, Clare Bambra, Professor of public health @new castle university, Lotta Nylen, PhD Public health sciences @Karolinska Institutet, PhD in Statistical Bioinformatics @Hasselt University, Lectures for master of public health programme and PhD course on social determinants of health, David Hunter, allergist-immunologist practicing for more than 20 years received his degree from Arizona State University, “ The recommodification of healthcare? A case study of user charges and inequalities in access to healthcare in Sweden 1980-2005”, Health Policy, November 7, )Access to healthcare is a well-recognised social determinant of health [1], and inequalities in access to healthcare exacerbate problems caused by wider social inequalities [2]. Access to healthcare affects inequalities in avoidable mortality, which is defined as the number of deaths that could be avoided through the timely application of medical care. There are significant socio-economic inequalities in avoidable mortality across Europe [3]. Healthcare usage is lower in lower socio-economic groups, even though their health needs are higher [4]. European healthcare systems have been substantially reformed during the past few decades. The reforms largely served to increase the market’s role in healthcare provision, and have included changes to system financing (away from general taxation and social insurance), the introduction of direct purchasing arrangements (an increase in co-payments and user charges), and changes in the organisation of service provision (privatisation, outsourcing and marketization of services) [5]. It can be argued that such reforms have recommodified healthcare—making access more dependent on an individual’s ability to pay, and thus largely on his or her labour market position. Many have speculated on the impact of such changes, but little research has been carried out into how recommodification has affected inequalities in access to healthcare [5]. The research that has been carried out has not employed a theoretical framework of recommodification. This paper presents a case study of reforms in the Swedish healthcare system and examines longitudinally the association between increases in user charges and inequalities in healthcare access between 1980 and 2005. It also examines whether recommodification has taken place.Over the last 25 years, the healthcare systems of most European countries have experienced extensive – and commonly market-based – organisational and financial reforms. These changes have been remarkably similar between different countries and under successive governments, regardless oftheir political affiliation. The emphasis has unswervingly been on promoting choice, competition and the role of markets in healthcare. The stated aims have been improving quality, stimulating innovation and promoting equity. Critics of the reforms have consistently questioned whether these aims have been achieved, contesting the evidence base for them and arguing that the reforms increase inequalities in access and reduce quality [5]. This has affected healthcare systems of different types, including national health systems (as in Sweden and the UK) and social insurance ones (as in Germany and France) [6]. Sweden has strong local government with tax-raising capabilities [7]. The 20 county councils own and run both hospitals and primary care clinics, although some county councils have sold their primary care clinics to the private sector [7,8]. User charges were set centrally until 1991, when the decision was devolved to the local level. At the same time, choice reforms were implemented by many county councils [9,10]. Between 1970 and 1998, user charges in healthcare increased faster than the consumer price index [11]. The average user charge for a visit to the primary care system is roughly 200 SEK and the charge for outpatient specialist care is roughly 350 SEK [12]. These reforms can be seen as part of a process of recommodifying the welfare state. The expansion of the welfare state and the incorporation of social rights into the model of citizenship that occurred during the post-war period resulted in a significant decommodification of health [13]. “Decommodification” refers to the extent to which individuals and families are able to maintain an acceptable standard of living, regardless of their market position [14]. Welfare states decommodify by providing both cash transfers and public services. Although transfers have received the most attention, Bambra [15] applied the concept to healthcare and constructed a healthcare decommodification index based on the proportion of private funding, the proportion of private provision of healthcare, and the rates of public coverage. “Healthcare decommodification”, therefore, refers to the degree of market involvement in healthcare. In more decommodified healthcare systems (largely national health systems), the role of markets is minimised and access to services is usually a right of citizenship. Markets are not simply another method of service delivery: for a market to work, there must be a commodity [16]. The establishment of market mechanisms in healthcare thus commodifies healthcare – or in a historical sense, recommodifies it [16]. The healthcare reforms in Europe since the 1980s must be understood within a wider context of the recommodification of labour and the retrenchment of social citizenship, and as part of a wider neoliberal project to rebalance the relationship between labour and capital [17]. 1.2. Case study: user charges in Sweden User charges are one example of the commodifying character of recent healthcare reforms and one with particular implications for equity in healthcare. The use of user charges to make up the shortfall in tax financing can be considered to be an extra tax on the ill [18]. Furthermore, vulnerable groups such as people on low incomes, single parents, unemployed people, and social assistance recipients are more likely to be price-sensitive than other groups, thus exacerbating socio-economic inequalities in healthcare access and consequently in health outcomes amenable to healthcare [11,19]. There is evidence from both the US and European countries (France, Italy and Germany) that user charges have a greater impact on healthcare in low income groups [20,21]. A recent review [5] found that market-style reforms, and especially reforms to payment methods (increaseduse of out-of-pocket payments and private health insurance) in healthcare reduce equity, while evidence regarding the marketization of service provision is less conclusive. User charges mainly act to control consumption, and contribute a very little to financing the healthcare system in Sweden [11]. A limit to the charges that any single user pays in any one calendar year has been implemented to avoid placing an undue burden on the chronically ill: once a person has reached the limit, any further healthcare during that year is free [21]. The Swedish healthcare system had a pro-poor bias during the 1980s, and people on low incomes were more likely to visit the doctor. By the 1990s, however, there was no difference in consumption rates by income [19,22]. Similarly, in 1988/89 there were no significant differences in reported unmet care needs, while by 1996/97 the people in the lower-income quintiles had higher odds of reporting having care needs for which they had not sought help [22]. Economic reasons are cited by almost 20% of those who have refrained from seeking needed care [23]. More people in disadvantaged areas than in prosperous ones report that they have not sought needed care for economic reasons [19]. Since charges are frequently advanced as justification for not seeking medical care, such charges may be a major cause of inequality in healthcare access. This hypothesis led us to investigate the link between charges and determining access to healthcare. In particular, we have investigated whether user charges in the Swedish healthcare system are associated with inequalities in seeking care by educational level, and if so, to what extent. We have compared educational inequalities in access to healthcare before and after the 1991 increase in user charges, and tracked the developments in inequalities and charges until 2005. This paper uses the Swedish experience as a case study, and (1) examines the association between user charges for healthcare consultations and educational inequalities in access to healthcare, both for the general population and for those with the highest health needs, and (2) frames this discussion within a discussion of the process of the recommodification of healthcare. We argue that user charges are a recommodification of healthcare, and, as such, are linked to increased educational inequalities in healthcare access. This is because such charges have the greatest effect for people of lower socio-economic status, who have less resources [19,22].National Health insurance perpetuates the Victorian notion of prudentialism, which situates the individual as the site of risk management and ensures the social exclusion offered by professionalized medical discoursesKemshall 2002 [Hazel Kemshall, Effective Practice in Probation: An Example of ‘Advanced Liberal’ Responsibilisation?, The Howard Journal Vol 41 No 1. ISSN 0265–5527, pp. 41–58] Hazel Kemshall is a Professor of Community and Criminal Justice at De Montfort University in Leicester.As Rose puts it, such prudentialism requires the citizen to adopt a calculating attitude towards all of his or her decisions, whether this be the traditional risks of the labour market, decisions over health, or the installation of burglar alarms. Giddens (1991) and Reddy (1996) have argued that such a calculative attitude is a central feature of the individual’s experience in late modernity in which a reflexive and self-monitoring approach to life is constantly required. Thus the individual becomes the primary site of risk management, not society, and the ‘good’ citizen is the responsible, prudential one. Prudence is not a new concept. The Victorian age stressed prudential behaviour along with its distinction between the ‘deserving’ and ‘undeserving poor’. However, what is new in the contemporary use of prudentialism is the ‘construction of active citizenship in an active society’ and that this underpins contemporary governmental forms regardless of political spectrum or political ideology (Rose 1996, p. 60). The no-fault victim of social welfare engineering has been replaced by the concept of a moralised and entrepreneurial citizen (O’Malley 1996). Citizens who fail to show the necessary ‘moral fibre’ and entrepreneurship are classed as in need of ‘ethical reconstruction’ (Rose 2000) or what he calls the social policy of ‘ethopolitics’ (Rose 1999). For Rose this reconstitutes the criminal as a misguided subject for whom his or her moral compass and self-steering ethical mechanisms have failed. This ethopolitics is exemplified in the increasing use of criminal justice policy to regulate conduct, through the techniques of risk management, identification of those intransigent and therefore deserving of segregation and exclusion, and those who can be re-moralised through effective programmes stressing ‘straight thinking’, rational choices, and self-management: New political rationalities, including those of crime control, came to be articulated in terms of this distinction between a majority who can and do ensure their own wellbeing and security through their own active self-promotion and responsibility for themselves and their families, and those who are outside the nexus of activity: the underclass, the marginalized, the truly disadvantaged, the criminals. These excluded sub-populations have either refused the bonds of civility and self-responsibility, or they are unable to assume them for constitutional reasons, or they aspire to them but have not been given the skills, capacities and means. (Rose 2000, p. 331) Whilst O’Malley (2000) reminds us that the concept of risk is not new either to the government of crime or the regulation of conduct, his distinction between the social actuarialism of the welfare state and the individualised risk ‘entrepreneurship’ of late modern society is a useful one. The social problems of the welfare state were seen as amenable to the calculations and resolutions offered by positivist human science, and the ‘psy’ disciplines in particular offered the promise of progress and the elimination of social ills (Leonard 1997). Social actuarialism was extended to all facets of social life, epitomised by national health insurance and the collective protection against risks offered by the welfare state (Rowe 1977; Simon 1987). Professional expertise, particularly that located in the ‘psy’ sciences, extended the disciplinary net of the welfare state to all citizens deemed in need of correction, or normalisation (Garland 1985).The medical endeavor gives decreasing results with increases in technical means, but society invests because of certain non-technical effectiveness of the establishmentIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] Now I look at the medical endeavour, which is really an engineering endeavour, in order to intervene for individuals who are sick, who might become sick, or in supposedly disease-making aspects of their environment, in order to improve health. Three years ago, I never thought that I would dare to say those things, for me clear simple observations, which now have become evidence. I say that medical endeavour gives decreasing results with increasing manpower, prestige and money invested in technical means, seeking technical effects. And notwithstanding, society is willing to throw ever more resources into this endeavour. The simplest explanation is that society does not finance medicine primarily because it seeks measurable, verifiable, specific technical results from technical investments but because of certain nontechnical results, certain non-technical effectiveness of the medical establishment. For instance, if some people consider it a privilege to have a certain kind of complex operation in a certain kind of society, one would consider that that society is bad as long as everybody in that society does not have access under similar conditions to the same very complex and expensive investment. Medical investments will be made in order to foster social equality. This is a positive external of medical investment: it is not directly related in any way to health. Some of these externals created by medicine clearly have the characteristics of burdens. Medical investment becomes increasingly more expensive. It imposes increasingly more problems on the city planner, on the transportation engineer, on the teaching establishment in a society, but these are still externals, though negative ones.When people live in a society where the medicine is the best financed, the external environment undergoes a symbolic transformation where medical rituals are fundamentally myth-making behaviors Illich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] The medicalization of resources for care of the sick sets in when most of the ordinary devices which our grandparents had at their disposal - useful or not (I am not discussing this aspect) but still used by doctors and very overwhelmingly used - are available only on prescription. But hand in hand with this social transformation of the external environment goes a symbolic transformation, when people live in a society in which the medical establishment is the best financed. You do not live in such a society, I should say, in the United Kingdom. For this reason, Britain at this moment makes the discussion of this issue everywhere in the world so difficult, because people say - in the United States, in Mexico, in India - 'Oh, if we could only reach British levels where for 4.3 per cent of our gross national product we have such marvellous coverage, when in the United States it is already 8.5 per cent of gross national product for much less marvellous coverage.' But I believe these to be marginal issues when in a society medicine becomes one of the structuring major influences on everyday life. In the United States, the health conglomerate - the combine of doctors, hospitals and pharmaceutical industries and their lackey institutions - is the most important economic sector immediately after the American war industry. Medicine overtook education some five or six years ago. The fact that it has not reached that proportion in Britain does not change the basic facts. When medicine becomes so important, people are from birth to death involved in medical rituals and the rituals - trivial behaviour which one does not consider really important - have one purpose, such as one social purpose: that of generating myths, like those concerning the management of pain, 'pain-killing'. Certainly, to some degree medicine can do that from the outside. But when the management of pain becomes such a prevailing myth that individuals cease to cultivate the culturally given, that is, the art of 'interpreting' pain, the performance by which the pain sensation is transformed into the real life situation, then pain management can very easily increase the level of unmanageable pain in society rather than decrease it. When in a society people begin to believe that all disease ought to be eliminated, they become increasingly less capable of dealing with disease on their own and the threshold for management of autonomous disease decreases. When in a society the doctor is represented as he who steps between the skeleton, death, and the patient (the very first picture of this kind I found dates from I919 and I have collected some I 700 pictures over 700 years representing death personalized and the doctor), when the doctor is conceived as he who will save me from death, the anguish of death, the preparation for this anguish all through life, becomes unmanageable. This is I call symbolic iatrogenesis.Access (Neoliberalism)Aff’s technocratic expansion of healthcare markets favors technique over genuine politics, assuming rational cost-benefit calculus on the part of the industry’s institutions as well as individualsSpence 13 (Lester K., Associate Professor of Political Science and Africana Studies at Johns Hopkins University; “The Neoliberal Turn in Black Politics”, Souls: A Critical Journal of Black Politics, Culture, and Society, 14:3-4, 139-159, Published online: 13 Mar 2013)Under neoliberal governmentality market principles become the primarily vehicle of problem solving (critiquing, creating solutions for, managing) the conduct of populations, of institutions, and of spaces. Various techniques are used to get individuals, populations, institutions, and spaces to act entrepreneurial and in accordance with market principles. A range of institutions and spaces from non-profit foundations to cities to nation-states are also increasingly expected to treat themselves as for-profit corporations and to work more ‘‘efficiently’’—I focus more on schools below, but increasingly school districts adopt strategies of governance designed for for-profit corporations. Furthermore a range of institutions including but not limited to the state tries to modify conduct. Expertise plays a central role in the development and deployment of these technologies, because experts are best able to use ‘‘reason’’ and ‘‘truth’’ to determine the proper mode of long-distance governance. Statistics are important here, as are social science theories of behavior, and a variety of practices associated with therepy. These technologies are deployed to manage individuals, populations, institutions, and spaces (in the latter two cases consultants often fulfill the same role as therapists). Public health officials use statistical analysis and mapping ferret out the relationship between various aggregate level health indicators. Bond rating agencies use complex algorithms to assess the risk and potential return of urban investment and through this data govern cities. Officials use rational choice theories of behavior to get people to recognize and act on their (narrow) self-interest. Management experts devise techniques of accountability that can be used to manage non-profit and for-profit institutions alike. Because expertise itself requires a certain type of expertise to critique the general processes of neoliberalization become technical rather than political—the problems and their solutions are taken out of the realm of politics traditionally considered because they are viewed as being ‘‘truthful’’ and ‘‘objective’’ and ‘‘apolitical’’ hence not subject to political engagement. I use the term ‘‘technology’’ above to depict government as the consistent application of technical know-how to problems of conduct. And two forms loom large—technologies of subjectivity designed to work on and through those able to govern themselves, and technologies of subjection designed to work on and through those unable to govern themselves. Under neoliberal reform welfare uses much more direction, surveil- lance, and sanctioning, it increasingly uses market logic to assess individuals as well as service providers, it significantly disciplines the use of lower-level discretion, and finally is wed to carceral systems (Schram et al. 2010). The neoliberalization of unemployment transforms the unemployed from passive citizens with a right to ben- efits into active job-seeking agents obligated to engage in a number of practices designed to build his=her human capital to the point where he=she can find a job—this in exchange for a short-term allowance. In these instances individuals who consistently reveal themselves as being unable to work on themselves to the point they are no longer dependent face more intensive and bureaucratically brutal modes of surveillance and discipline. After Thatcher-era reforms, British uni- versities were redefined as corporate enterprises, and increasingly evaluated based on their ability to generate income (through research grants) and to ‘‘train’’ (as opposed to ‘‘educate’’) students by giving them marketable skills (Shore 2008). Political and institutional leaders increasingly think of themselves as entrepreneurs in part because the municipalities and institutions they manage require them to do so. And again expertise plays an important role here as expertise helps diagnose problems, identify tools, and provide (technical) solutions.Expertise, technical problem-solving, etc all depoliticize healthcare and prevent legitimate political resistance, instead responsibilizing the dilemma at handSpence 13 (Lester K., Associate Professor of Political Science and Africana Studies at Johns Hopkins University; “The Neoliberal Turn in Black Politics”, Souls: A Critical Journal of Black Politics, Culture, and Society, 14:3-4, 139-159, Published online: 13 Mar 2013)But again, even though we can use some of these approaches to examine how poor black men and women almost always tend to lose compared to their well-off counterparts, what such an approach misses is the role techniques and technology plays in identifying and distinguishing between populations, the way these techniques are adapted by individuals to problem-solve their own condition, and the very specific modes adopted during a neoliberal period under which everyone is expected to be entrepreneurs of themselves. We do not simply live in a period of class dominance. Focusing specifically on black communities, we do not simply live in a period of black elite dominance—a period in which a black President can garner applause by blaming (black) poverty on (black) fathers. We live in a period in which many of the central problems we face, problems that have political roots and political solutions, have been taken out of the realm of the political because blacks increasingly present these problems as technical problems that should be treated with very specific practices rather than as political problems that call for political organization and mobilization. How do we see this play out in these anecdotes? First note the role the market plays in each example, and the way market logic is connected to techniques used to solve crises that are structural (and political) in nature. The solution to the racial achieve- ment gap is to create a literal academic success market in schools that makes the children more entrepreneurial about their academic habits, based on economic theories on incentives. And although I focus on populations here, it’s impossible to understand this specific technique without also understanding the way this technique is also deployed on school systems and cities themselves. President Obama’s Race to the Top program, much like President Bush’s No Child Left Behind, and even President Bill Clinton’s Empowerment Zone pro- gram, incentivizes school districts (and in Clinton’s case, cities) in much the same manner, forcing school districts=cities to practice market-type competition over scarce resources. In the religious example we do not see market competition per se ?. Here the solution to the economic crisis is to better apply the lessons of the Bible to one’s daily practice, to get rid of the poverty mindset. Market competition is not created here, but market principles and biblical principles are implicitly connected. And this connection is driven home through Pastor Robinson’s ‘‘financial empowerment’’ work- shops, that come replete with ‘‘financial planning guide=workbooks’’ participants are expected to work their way through as part of the workshops. On the surface the HIV=AIDS example does not quite seem to fit here. But the health promotions campaign itself is based off of the traditional ad campaign model that seeks to get consumers to make purchases they might not make in other ways. In this way the HIV=AIDS issue is not treated as a structural issue, not for instance a matter of the lack of access to drug treatment, the lack of access to clean needles, the lack of universal health care, but rather is treated as an issue of people simply not making the proper choices about their own bodies. People become consumers, and consumption is tied to ‘‘healthy choices.’’ Race is not in the background in any of these instances. The racial achievement gap is one of the explicit drivers of both the No Child Left Behind and the Race to the Top policies. Furthermore a desire to reduce this and other racial gaps are what purportedly drives Roland Fryer’s research agenda as well as his desire to found EdLabs in the first place. The vast majority of Fryer’s research deals with race and with the impact of racial discrimination. Similarly, the various HIV=AIDS social media campaigns target African Americans (and increasingly Latinos) because the HIV=AIDS rates among black men and women are so incredibly high compared to other popula- tions. One might argue that this plays less of a role in the church instance. But in other sermons in the series Pastor Robinson is clear about the role race plays in life circumstances. In fact, one could argue that the reason the programs are deployed is in part because they exhibit an earnest effort to deal with the exigencies of racism. Race is not invisible here, race is not hidden, nor privatized. Rather it is intensely public. And again this racial knowledge is itself the pro- duct of statistical techniques of aggregation and measurement. Iris Marion Young argued persuasively that care is a powerful political resource. But what her analysis misses is the way ‘‘care’’ can be deployed in instances like the ones I trace to further reduce the ability of populations to organize on their own behalf in the (caring) attempt to render black problems solvable. I noted the role expertise plays. In each anecdote we see expertise deployed in such a way as to render the problem under consideration technical as opposed to political. This is most apparent in the edu- cation case—the solution to the racial achievement gap is not organiz- ing parents and teachers to rail against budget cuts. Rather it’s to properly incentivize students using techniques based on careful peer-reviewed social science research. A related type of expertise played a central role in the HIV=AIDS campaign—experts helped devise the media ads used, experts were used to helped generate the most productive testing regiment. Pastor Robinson uses biblical expertise, but he also uses expert-designed financial packets to teach his churchgoers the rudimentary aspects of financial literacy. Expert- ise works in these cases to render them apolitical and technical. And in two of the three cases it works in them to render them measur- able—Fryer and the HIV=AIDS experts possess an array of metrics they can use to examine whether the techniques themselves worked and who they worked on if they did work. Furthermore they used aggregate-level statistical data to determine the proper spatial con- text in which to use the techniques. This is particularly apparent in the health case—the ads are not only tailored to specific populations deemed to be ‘‘high risk.’’ They are tailored to very specific neighbor- hoods—the billboards in Baltimore for instance appear in some of the poorest black neighborhoods as well as almost all of the bus stops black Baltimoreans frequent, and this knowledge comes from combin- ing knowledge of HIV=AIDS rates with knowledge of the race and class demographics of Baltimore neighborhoods. To the extent logical questions can be raised here, these questions concern technique and even these questions require a certain level of experience and expertise to muster. Relatedly, these techniques are incredibly mobile, swiftly travelling across space and across issue area. Fryer was able to take the experi- ment he devised and apply it, with some modifications, to a range of cities. The HIV=AIDS health promotions campaign was not only eas- ily spread to a number of cities throughout the country, the technique itself can easily be modified to deal with other similar health issues. And the type of financial empowerment workshops connected to Pastor Robinson’s sermon—workshops themselves conducted by finan- cial experts—are not only conducted in churches. The Hip Hop Sum- mit Action Network used similar techniques in their hip-hop summits. Now one might ask, given my focus on technique, why does this matter? Should we not use expertise of some sort to solve the problems we face? One reason this matters is because neoliberalism relies on two sets of technologies—technologies of subjection and technologies of subjectivity. Here I focus largely on technologies of subjectivity—technologies applied to populations that have expressed or can potentially express the ability to be self-governing according to neoliberal dictates. The techniques above are designed by experts but they are designed in such a way as to get individuals to govern themselves, to ‘‘take control’’ of their own lives through technical modifications in their own behavior instead of through political organization. And it’s very important to note that these techniques work through the desires of the populations they are applied to. In the education instance kids want to do well—the research suggests no substantive differences between black and white desires to do well in school (Carter 2005)—and kids want to make money. In the religious instance, churchgoers want to succeed economically, parti- cularly when they cannot count on a social safety net—and they also want to ‘‘be right with God.’’ Finally in the public health example, people want to be healthy, but more than that they want to be attractive. However, there is a flipside. The techniques above make clear distinctions between populations. The successful kids are the ones able to properly manifest academic improvement. The healthy men and women are the ones able to maintain testing regimes, are the ones who always practice safe-sex, are the ones who always ask (and truthfully answer) questions about sex-al habits. Prayerful men and women are the ones who have success- fully wedded their biblical understanding to their lived (fiscal) practice. They are all, in effect, deemed to be winners. However, while technologies of subjectivity are used on (and by) the winners, gradually technologies of subjection are used on (and never by) the losers. And it becomes very difficult to contest the losers’ status politically. Using the HIV=AIDS example, ‘‘losers’’ are not willing to consistently test themselves, are not willing to disclose their status, and are not willing to engage in safe sex practices—who would fight for them? Given how deadly the disease still is, we view those unable or unwill- ing to continually test themselves, to continually practice safe sex, and to be open about their sexual history (and to expect such open- ness from their partners) as losers worthy of death, and this is a pro- duct of the techniques we use to manage and problem-solve this and other problems within black communities. One reason we should be incredibly skeptical about expertise then is because this specific form of governmentality (and arguably other forms as well) seem to always involve making decisions about which populations are worthy of life and which populations are worthy of death. And a range of austerity policies designed to reduce the amount of life-sustaining resources poor populations have access to depend on this approach—given the realities of white supremacy usually do not turn out well for black (and other non-white) populations. But another reason is that these techniques and the theories they are based severely simplify the rich ways black populations attempt to live their lives. They simplify the complications black men, women, and children have to overcome as their routine every day struggle, they simplify the various and sundry alternatives we might adopt in order to sustain our lives. Finally, while I have focused on populations, we can lash these examples up to similar modes used to discipline, manage, and pun- ish institutions and spaces. Philadelphia, Washington D.C., and Baltimore—all represented by black mayors by the way—are all dis- ciplined by bond rating agencies and by experts, who make life and death funding decisions based on their ability to govern themselves according to technologies of subjectivity. Finally, we can easily imagine a family governed by all three sets of techniques—an HIV?father who attends a prosperity gospel church along with his school-aged son not only attempts to use these techniques to make healthy choices (to develop a rigorous HIV testing regiment for example), but attends a local church using the pastor’s sermons to get his financial house in order, while his son competes with other kids for cash prizes. Caught in overlapping frameworks of govern- ance, this father and child can potentially understand their lives as being determined by political circumstances they are not respon- sible for. But it is far more likely they will fault themselves (and each other) for their condition. And as these modes of government play an increasing role in our lives, it is far more likely we will as well.Access (Race/Coloniality)Their move to include more populations in medical access is violent – contemporary medicine is colonial and anti-blackHunter 10 (Shona, Lecturer in Sociology and Social Policy Governance at the University of Leeds, and Research Associate at the Research Centre into Visual Identities in Architecture and Design at the University of Johannesburg. “What a White Shame: Race, Gender, and White Shame in the Relational Economy of Primary Health Care Organizations in England”, 25 October 2010, Social Politics, Volume 17, Issue 4, Winter 2010)In practical terms, medicine preserved the health of overseas troops and the expanding British colonial administration. Ideologically, it constituted a form of “medical government” (Bashford 2000). It instigated the very categorization of bodies into races used to justify slavery and imperialism (Bhopal 2001, 934, see also Gilman 1985) and was an integral part of the Christian “civilizing mission” in the colonies where the provision of medicine was used to break down opposition to colonial rule (Doyal and Pennell 1994, 249–55). This civilizing process worked two ways, civilizing the white self as much as the colonized Other because it was pivotal to producing whiteness as more than skin color. It was about “how one lived, how one arranged one's moment by moment existence in space and time: daily routine, exercise, diet, leisure and mental diversions” (Bashford 2000, 266). In other words, colonial medicine was crucial to enacting whiteness as a form of accumulating cultural capital whose power rests on the binary oppositions constructed between colonizer/colonized (Fanon 1986; Lopez 2005; McClintock 1995), being developed/being underdeveloped (Heron 2007), First World/Third World (McClintock 1995). It is because whiteness is accumulated as a form of material and symbolic capital that it is better to think in terms of whitened rather than white people. Through European colonial expansions, race and medical science were mutually reinforcing myths in the pursuit and expression of Empire and in the construction of whiteness as a “universal ideal and the peak of humanity”(Bonnett 2000, 42), the bearer of “Western civilization.”3 Moreover, whiteness is constructed through interlocking systems of race, class, gender, and sexuality. White women have historically supported and enabled the construction and reproduction of white masculinity through the classed and racialized “cult of domesticity.” Following McClintock (1995), this cult operated to merge domesticity and empire through distinction between the public/civic/political and private/home/natural, constructing this division as crucial to the white liberal middle-class male identity. Thus, white masculinity is defined by its enterprising nature constituted through, energy, dynamism, heroism, will-power, far-sightedness, and control of self and Other, including women and “natives.” White men are constructed as natural born leaders, with Imperialism giving this character its logical expression (Dyer 1997, 30–32); they have the right, indeed the duty to civilize. Medical expertise increasingly confirmed the salubrious benefits of European camaraderie.?…?White prestige became redefined by the conventions that would safeguard the moral, cultural, and physical well being of its agents, with which European women were charged. Colonial politics locked European men and women into routinized protection of their physical health and social space in ways that bound the racial cleavages between “us” and “them” (Stoler 2002). The colonial medic then, in his leadership role over the construction of colonial whiteness as well as blackness, was in many senses the epitome of this white masculine ideal. He embodied the dynamic and heroic spirit and practice of Empire. Whereas imperial pasts may appear to be clearly structured through relations of white dominance and minoritized subordination, contemporary postcolonial English welfare contexts are characterized by the more subtle differential inclusion of Black and Asian subjects into the nation. Gail Lewis (2000) uses this notion of differential inclusion to acknowledge the paradoxical, complex, and contested position of Black and Asian subjects who have struggled against racism in welfare provision and employment to create a place for themselves within the professional structures of service provision. Despite these gains, inclusion is predicated on terms which continue to construct these professionals as Other, the ones to be integrated or encompassed into Britishness or Englishness, the ones to be melded into “us” (Henry 2007; Raghuram 2007; Smith and Mackintosh 2007). From this perspective, multicultural claims to “value difference” and “work with diversity” constitute part of these relations of differential inclusion. Rather than presenting a straightforward challenge to the hierarchically ordered relations of racialized domination and subordination, these claims to liberal tolerance serve to reconfigure the boundaries of inclusion and exclusion through the creation of new categories of legitimate national and organizational belonging.Access (Sexopolitics)A renewed focus on expanding health care reinscribes sexopolitics – a tool of the pharmacopornographic regime that uses sex, sexuality, and sexual identity as the somato-political centers for producing and governing subjectivity.Preciado 13 (Paul Preciado, PhD, "The History of Technosexuality", Testo Junkie: Sex, Drugs, and Biopolitics in the Pharmacopornographic Era, p. 68-73, Feminist Press at the City University of New York)The discontinuity of history, body, power: Foucault describes the transformation of European society in the late eighteenth century from what he calls a “sovereign society” into a “disciplinary society,” which he sees as a shift away from a form of power that determines and ritualizes death toward a new form of power that technically plans life based on population, health, and the national interest. Biopouvoir (biopower) is his way of referring to this new form of productive, diffuse, sprawling power. Spilling beyond the boundaries of the legal realm and punitive sphere, it becomes a force of “somato-power” that penetrates and composes the body of the modern individual. This power no longer plays the role of a coercive law through a negative mandate but is more versatile and welcoming, taking on the form of “an art of governing life,” an overall political technology that is transformed into disciplinary architectures (prisons, barracks, schools, hospitals, etc.), scientific texts, statistical tables, demographic calculations, how-to manuals, usage guidelines, schedules for the regulation of reproduction, and public health projects. Foucault underlined the centrality of sex and of sexuality in this modern art of government. The biopower processes of the feminine body’s hysterization, children’s sexual pedagogy, the regulation of procreative conduct, and the psychiatrization of the pervert’s pleasures will be to Foucault the axes of this project that he characterized with some degree of irony as a process of sexual modernization.1 In keeping with the intuitions of Michel Foucault, Monique Wittig, and Judith Butler, I refer to one of the dominant forms of this biopolitical action, which emerged with disciplinary capitalism, as sexopolitics.2 Sex, its truth, its visibility, and its forms of externalization; sexuality and the normal and pathological forms of pleasure; and race, in its purity or degeneracy, are three powerful somatic fictions that have obsessed the Western world since the eighteenth century, eventually defining the scope of all contemporary theoretical, scientific, and political activity. These are somatic fictions, not because they lack material reality but because their existence depends on what Judith Butler calls the performative repetition of processes of political construction.3 Sex has become such a part of plans for power that the discourse on masculinity and femininity, as well as techniques of normalizing sexual identity, have turned into governmental agents of the control and standardization of life. Hetero- and homosexual identities were invented in 1868, inside a sphere of empiricism, taxonomic classification, and psychopathology. Likewise, Krafft-Ebing created an encyclopedia of normal and perverse sexualities where sexual identities became objects of knowledge, surveillance, and judicial repression.4 At the end of the nineteenth century, laws criminalizing sodomy spread throughout Europe. “Sexual difference” was codified visually as an anatomical truth. The fallopian tubes, Bartholin’s gland, and the clitoris were defined as anatomical entities. One of the elemental political differences of the West (being a man or a woman) could be summed up by a banal equation: whether one had or did not have at birth a penis that was a centimeter and a half long. The first experiments in artificial insemination were accomplished on animals. With the help of mechanical instruments, interventions were made in the domain of the production of female pleasure; whereas, on the one hand, masturbation was controlled and prohibited, on the other, the female orgasm was medicalized and perceived as a crisis of hysteria.5 Male orgasm was mechanized and domesticated through the lens of a budding pornographic codification . . . Machinery was on the way. The body, whether docile or rabid, was ready. We could call the “sexual empire” (if we can be allowed to sexualize Hardt and Negri’s rather chaste catchword)6 that biopolitical regime that uses sex, sexuality, and sexual identity as the somato-political centers for producing and governing subjectivity. Western disciplinary sexopolitics at the end of the nineteenth and during a good part of the twentieth century boils down to a regulation of the conditions of reproduction or to those biological processes that “concern the population.” For the sexopolitics of the nineteenth century, the heterosexual is the artifact that will rake in the most success for government. The straight mind, to borrow an expression developed by Monique Wittig in the 1980s to designate heterosexuality— taken not as a sexual practice but as a political regime7—guarantees the structural relationship between the production of sexual identity and the production of certain body parts (to the detriment of others) as reproductive organs. One important task of this disciplinary work will consist of excluding the anus from circuits of production and pleasure. In the words of Deleuze and Guattari, “The first organ to suffer privatization, removal from the social field, was the anus. It was the anus that offered itself as a model for privatization, at the same time that money came to express the flows’ new state of abstraction.”8 The anus as a center of production of pleasure (and, in this sense, closely related to the mouth or hand, which are also organs strongly controlled by the sexopolitical campaign against masturbation and homosexuality in the nineteenth century) has no gender. Neither male nor female, it creates a short circuit in the division of the sexes. As a center of primordial passivity and a perfect locale for the abject, positioned close to waste and shit, it serves as the universal black hole into which rush genders, sexes, identities, and capital. The West has designed a tube with two orifices: a mouth that emits public signs and an impenetrable anus around which it winds a male, heterosexual subjectivity, which acquires the status of a socially privileged body. Until the seventeenth century, the sexual epistemology of the sovereign regime was dominated by what the historian Thomas Laqueur calls “a system of similarities”; female sexual anatomy was set up as a weak, internalized, degenerate variation of the only sex that possessed an ontological existence, the male.9 The ovaries were considered to be internal testicles and the vagina to be an inverted penis that served as a receptacle for male sex organs. Abortion and infanticide, practices of the time, weren’t regulated by the legal apparatus of the state but by different economic-political micropowers to which pregnant bodies found themselves affixed (the tribe, the feudal house, the paterfamilias . . . ). Two hierarchically differentiated social and political expressions divide the surface of a “monosexual” model: “man,” the perfect model of the human, and “woman,” a reproductive receptacle. In the sovereign regime, masculinity is the only somatic fiction with political power. Masculinity (embodied within the figures of the king and the father) is defined by necropolitical techniques: the king and the father are those who have the right of giving death. Sex assignment depended not only on the external morphology of the organs but, above all, on reproductive capacity and social role. A bearded woman who was capable of pregnancy, of putting a child into the world and nursing it, was considered a woman, regardless of the shape and size of her vulva. Within such a somato-political configuration, sex and sexuality (note that the term sexuality itself wouldn’t be invented until 1880) do not yet amount to categories of knowledge or techniques of subjectivization that are likely to outdo the political segmentation that separates the slave from the free man, the citizen from the metic, or the lord from the serf. Differences between masculinity and femininity remain, as well as between several modes of the production of sexual pleasure, but these do not yet determine the crystallizations of sexopolitical subjectivity.Healthcare itself is caught up in the biopolitics of the regulation of sex drugs and sexPreciado 13 (Paul Preciado, PhD, "The Edible Panopticon", Testo Junkie: Sex, Drugs, and Biopolitics in the Pharmacopornographic Era, p. 173-181, Feminist Press at the City University of New York)During the period when the notion of gender, the H-bomb, silicone breast implants, electric prostheses, the computer, and Formica furnishings begin circulating in Western societies, a pioneering domestic, portable, and consumable nanotechnology of hormonal modification is produced. In 1951, a mistake made by Gregory Pincus at G. D. Searle and Company laboratories leads to the invention of the first contraceptive pill in the form of the molecule norethindrone, a synthetic variant of the active molecule progesterone that can be administered orally. The production of a portable and edible contraceptive pill enables the entrance of synthetic hormones (and therefore endocrinological and governmental birth control techniques) into the domestic space, which becomes a consumption/production knot within the pharmacological network. This is part of a larger biopolitical process of the medicalization and pharmacological regulation of domesticity that was already at work earlier in the twentieth century. At the farthest boundary of the same traffic, moving from the domestic to the colony, endocrinological programs for controlling natality and gender production were targeting the racialized body, circulating first within the slavery trade and later within urban segregated spaces, as well as the “disabled,” or the “sexually deviant.” As we will see, most clinical trials with sexual hormones are done in colonial settings, in psychiatric institutions (where homosexual, intersexual, and transsexual bodies, regarded as physical or mentally ill, are submitted to endocrinological and surgical procedures), and in penitentiaries and correctional institutions until hormones, produced and designed as consumption goods, end up being absorbed into the everyday American heterosexual domestic space. There is a Pill geography where bodies, fluids, molecules, and capital are produced and distributed. An examination of the economic and technical networks that resulted in the production of the Pill reveals that, while originating with Pincus’s project, the Pill was perfected by John Rock within the unexpected framework of experimental research on aiding procreation for sterile white Catholic families. Pincus’s and Rock’s research projects, although conflicting in relation to their vision of the function of white women in society, shared an understanding of nonwhite and deviant subjects as bodies whose reproductive power should be restricted by the state in order to “reduce hunger, poverty, and disease while fostering economic stability.” The antibaby molecule was intended to be made into a “simple, cheap, safe contraceptive to be used in poverty-stricken slums, jungles, and among the most ignorant people.” In the context of an emerging politicization of racial, ethnic, and sexual minorities in the United States, the contraceptive molecule was thought of as an urban eugenic device and as a method of controlling nonwhite population growth, as well as the population growth of nations that had not yet entered postwar liberal capitalist economies. Protocols of research and evaluation of the Pill’s technical effectiveness reveal its disciplinary and colonial roots. After the success of the preliminary Boston trials for the Pill in 1954 and 1955, John Rock and Gregory Pincus needed a large-scale human group to test the new molecule in order to receive approval from the US Food and Drug Administration, or FDA, to bring the drug to market. The first large clinical contraceptive pill trials were performed by Searle on several groups of female psychiatric patients at Worcester State Hospital and on male prison inmates in the state of Oregon in 1956–57. The tests were intended to measure the effectiveness of using synthetic oral hormones as a method of birth control in women, and also the effectiveness of these substances in controlling and decreasing “homosexual tendencies” in men. In fact, the relationship between hormonal research and the Worcester State Hospital was crucial for the development of the Pill. Founder and feminist activist Katherine McCormick had decided to invest in research on the Pill in order to fight the hereditary transmission of mental illness. Her husband was diagnosed with schizophrenia, and since at that time the illness was considered hereditary, she tried to locate a safe way of preventing pregnancy in people suffering from the condition who were potential parents. In 1944, the McCormicks helped Dr. Hudson Hoagland found the Worcester Foundation for Experimental Biology, dedicated to the study of the influence of hormones on mental conditions, and this transformed the Worcester Hospital into a major pharmacological laboratory. Constructed in 1833 following the Thomas S. Kirkbride plan, also known as the “building as cure” theory, according to which architecture itself was meant to have a therapeutic effect, the Worcester State Hospital in Massachusetts was one of the most prestigious institutions of its time, well known for having been visited by Freud in 1909 when he traveled to the United States. The Worcester State Hospital was the American version of the modern machine à guérir (cure machine), to use the expression coined by Jacques René Tenon in his Mémoires sur les h?pitaux de Paris (1788), which Michel Foucault used as the key document in his study of the emergence of a new set of techniques of “public hygiene” that came to spatialize the sick body within the modern city. As Foucault argued, after the end of the eighteenth century, the modern hospital and the prison became the paradigmatic architectures of a pervasive medicalization of social and political space. A visual and spatial machinery to produce knowledge about madness and reason, the Worcester Hospital combined prison architecture with large collective rooms and numerous workshops for experimental treatment, such as saunas and rotating chairs intended to cure patients. Whereas the architecture and the treatment were still derived from the nineteenth-century disciplinary biopolitical model for understanding madness and therapy, the hospital also introduced within its walls new “soft” and molecular techniques invented during the Cold War period. But mental and prison institutions were not ideal settings for testing the Pill. The Worcester and Oregon trials were not enough to obtain approval from the FDA to commercialize the Pill or to test the ability of ordinary women to take the Pill regularly outside medical institutions. Since strong anti–birth control laws in Massachusetts and in many other states made it impossible for Searle to conduct the large study of humans required by the FDA, it turned to Puerto Rico, which already had a long history of governmental birth control programs. The pseudocolonial island of Puerto Rico became the most important clinical site for testing the Pill outside the national disciplinary institutions of the asylum and the prison and functioned as a parallel, life-sized biopolitical pharmacological laboratory and factory during the late 1950s and early 1960s. During the Cold War period, Puerto Rico would become the United States’ biggest pharmacological backyard. The island was the invisible factory behind the Playboy mansion and the white liberated middle-class American housewife. In 1955, American physician Edris Rice-Wray, the medical director of the Puerto Rican Family Planning Association, already working with Searle, offered Pincus the possibility of conducting the Pill trials at Rio Piedras, a suburb of San Juan where a new housing project had been set up as part of a slum clearance campaign. In the summer of 1955, Pincus visited Puerto Rico and immediately decided that the Rio Piedras housing was the perfect location for a large-population, long-term Pill trial. The general features of legally enforced pharmacological experimentation in an environment of imposed isolation spread from Europe and North America to colonial and postcolonial regions, transforming the design models of their penal and medical institutions. Puerto Rico was a paradigmatic case of transition from the colonial regime to postcolonial economic and political control. At the end of the nineteenth century, the Spanish colonial regime left the island overpopulated and in extreme poverty. After the end of the anticolonial war of 1898, the island became a US territory. Already in 1917, the Puerto Rican ruling classes and the American government, inspired by neo-Malthusianism ideas, had drawn up the first population control plan for the island. In 1925, in the overpopulated slums of Ponce, Dr. José A. Lanause Rolón founded the Birth Control League, built on an educational program. These early birth control programs understood sterilization as a safe means of reducing natality and “cleansing” the slums, where reduction of population was to be a first step followed by urban modernization and the development of employment, to transform agrarian Puerto Rico into an industrial economy. In fact, Puerto Rico was not a stranger to forced sterilizations. As early as 1907, the United States had instituted public policy that gave the state the right “to sterilize unwilling and unwitting people.” By 1936, there were more than one hundred birth control clinics operating on the island under federal law. As Katherine Krase has argued, in order to “catalyze economic growth” and respond to “depression era unemployment,” in 1937 the “Eugenics Board” passed Law 136, an event that signified the institutionalization of these population control programs and the legalization of sterilization techniques. “Both U.S. government funds and contributions from private individuals supported the initiative.” Laws similar to Law 136 were passed in thirty states. These policies identified the “insane,” the “feebleminded,” the “dependent,” and the “diseased” as incapable of regulating their own reproductive abilities, thereby justifying government-imposed sterilizations. Legitimizing sterilization for certain groups led to further exploitation, as group divisions were made along race, class, and disability lines. From the beginning of the experimental trials with hormones, the challenge was how to switch from animals to human subjects confined to institutions and finally to the general population. As McCormick infamously said, in stressing the connection between imprisonment and scientific control, the key issue was to find a “cage of ovulating females”: “Human females are not easy to investigate as are rabbits in cages. The latter can be intensively controlled all the time, whereas the human females leave town at unexpected times so cannot be examined at a certain period; and they also forget to take the medicine sometimes—in which case the whole experiment has to begin over again, —for scientific accuracy must be maintained or the resulting data are worthless.” For Pincus, the island of Puerto Rico offered the most accessible and most easily monitored population pool that McCormick could ever want: the island itself was already a hermetic cage. Puerto Rican women were considered to be not only as docile as laboratory animals, but also as poor and uneducated and therefore an exemplary group: if they could follow the regimen involved in taking the Pill, any white American woman could do the same. The island of Puerto Rico itself was treated as an extended, nonwhite, female body to which the Pill was administered in terms of what Foucault called “urban therapeutics.” As historians of medicine Jordan Goodman, Anthony McElligot, and Lara Marks have shown, Puerto Rico’s trials are not an exception but rather belong to a larger history of colonial and hygienist scientific experimentation involving humans that occurred during the twentieth century: “Doctors and biohygenists became the determinators of a bioracially constituted state; they saw themselves as its gatekeepers and guardians, programmed with the mission to secure a utopian healthy society.” However, after World War II, with the scandals of Nazi medicine and the Nuremberg Code, the role of the state in pharmacological and medical experimentation became less clearly visible, as this experimentation moved from state institutions to industrial pharmacological companies. As part of a larger mutation from a disciplinary to a pharmacopornographic regime, “research became ‘de-centered’ as it became more commercialized, and moved beyond the immediate sphere of the state or state-related agencies and transcended national borders, borne on the wings of multinational corporations.” The birth control programs tested in Puerto Rico clearly show the complicity between national eugenic programs and private pharmacological interests before the war and the transition from the colonial and state model to the postcolonial and neoliberal multinational model of drug production and population control after the 1940s.AddictionBiomedical discourses have constructed opiate use as a problematic behavior to be corrected by the application of therapy to rectify the perceived moral illness.Bergschmidt 2010 [Viktoria Bergschmidt, Pleasure, power and dangerous substances: applying Foucault to the study of ‘heroin dependence’ in Germany, Anthropology and Medicine Volume 11 issue 1 pgs. 59-73. ] Viktoria Bergschmidt is a professor of Social Work at Evangelische Hochschule Berlin.The emergence of both biomedical discourses that define opiate use as a health problem and of administrative controls targeting this problem since the second half of the nineteenth century is part of the ‘explosion’ of the life‐regulating techniques. The introduction of narcotic drug laws on both national and international levels belongs to the most significant attempts to bring about abstinence from ‘dangerous’ substances in populations. Under the German narcotic drug law, obtaining dangerous substances in any way is punishable by imprisonment. However, German law cannot directly prohibit the consumption of dangerous substances, because the right to free development of the personality, which also includes self‐damaging behaviour and suicide, is constitutionally guaranteed. Thus, consumption as such, proven, for example, by means of a blood or urine control, is not punishable. However, this self‐imposed limitation of juridical power is superseded, because in order to consume a drug, it has to be ‘obtained’ in some way, even if it is not ‘possessed’. In legal jargon, this strategy is termed ‘the surrounding of consumption by criminal law’ (B?llinger?et al.?1995B?llinger?L?St?ver?H?Fietzek?L?(1995)Drogenpraxis, Drogenrecht, DrogenpolitikFachhochschulverlag, Frankfurt/Main?, p. 186, my translation). If juridical power claims to remain extrinsic to the subject, one could then argue that bio‐power fills the gaps in regulation by producing disciplined, normalized and ‘governmentable’ subjectivities. Foucault defines governmentality as ‘the ensemble formed by institutions, procedures, analyses, and reflections, the calculations and tactics, that allow the exercise of this specific albeit complex of power, which has at its target population’ (1979, p. 20). Furthermore, the merging of the words ‘to govern’ and ‘mentality’ indicates that governance is effective only if there is a certain readiness to be governed. But bio‐power does not only fill the gaps in juridical power. It is the matrix for the historical shifts in legal regulations. In 1981, the punitive goal of German narcotic drug law was supplemented with an auxiliary goal: the threat of punishment should be primarily an aid to bring about therapy motivation. The shift of the guiding principle of German narcotic drug law towards ‘therapy instead of punishment’ reads almost like an illustration of Foucault's analyses (1976, 1980) of power shifting from punishment to discipline and normalization.BiocommunicabilityMedicalization is on steroids in the status quo – our society’s worship of scientistic objectivity victim-blames unhealthy and marginalized populations for their so-called refusal to make economically rational choices about their health careBriggs and Hallin 07 (Charles Briggs and Daniel Hallin, “Biocommunicability: The Neoliberal Subject and Its Contradictions in News Coverage of Health Issues,” Social Text, 25 (4), p. 49-51, Laboratory of Comparative Human Cognition, University of California – San Diego)The assumption that medical science produces objective and highly specialized technical knowledge sets the medical realm off from many other realms of discourse, where more populist, relativist, or democratic communication ideologies prevail. The biomedical authority model of biocommunicability imagines a natural, necessarily linear trajectory that moves through space, time, and states of knowledge and agency, starting from the production of knowledge about health, its codification into texts (reports, scientific articles, pronouncements by public health officials, and so on), the translation of scientific texts into popular discourse (through health education, statements to reporters by health professionals, and media coverage), its dissemination through a range of media, and its reception by “the public.” A common type of article in this modality is generated by news reporting of the release of major research findings: “UCLA researchers said yesterday they’ve created the first test that records the onset of Alzheimer’s disease. The test, which identifies Alzheimer’s markers in a person’s brain, could improve early diagnosis and lead to more effective treatment, said Dr. Stephen Bartels, President of the American Association of Geriatric Psychiatry.”23 Standard elements include mention of the major medical journal publishing the article (or other source), a summary of the findings, quotes from authors and from other “experts,” and policy recommendations. When the article is generated by a local reporter (rather than coming from national news services), the reporter may also use quotes from local health professionals to bring the information “closer” to readers. Another version of this model can be found in the health advice column. “Type 2 Diabetes,” writes Jane Brody, “. . . requires a kind of intervention that only 50 Briggs/Hallin the potential and actual victims can provide: making better food choices, getting more exercise and — most important of all — avoiding excess weight or taking it off. . . . One third of the people who have this disease do not know they have it.”24 The article goes on to give patients advice on how to calculate their body mass index (BMI). The mode of exposition is didactic, and most of the information is presented without attribution, simply as fact — a rather unusual practice in journalism. In this sense, the voice of biomedical authority addresses the members of its audience directly, and the journalist’s mediating role remains in the background. The article does quote one endocrinologist to establish the authority of the information, and it cites a study by the Department of Health and Human Services. Patients seldom speak in these articles, and there is hardly ever a human interest angle, but many articles include a photograph of a patient and/or one of the quoted professionals. Laypeople are sometimes interpellated as eavesdroppers, listening in on a conversation that does not yet include us, sometimes instructed in the didactic mode of the advice column, and sometimes, like the photographed patients, as waiting to see how local physicians will bring this new knowledge to us. At one time, the hierarchical model of biomedical authority was overwhelmingly dominant in public communication about health. Research by Nancy Lee shows that health reporting in the mid-twentieth century typically admonished laypeople to rely exclusively on their family physician for health information.25 Admonitions to trust medical authority still appear today, though often in different forms and contexts. “Health hoaxes . . . zip around cyberspace like flies around fresh meat,” warns one article splashed across most of the front page of the Currents section of the U-T. The article goes on to detail “the phony health scares exposed on a hoax-debunking Web site of the federal Centers for Disease Control and Prevention (CDC)” and to advise readers about Web-based sources of health information properly inserted within established channels of dissemination of biomedical knowledge.26 Other articles warn of unapproved medical practitioners across the border in Mexico, or focus on “phony medical clinics thriving in immigrant communities.”27 The hierarchical model of biomedical authority is probably more frequently found in articles on nondominant populations, who are often assumed to remain outside the circuits of information that define the model of active governmentality. Rose argues that advanced liberal democracies are dominated by “an ethic in which the maximization of lifestyle, potential, health, and quality of life has become almost obligatory, and where negative judgments are directed toward those who will not, for whatever reason, adopt an active, informed, positive, and prudent relation to the future.”28 In characterizing people as biocommunicable outsiders, reporters extend logics that justify health disparities by suggesting that targeted populations fail even to acquire the knowledge that would permit them to fashion themselves as biomedical citizens. While the hierarchical model remains a powerful influence on almost all health care coverage, however, it is not the dominant model today. Most of the time it appears alongside, and sometimes in tension with, other models of communicability; at times it is present essentially as an absence, as a nostalgic contrast to neoliberal models of biocommunicability. In its classic form, this model projects a circuit of communication in which medical knowledge is produced by specialists and transmitted to patients by their primary-care physicians. If it works as intended, it is not a public process, and has no significant place for journalists as nonspecialist mediators. Health education campaigns modify the traditional model in part by inserting mass media into it — a modification often motivated, as in the example above, by the concern that the normal process is not functioning for part of the population or that the unhealthy effects exerted by nefarious advertisers and ignorant or ill-willed reporters need to be countered through the same media. The linear, “hypodermic,” or “process” model of communication has continued to inform health education and health promotion, even as audiences come to be seen as active, selective, and heterogeneous “consumers” of health information.29 But the central role of mass media in health communication today attests to the increasing marginalization in the age of neoliberalism of the benevolent patriarchal authority symbolized in an early era by the image of the family physician.ChoiceMoving from a trust to choice based systemFotaki 14 (Marianna Fotaki, Professor of Business Ethics at Warwick Business School and a visiting professor at The University of Manchester., “Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care”, Sociology of Health & Illness Vol. 36 No. 8 2014 ISSN 0141-9889, pg 1276-1277, Rawle)The move from trust to choice is based on the economic premise of rational individuals who, if given the necessary information, will make decisions that will maximise their welfare. However, there are strong arguments against replacing trust with choice, because the inherent imbalance of knowledge and power characterising health relations between patients and health professionals, the vulnerability that often accompanies ill health and the importance of health to achieving one’s life goals, makes the distinction between choice and trust a rhetorical one (Goold 2002, Pilgrim et al. 2011). Instrumental approaches to choice tend not only to ignore the intrinsic value of trust but also the way its fragility is easily undermined by egoistic action (Taylor-Gooby 1999). There is also uncertainty as to how the increase of information necessary to allow users of health services to exercise choice will affect various dimensions and levels of trust in the NHS (Taylor-Gooby 2006). In general, it may be that introducing consumer choice alters the meaning of trust in different situations in health care. Whether this is the case, and if so, how far it might impact upon patients and services, remains to be established.Choice in the health care system and policy making – squo health systems badFotaki 14 (Marianna Fotaki, Professor of Business Ethics at Warwick Business School and a visiting professor at The University of Manchester., “Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care”, Sociology of Health & Illness Vol. 36 No. 8 2014 ISSN 0141-9889, pg 1276-1278, Rawle)The close relationship between individual choice and trust is explicit in marketised health systems such as that of the USA where: ‘the act of choice in placing trust is central: trust without choice is dependency (when one party is bound to the other and at risk from the other without choice)’ (Davies and Rundall 2000: 612). However, the rapidly rising cost of US health care forced policymakers in the 1980s to curtail rather than extend individual patient choice by shifting it to insurers in managed care reforms. A system based on the competence and fiduciary ethic of individual physicians was thus replaced by one mostly centred on managing performance (Gray 1997). The situation is somewhat different where health services are publicly owned and provided and where choice has been or is perceived to have been historically lacking. Until relatively recently, individual choice was not a high priority in the NHS and trust was taken for granted (Gilson 2003); doctors were bound by the rules of professional conduct and were assumed to be trustworthy. A series of health scandals involving high-profile inquiries into public health system failures in England (Quick 2006) raised questions about the usefulness of unconditional trust in a self-regulating medical profession. Moreover, ‘relatively isolated cases were manipulated to construct an exaggerated fear of the possibility of widespread clinical malpractice within the NHS’ (Brown 2008: 350). Doctors began to be portrayed as rent-seeking bureaucrats or knaves who do not have their patients’ well-being at heart (Le Grand 2003). Such ideological narratives by influential academics promoted market choice and competition as a means of addressing the alleged problem. Turning patients into informed consumers would, it was presumed, reduce the power of doctors and improve quality of care. The rationale driving such arguments is simple: providing patients with information enabling them to seek treatment elsewhere will prompt health providers to both disclose information on their performance and improve it, or close down. Giving NHS patients free choice of who to be treated by, and when and where and how, would, it was suggested, not only lead to more responsive care but also reduce the importance of interpersonal trust, which this view equates with dependency (Davies and Rundall 2000). The use of market-style mechanisms to empower the consumer and keep self-serving state officials on their toes has a long intellectual heritage in the liberal tradition (for example, Hayek and the Austrian School) and among neoclassical economists (Freidman) or philosophers (Nozick) (see Hindess 1987). Lately, the theoretical premises of postmodernism have also influenced policy development and reforms in many health systems: trust in individuals is seen as a pre-modern concept associated with dependency and at odds with the needs of people in postmodern societies, who are reflexive designers of their own lives (Giddens 1990) and for whom everything is negotiable and a matter of choice. In other words, in such societies widening consumer choice in health care is believed to be desired by patients (Milburn 2003, Williams and Rossiter 2004).Disadvantaged groups having less trust in the health system causes more bad thingsFotaki 14 (Marianna Fotaki, Professor of Business Ethics at Warwick Business School and a visiting professor at The University of Manchester., “Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care”, Sociology of Health & Illness Vol. 36 No. 8 2014 ISSN 0141-9889, pg 1282-1283, Rawle)Three main conclusions emerge. The first is that while the instrumental and intrinsic value of choice in health services is potentially significant for all patients, asymmetry of access to resources, social capital and information is likely to lead to inequalities in choice (Burge et al. 2005) and trust (Baier 1986). Patients’ experience of disadvantage may lead to their having little trust in the system, causing them to delay seeking help, potentially leading to worse health outcomes (Armstrong et al. 2006, Klassen et al. 2002). Secondly, patients are likely to trade off choice against trust. In the case of such trade-offs, those who are relatively disadvantaged in socioeconomic terms are less likely to choose and more apt to continue to rely on trust (Dowding and John 2009). And while users of health services across the EU want a more balanced relationship with their doctors, this is particularly true of younger, well educated patients, those with chronic conditions and those living in Western Europe (Eurobarometer 2012). Thirdly, interpersonal and embodied forms of trust continue to be important factors against which consumerist choice is likely to be traded-off in health care. Especially ‘in the face of intimidating and emotion-laden decisions... individuals may rely more on trust than on informed choice’ (Goold and Klipp 2002: 880). Trust is still rooted in patients’ need for physicians: the greater their sense of vulnerability, the higher their need for trust. The reasons are both existential: ‘the act of trust is a solution to a problem of uncertainty by anticipating an unknowable future’ (Barbalet 2009: 372) and practical: most people may not be able to acquire the expertise needed to make informed judgements about treatments, but they have a vital interest in the outcome (Taylor-Gooby 2006: 99). The enthusiasm for the desired but unproven effects of choice by policymakers in spite of the limited uptake and mixed results is surprising, all the more so since the attempt to substitute market choice for trust, and the undue focus on risk assessment (Rowe and Calnan 2006) in health services, poses some serious problems. The empirical examples from health care presented above demonstrate that while the market may or may not enhance users’ empowerment and improve the quality and efficiency of services, it could still have a potentially negative impact on social, relational, affective and embodied aspects of trust. Similarly, the ideas of risk assessment, and of the patient as a rational chooser, which are driving the current health reforms in England, overlook the way that differences in patients’ personal characteristics and health conditions impact on their choices and trusting behaviour. The reliance on the notion of calculation as a basis for understanding trust is therefore both insufficient and inadequate. It does not account for embodied and relational aspects of trust in micro-level interactions between doctors and patients (see Brown et al. 2011), or altruistic motives for providing care exceeding the motives of health professionals that are based on expected benefits (Ruscio 1996). It also fails to consider how a complex web of relationships impacts on the overall functioning of the health system: the notion of interdependence as the foundation of organised life is missing from these accounts. Last but not least, a framework driven by instrumental rationality or a notion of confidence enforced by surveillance and consumerist market choice, offers an impoverished alternative to the trust that depends on voluntary interpersonal reciprocity (Harrison and Smith 2004, Ruscio 1996).Choice-oriented policies turn their decisionmaking arguments on frameworkFotaki 14 (Marianna Fotaki, Professor of Business Ethics at Warwick Business School and a visiting professor at The University of Manchester., “Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care”, Sociology of Health & Illness Vol. 36 No. 8 2014 ISSN 0141-9889, pg 1283, Rawle)Derived from early 20th century theories of consumer demand and neoclassic economics, the prevailing logic of choice in health care illustrates how ‘practical men’ often become unwittingly the slaves of some ‘defunct economist’ (Keynes 1936: 383). In this instance it is a matter of assuming that patients act as calculating and rational utility-maximisers even though people are known to not generally behave as economic models predict. The caricature of choice that policymakers have embraced therefore needs to be replaced by frameworks that reflect more accurately the nuanced and complex way in which patients make decisions about their health. Interdisciplinary insights can be drawn on to build models of choice relevant for health-care contexts in which trust, subjectivity and affect occupy a central position, and in which compassion enters into the decision-making process. There is also a need to appreciate the way affect is involved in the decision-making and trust-based behaviour of health service users, as has long been recognised in relation to the consumers of market goods (for example, see Baumgartner et al. 1992, Ferraro et al. 2005). Normative theories of choice and trust capture some of these nuances and complexity. Drawing on Max Weber and Amartya Sen, Taylor-Gooby for instance, explains that ‘individuals’ choices represent a commitment to ways of life and values rather than an instrumental means to an end’ (Taylor-Gooby 1999: 100). Barbalet (2009) also stresses that the strong emotional, contingent and non-transitive properties of trust act as powerful resources for overcoming future uncertainty and contribute to the substantive rationality of decision-making. M€ollering (2006) offers a model of reflexive engagement combining both rationality and emotions, with emotions not merely complementing rationality but enabling it. However, neither of these approaches centres on affect as an organising principle of trust at various levels of care, that both makes possible individual relations between patients, doctors and health professionals and also maintains institutional trust in the health system. To account for these important dimensions of trust in shifting health policy environments I propose an alternative, affective, psychosocial approach which builds on the existing research but takes it further. It focuses specifically on how the emotions involved in relations between patients and doctors form interpersonal trust, and how this is interwoven with the socially organised affect underpinning systemic trust. The next section outlines this alternative conception of trust and details the unique contribution it can make to enhance an understanding how trust operates in health care.DisabilityContemporary medical treatments of disability presume that disabled individuals must be cured rather than that disability is a social phenomenon. This leads to professionalization of medical experts and authoritarian control over disabled bodies.MDRC ND (Michigan Disability Rights Coalition, MDRC cultivates disability pride and strengthens the disability movement by recognizing disability as a natural and beautiful part of human diversity while collaborating to dismantle all forms of oppression., “Models of Disability”, Copower, , Rawle)The medical model came about as "modern" medicine began to develop in the 19th Century, along with the enhanced role of the physician in society. Since many disabilities have medical origins, people with disabilities were expected to benefit from coming under the direction of the medical profession. Under this model, the problems that are associated with disability are deemed to reside within the individual. In other words, if the individual is "cured" then these problems will not exist. Society has no underlying responsibility to make a "place" for persons with disabilities, since they live in an outsider role waiting to be cured. The individual with a disability is in the sick role under the medical model. When people are sick, they are excused from the normal obligations of society: going to school, getting a job, taking on family responsibilities, etc. They are also expected to come under the authority of the medical profession in order to get better. Thus, until recently, most disability policy issues have been regarded as health issues, and physicians have been regarded as the primary authorities in this policy area. One can see the influence of the medical model in disability public policy today, most notably in the Social Security system, in which disability is defined as the inability to work. This is consistent with the role of the person with a disability as sick. It is also the source of enormous problems for persons with disabilities who want to work but who would risk losing all related public benefits, such as health care coverage or access to Personal Assistance Services (for in-home chores and personal functioning), since a person loses one's disability status by going to work. Expert/Professional Model of Disability The Expert/Professional Model has provided a traditional response to disability issues and can be seen as an offshoot of the Medical Model. Within its framework, professionals follow a process of identifying the impairment and its limitations (using the Medical Model), and taking the necessary action to improve the position of the disabled person. This has tended to produce a system in which an authoritarian, over-active service provider prescribes and acts for a passive client. This relationship has been described as that of fixer (the professional) and fixee (the client), and clearly contains an inequality that limits collaboration. Although a professional may be caring, the imposition of solutions can be less than benevolent. If the decisions are made by the "expert", the client has no choice and is unable to exercise the basic human right of freedom over his or her own actions. In the extreme, it undermines the client’s dignity by removing the ability to participate in the simplest, everyday decisions affecting his or her life. E.g. when underwear needs to be changed or how vegetables are to be cooked.Inequality (Racial)The aff’s extension of medicalization and healthcare treatment to black communities merely extends biopolitical forms of surveillance which reify antiblackness through the individualization of responsibility for risk, depoliticization of racism, and securing of racial “problem spots”Shiloh and Ehlers 17 (Krupar Shiloh, Geographer, Provost's Distinguished Associate Professor, and Field Chair of the Culture and Politics Program in the Walsh School of Foreign Service at Georgetown University and Interim Co-director of the National Toxic Land/Labor Conservation Service; Nadine Ehlers, Department of Sociology and Social Policy at The University of Sydney. “Biofutures: race and the governance of health”, Environment and Planning D: Society and Space, Vol 35, Issue 2, 2017.)On 1 August 1896, W. E. B. Du Bois began a 15-month sociological study commissioned by the University of Pennsylvania, which was eventually published as The Philadelphia Negro: A Social Study (1899). Widely recognized as the first great empirical book on black life in American society, Du Bois' study included an analysis of the health conditions of Philadelphia's black population and might be seen as a race-specific biopolitics of health. The biopolitics of health refers to the administration of health that manages and standardizes the life of the population-to make the "biological citizens" of the nation live more. What Du Bois makes clear in his study, however, is that the administration of the biological life of the population in the U.S. has been "cut" by racism and entrenched racial disparities. The first function of racism, Michel Foucault (2003: 255; Rose, 2007: 24-25) tells us, is "to fragment, to create caesuras within the biological continuum." The "cut" of racism has meant that different segments of the population have been administered in distinct ways and that white lives have been affirmed and made to live in ways that black lives have not. As Michael Dillon and Andrew W. Neal (2008: 168) argue, race functions as a marker that biopolitically adjudicates: Race "does not only specify life's eligibilities for this or that good--it ultimately specifies whether or not a life is to be considered eligible for life as such." Viewed through this lens, the differential governing of black subjects both operates as a form of violence against the black body/subject and situates African Americans as separate from the wider population and the polis. Du Bois' investigation highlights that the city of Philadelphia--by way of commissioning this work--sought to better manage and secure what were seen as the potentially dangerous problems of the African American population. (1) It is in this way that the study operated as a race-specific biopolitics of health, wherein black life (and blackness itself) was articulated as an ontological problem (the infamous "Negro problem") to be studied, measured, and ultimately contained. (2) The political problem of black life was deemed the product of supposed inherent black difference--a difference that required regulation. Du Bois both refused and inverted this logic: Reframing the so-called Negro problem in terms of environmental factors and relentless historical disenfranchisement, he showed that African American problems regarding health were "largely a matter of the condition of living" (Du Bois, 1899). Ultimately Du Bois insisted that, as a problem produced through social conditions, black health--or lack thereof--needed to be attended to and normalized in line with the cultivation of white subjects. We might say, then, that the Du Boisian study was a demand that the "cut" in the biopolitical fostering of life--along the color line--be remedied through a more affirmative focus on black health. For Du Bois, however, this would be achieved not through a focus on blackness as a "problem" but through addressing manifold social factors that thwart black life. Biomedical targeting of race Contemporary biomedical technologies that target race seem to ameliorate the "cut" of systemic racism--by targeting supposedly race-specific health factors or directing health care toward particular spaces to alleviate health disparities. In what follows, we consider two examples of biomedical targeting technologies and their biopolitical operations. First, we focus on BiDil, a pharmaceutical approved by the U.S. Food and Drug Administration (FDA) in 2005, and subsequently marketed as a race-specific drug for self-identified African Americans suffering from heart failure. Second, we turn to what is known as "medical hot spotting," a practice that began in Camden, New Jersey in 2007, and that uses GIS technologies and spatial profiling to identify populations that are medically vulnerable ("health care's costliest 1%") in order to provide preemptive care at home and lower hospital admissions and health care costs. These targeting operations are deployed ostensibly to affirm life: They are said to redress past forms of biomedical neglect and enable the tailoring of biomedical intervention into vulnerable communities, and they are advocated as the means through which to foster the health of those populations--through attention, through targeting. Such forms of redress and attention might be understood, then, as the attempt to practice--and actualize--a different racial future, precisely through attending to inequities in the present. However, targeted health interventions may in effect signal inequitable and endangering forms of biomedical administration. (3) We advance this more cautionary view through three foundational claims. First, regardless of the motivations for biomedical targeting--that is, the will to attend to black health--the operation of race-specific biomedical targeting of black subjects is structured through an epistemology of anti-blackness. More than racist actions against blacks, the architecture of racial discrimination, or a paradigm that binds blackness and death together, anti-blackness is a form of knowledge that positions the black subject outside of the category Human. (4) This positioning stems from liberal humanist thought and is constitutive of Western modernity (Barrett, 2014). Not only has the epistemology of anti-blackness shaped the racial past in the U.S., but it also curtails the present and future of black life. Such expulsion of black lives from the normative position Human is undeniable, "[g]iven the histories of slavery, colonialism, segregation, lynching" and the ongoing daily imperiling of black lives through police brutality and mass incarceration (Weheliye, 2014: 19). That biomedical targeting is structured through anti-blackness is evident in the way it reinstitutes racial difference and separation and, as we will show, stages an additional form of violence by actually expelling blacks from the possibility of optimal health. Black lives have been consistently imperiled in and through the biomedical encounter, in the form of lack of access to care and health insurance, inequities in caregiving, and the medical abuse of black bodies, from grave robbing for medical experimentation, to the Tuskegee Syphilis Experiments, and the appropriation of the Henrietta Lacks cell line (Duster, 2003a; Institute of Medicine Report, 2002; Nelson, 2011; Roberts, 2012; Van Ryn and Fu, 2003; Washington, 2008). Anti-blackness continues to thwart black life and futurity through biomedical targeting operations that subject African Americans to what Du Bois (1899) named as a "social atmosphere ... which differs from that surrounding whites." (5) Race-based targeting efforts that are aimed at redressing health inequities recursively secure anti-blackness by refusing to acknowledge its structuring logic, thus equating blackness with inevitable vulnerability, risk, threat, and premature death. (6) Second, and related to our first point, these biomedical targeting operations extract the conditions of black health and illness from the broader contexts of structural racism. Biomedical targeting generally fails to recognize the social conditions in which poor health emerges and, in the case of black subjects, how poor health, institutional racism, and the epistemology of anti-blackness are ontologically enmeshed. The targeting of black populations--specifically the two cases we explore here--does not simply direct resources to black subjects. Instead, in such operations, race is objectified as that to be targeted, meaning that race itself is not undone: That is, race as a stratifying mechanism that orders the social--a social order characterized by anti-blackness--is not called into question. Both BiDil and medical hot spotting demarcate populations, with supposedly distinct bodies, and name them as a political problem in need of specific health governance; black bodies and racialized spaces are targeted in order to manage the life of the population. Accordingly, BiDil might be seen to ontologize blackness as a corporeal truth for market accumulation, while medical hot spotting can be said to spatially ontologize structural racism in order to secure cost efficiencies of the health care system. BiDil is predicated on financial extraction; medical hot spotting is predicated on threat containment. These biomedical targeting technologies reveal how health interventions do not necessarily support or achieve a better future for African Americans. Instead, they advance the epistemological violence of anti-blackness by concentrating the "problem" of black life in the U.S. at the scales of: (1) the racialized body (BiDil) and (2) space (hot spots), which both become objects of ever more heightened administration, financial exploitation, and securitization. BiDil positions African Americans as "problem bodies" that must take on responsibility for their own racialized embodied risk through the act of buying and consuming race-based medicine; here, anti-blackness operates through the black responsibilization of risk. Medical hot spotting tracks, maps, and fixes high-cost health care users in "problem spaces" that are positioned outside the populace; hot spotting locates and reifies the structural position of anti-blackness in space for the purposes of surveillance, anticipation of risk, and containment. Third, contemporary biomedical targeting technologies are an endangering form of health administration exacerbated by the logics of neoliberalism. Under neoliberal conditions, populations previously excluded from the vital politics of the nation are now ostensibly being addressed. However, the two biomedical targeting technologies that we explore reveal a predatory power to demarcate race for purposes spanning financial extraction to threat containment--even as such "targeting" is advocated as the means for addressing the embodied and spatial effects of racial inequality. In neoliberal times, the color line no longer operates as a clear and obvious modality of exclusion, as Du Bois would have it (Goldberg, 2008). The neoliberal biopolitics of health increasingly emphasizes customizing health, the body, and life itself through biomedical practices (Clarke et al., 2003: 181-182). Our two case studies reveal how customizing health seems to be an operation of inclusion (directly or indirectly by race) within biomedicine: BiDil is a customized drug that attends to black health; it targets racial minorities supposedly to extend life. Medical hot spotting is also a form of customization through care delivery: It delineates "problem spaces"--where high utilizers of health care are located--in order to direct resources and generate efficiencies in health provisions. "Customizing" works in the first case through "color awareness" and marketing within biomedicine (i.e. the racialized spectacle of the body), and paradoxically in the second, through invisibilizing race at the level of "location"/space according to the so-called colorblind agency of the free market and cost-benefit analysis (O'Boyle, 2007). While both targeting technologies may attempt to alleviate racial health disparities, they simultaneously augment racial difference and exacerbate racial inequalities--but they do so in very different ways: thus emphasizing the importance of tracing out the empirically distinct means through which each technology resecures the epistemology of anti-blackness. BiDil highlights the neoliberal refusal to acknowledge the social production of risk, by casting health as an individual--not social--enterprise. Medical hot spotting disavows the historical and spatial processes of racial formation that structure the present and simultaneously shows that certain (racialized) subjects are positioned--in advance--as risk failures within the paradoxically "race-neutral future" of the nation. To begin exploring these ideas, we turn to the case of BiDil, the oft-disputed first pharmaceutical with a race-specific indication.InstitutionalizationThe current health care industry is counterproductive to the natural “conviviality” of the human spirit Miller 12 (Bruce, Professor of Law at Western New England University, “The Place of Law in Ivan Illich's Vision of Social Transformation” Digital Commons @ Western New England University School of Law, pg. 114 – 115, 2012, ) Johnson Drawing from his studies of the health care industry,59 public education,60 and public transportation systems,61 Illich, in Tools, argued that the organizational structures created by these and other economic institutions characteristic of the developed world are both counterproductive and inimical to the natural “conviviality” of the human spirit.62 His assault on these structures was as comprehensive as it was fundamental. Illich’s central claim was that they transferred power from independent people to anonymous bureaucracies.63 More specifically, they protected formal, hierarchical educational arrangements at the expense of actual learning;64 exploited nature rather than recognizing its preservation as a “convivial” value;65 created material abundance while undermining the possibility of meaning in ordinary life;66 fostered social mobility at the expense of personal security and a sense of place;67 and, finally, insisted on perpetual innovation at a pace which precludes the sustenance of an organic tradition.68 Above all, Illich insisted that prevailing corporate forms of industrial production degrade social relations, monopolize imagination and motivation, and eventually commodify every aspect of human life.69Against this dispiriting picture, Illich urged what he called the “inversion” of the social arrangements and institutions of industrial society.70 By this, he meant a political process by which people become enlightened about the necessity to opt for a more “frugal” standard of living, enter into social movements aimed at reclaiming more convivial ways of life, and, finally, rediscover and revalue the political and legal tools that can help establish and protect these convivial life forms as they emerge.71put it, to recover, three key cultural institutions: science,73 language,74 and law.75 Illich argued that the ways in which these institutions approach and apprehend the world can not only generate new social structures, but, just as importantly, can do so using means that are themselves examples of the more convivial forms of life these new structures encourage.76Mental IllnessMental illness is medicalized by the professionalization of psychiatryBarker 03 (Phil Barker, Clan Unity Mental Health Consultancy, Fife, Scotland, United Kingdom, “The Tidal Model: Psychiatric colonization, recovery and the paradigm shift in mental health care”, International Journal of Mental Health Nursing (2003), pg 97, Rawle) Szasz’s emphasis of the metaphorical status of mental illness is, however, only one dimension of the movement, loosely called ‘critical psychiatry’, which challenges mainstream psychiatric thinking on a range of gender, race, culture and scientific issues, all with implications for the practice of mental health care (Newnes et al. 1999). The social construction of mental illness, especially through the diagnostic process, has long been the subject of debate (e.g. Conrad 1992; Daniels 1970; Farber 1987). However, Kirk and Kutchins (1992, 1997) made the original observation that the repeated revisions and additions to the DSM were not initiated by working clinicians, but rather stemmed from the influence of the census, medical groups, the army or psychiatric researchers. Arguably, the ‘good clinician’ knows that however many diagnostic categories are available, the resolution of the person’s problems (of living) begin with someone who seeks to understand rather than classifying the ‘patient’. Aside from concerns about the reliability and validity of psychiatric diagnosis (Kirk & Kutchins 1992), the narrowness of the diagnostic approach is problematic. As Laing (1967) noted, ‘it is an approach that fails to view persons qua persons, and degrades them to the status of “objects”’. Over 30 years later, psychiatry’s failure to try to understand people and the critical role of the creation of meanings within the therapeutic relationship, remain enduring concerns (Kismayer 1994; Modrow 1995). Such concerns led Grob (1983) to describe psychiatry as a political and professional ‘movement’ rather than a scientific enterprise concerned with caring for people who were definably ‘ill’. Beverly Hall, the distinguished North American nurse, recognized how psychiatric diagnosis and the medical model served only to disempower people, rather than help them. Their adverse effects upon nursing practice led Hall (1996) to argue for the recognition of human values over ‘objectivity’ in mental health care. In a related vein, Dumont (1984) exposed the fallacious distinction between illness and wellness in Western thought, suggesting the urgent need for a paradigm shift in the conceptualization of ‘mental illness’. However, psychiatry has a remarkable capacity to shrug off its many critics, whether philosophical, scientific, social or political. Despite being the butt of many popular jokes, at the beginning of the 21st Century, psychiatry retains its patriarchal power (Barker & Stevenson 2000), evidenced by the number of people around the world who are hospitalized, or required to accept (often dangerous) psychiatric treatment (many against their will), for an ‘illness’ or ‘disorder’ for which there exists no definitive empirical ‘test’. Neither should we forget the cruel irony in the fact that: ‘Psychiatrists, of course, do ask for tests such as CT scans on their patients, but these are to exclude the possibility of brain damage. In other words, they are checking to see if there is a real brain problem, evidence of illegal drug use or whatever. Once they have concluded that there is nothing demonstrably amiss with the patient’s brain or biochemistry, they tell the person that they have a condition that results from a biochemical problem. But they don’t have a test that could prove a so-called mental illness was actually organic in origin.’ (Newnes 2002) The idea of people taking (or being required to take) powerful drugs, with multiple deleterious ‘side-effects’, for a physical condition – like cancer or diabetes – in the absence of a diagnostic test, would be seen as ludicrous if not morally suspect. That so many people, in most Western cultures, readily accept this state of affairs, and that so many nurses – traditionally defined as their carers, if not ‘advocates’ – shore up this system, attests to psychiatry’s enduring power. COLONIZATION AND POWER For the past 30 years Szasz has focused on slavery as the choice psychiatric icon (Szasz 2002). ‘The psychiatric profession has, of course, a huge stake, both existential and economic, in being socially authorized to rule over mental patients, just as the slave-owning classes did in ruling over slaves. In contemporary psychiatry, indeed, the expert gains superiority not only over members of a specific class of victims, but over the whole of the population, whom he may “psychiatrically evaluate”.’ (Szasz, 1974: 135) In Szasz’s view, any form of involuntary hospitalization is a ‘crime against humanity’, and the practice of psychiatry echoes the fundamental human rights violation perpetrated by slave-owners, who also justified their practices as being, somehow, in the ‘best interests’ of the childlike, primitive, or otherwise enfeebled ‘negro’. In this sense, Szasz was the first writer to explore psychiatry’s colonization of the self.The medical model applied to psychotherapy is inaccurate and perpetuates commercial coercion and obscures the human element of growth and emotion.Elkins 2007 [David Elkins, The Medical Model in Psychotherapy: Its Limitations and Failures, Journal of Humanistic Psychology, Volume: 49 issue: 1, page(s): 66-84. ? ] David Elkins is a professor emeritus of psychology at Pepperdine.To summarize, the medical model has serious limitations: (a) The model fails to describe accurately what actually occurs in therapy; (b) the model continues to dominate the field not because of its accuracy but rather because of its questionable ties with medicine, science, and the health insurance industry; (c) the model obscures the fact that psychotherapy is primarily an interpersonal process rather than a medical procedure; and (d) the model cannot account for the fact that the vast majority of clients who seek psychotherapy do so for reasons other than mental illness.Psychotherapy treatment in the status quo serves to reify the existing power-knowledge relations that see life as a subject and binds the client to the norms of that subjection.Roberts 2005 [Marc Roberts, The production of the psychiatric subject: power, knowledge and Michel Foucault, Nursing Philosophy volume 6, issue 1, pgs. 33-42.] Marc Roberts is a lecturer at Albertay University, having earned his PhD in philosophy from Staffordshire University.In doing so, the Panoptic power of psychiatry can be seen as moving beyond the boundaries of the hospital ward and functioning throughout the community. Indeed, in so far as a client’s family, friends and significant others may observe and monitor the client, then Panoptic power can be seen to be exercised by ‘non-professional’ groups. In this way, Panopticism traverses the traditional, liberal-democratic division between the ‘public, political sphere’ and the ‘private, personal sphere’ (Heywood, 1997, pp. 7–8). Exercised by ‘professional’ and ‘non-professional’ groups alike, the Panoptic power of psychiatry can be seen to infiltrate what has traditionally been thought of as the private, personal sphere: the sphere of the home, the family and personal relationships. Accordingly, Panopticism is said to discipline what are commonly conceptualized as non-disciplinary spaces and therefore is to be understood as an ‘interstitial’ form of power; a form of power that seeks to infiltrate every aspect of a person’s life and to give ‘a permanent account of individuals’ behaviour’ (Foucault, 1991a, p. 214). Importantly, however, it is not only a client’s behavior that is continually monitored but also, by way of a variety of psychotherapeutic approaches and techniques, their thoughts and feelings. On a Foucauldian analysis, psychotherapy can be seen as a manifestation of one of the most pervasive examples of the power–knowledge relation that has existed within Western societies; namely, ‘the confession’ (Foucault, 1998, p. 58). As a power–knowledge relation, the historical proliferation and transmutation of the confession is said to have become so pervasive that ‘we have since become a singularly confessing society’ (Foucault, 1998, p. 59). Indeed, the obligation to confess is now so ‘deeply ingrained’ within us that we no longer experience it as a constraining power, but as the ‘true voice’ of our ‘innermost selves’ that ‘demands’ to be expressed. This transmutation of the confession within contemporary society is so complete that a reluctance to confess is seen as the effect of a ‘constraint’ that holds the confession in place, and which ‘can finally be articulated only at the price of a kind of liberation’ (Foucault, 1998, p. 60). As a manifestation of the confession therefore psychotherapy can be understood as that power–knowledge relation in which the client is invited to disclose or ‘confess’ their thoughts and feelings so that they can be observed and monitored by the psychotherapist. Within this process, the psychotherapist is not to be understood as some form of neutral, value-free and passive observer; rather, in so far as all psychotherapies possess a body of knowledge or a theoretical framework, a conception of ‘normality’ and ‘abnormality’ and of how the latter should be addressed (Nelson-Jones, 2001), then what is dis-closed by the client is actively interpreted and acted upon by way of that theoretical framework. Rather than being fully formed, what is disclosed by the client is incomplete, ‘blind to itself’, and only reaches ‘completion’ in the one who records, interprets and assimilates what has been disclosed; as Foucault(1998) notes, a confession is always constituted in two stages: ‘the revelation of confession [has] to be coupled with the decipherment of what [is] said’ (p. 66).Therefore, on a Foucauldian analysis, the psychotherapist is not to be understood simply as ‘the interlocutor’, but as ‘the authority who requires the confession, prescribes and appreciates it, and intervenes in order to judge . . .’ (Foucault, 1998, p. 61).Rather than remaining passive within this process, however, the client is invited to adopt or, using Foucault’s (1991a) terminology, ‘inscribe within them-selves’ (p. 203), the power–knowledge relation that psychotherapy is said to embody. That is, the client is invited to observe and monitor their own thoughts and feelings and, on the basis of the psychotherapist’s theoretical framework, adjudicate for themselves which are to be understood as ‘normal’ and ‘abnormal’, and to regulate their thoughts, feelings and behavior accordingly. In this way the client can be understood as playing both the role of the psycho-therapist and the client, as internalizing the particular psychotherapy’s theoretical framework, categorizations, techniques and strictures and therefore as becoming the ‘principle’ of their own ‘subjection’(Foucault, 1991a, p. 203).The medical gaze of the modern patient has lead to mass major misdiagnosis of mental illness- we should criticize the lack of comparative perspectives in the squo in order to have better policy making in the medical sphereOlafsdottir, 10 (Sigrun, Ph.D. in Sociology from Indiana University, “Medicalization and Mental Health: The Critique of Medical Expansion, and a Consideration of How Markets, National States, and Citizens Matter”, Sage handbook of mental health and illness, )Medical innovations and ideologies mirror societal developments and values. The nineteenth century witnessed enormous improvements in health, due in significant part to improvements in social conditions and medicine (McKeown, 1979; McKinlay, 1981). The twentieth century turned to a subsequent reliance on medical solutions for conditions historically not viewed as medical. This increased reliance on medicine, labeled as medicalization, represents a major societ-al transformation in advanced, industrialized nations (Clarke et al., 2003). It refers to a process in which medical authority has to a large degree replaced religious and legal authority systems (Conrad and Schneider, 1992; Zola, 1972). Social behaviors previously defined as a sin or as a crime are increasingly defined as an illness. Similarly, the sinner and the criminal have been replaced by the patient. The acknowledgment of human difference is not a new development; in fact, societies have always viewed some individuals as “different.” However, the way in which the “difference” is understood and addressed varies over time and context. On the one hand, responses can be inactive, such as ignorance, tolerance, or even appreciation. On the other hand, responses can be active, such as concern, prejudice, or even protection. In any case, these responses involve major social institutions, such as religion, the legal system, or medicine. In fact, the changes from inactive to active responses lie at the heart of medicalization (Conrad and Schneider, 1992). Behavior that previously went unnoticed, was frowned upon, or punished is increasingly viewed through the medical lens, signaling a biological problem that can be fixed with medical solutions. This process of medicalization has been conceptualized as “defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to ‘treat’ it” (Conrad, 2000: 322). Inevitably, the process of medicalization has resulted in a wide array of social behaviors and emotions to be viewed as a medical problem. In some cases, normal biological processes have been medicalized, including childbirth (Oakley, 1980; Rothman, 1982, 1989), fertility (Becker and Nachtigall, 1992; Friese et al., 2006), sexual function (Carpiano, 2001; Conrad, 2007; Graham, 2007), menopause (Bell, 1987, 1990; Meyer, 2001), andropause, (Szymczak, and Conrad, 2006), aging (Downs, 2000; Harding, and Palfry, 1997) and death (Conrad, 1992). Yet, many conditions subjected to medicalization, and importantly, some of the most contested conditions, fall under the mental health jurisdiction, including children’s behavioral problems (Conrad, 1975; McLeod et al., 2004), adult ADHD (Conrad and Potter, 2000), alcoholism (Schneider, 1978), sadness (Horwitz and Wakefield, 2007), PMS (Figert, 1996), and gambling (Rosencrance, 1985). The contested nature of mental health problems makes them ideal to consider in a comparative perspective as they lie at the heart of sociological debates about the social construction of reality (Berger and Luckman, 1966). As early as the 1960s, many prominent scholars, including psychiatrists, argued that mental illnesses were partly or even exclusively a social construction. For example, Scheff (1966) suggested that mental illness was as much a social role as “real illness.” Szasz (1961, 1970, 1978) viewed mental illness merely as a myth, (1965) illustrated how persons with mental illness were viewed as less acceptable human beings in the seventeenth century. And while later approaches frequently acknowledged the role of biology, they highlighted the role of culture in understanding health, illness, and healing. Here, they pointed out that the categories used to distinguish the sane from the insane are equally constrained by culture and history as biology (Kleinman, 1988; Horwitz, 2002) and interpretations and responses to mental illness are bound by culture (Angel and Thoits, 1987). Further, problems are not merely constructed by others, individuals also use symbols from the larger cultural context to label themselves normal or abnormal (Link and Phelan, 2001. Thoits, 1985). Currently, many social scientists would agree that some mental illnesses have a biological component, yet what is viewed as a mental illness and seen as an appropriate response is, at least in part, socially constructed (Link, 1982; Link et al., 1989; Martin et al., 2000, 2007). Theories of medicalization are ultimately theories of power: who has the power to define, describe and respond to various social behaviors. Therefore, it is not surprising that researchers interested in medicalization focus on the driving forces of medicalization, often attempting to understand how and why the medical profession became one of the key agents of social control in advanced, industrialized nations during the twentieth century. And as the profession was seen as losing extreme power, looking to the countervailing forces in the present (Conrad and Leiter, 2004; Light, 2000) factors underplayed in the past (Pescosolido, 2006; Pescosolido and Martin, 2004) as well as the ways in which medicalization has been helpful, rather than harmful (Ballard and Elson, 2005; Broom and Woodward, 1996; Williams, 2001). And more recently, they have pointed out the possible influence of the pharmaceutical industry, consumers, and managed care (Ballard and Elston, 2005; Barker, 2008; Conrad, 2005; Conrad and Leiter, 2004; Moynihan and Cassels, 2005), with some even arguing that medicalization has transformed into biomedicalization, driven by technological imperatives (Clarke et al., 2003). Although medicalization is a broad societal process that has taken place in all advanced, industrialized nations (Conrad, 2007), theories of medicalization have rarely compared medicalization processes across societies, and usually focus on a single society, most frequently the US, and to a less extent the UK. Given the important interplay of cultural understandings and biological realities, I argue that the lack of comparative perspective is problematic resulting in an incomplete, even inaccurate, understanding of medicalization processes. In general, the comparative perspective helps us to identify settings that are associated with particularly low or high levels of phenomena (Martikainen et al., 2004). They are often the only feasible way to evaluate relationships between policies and outcomes and they improve our understanding of the limits and generalizability of sociological theories and research (Martikainen et al., 2004). Given the unique relationship between the market, the state and medicine in the US, a comparative perspective on medicalization is critical. For example, it has been assumed that medicalization processes have reached greater heights in the US than in any other nation (Conrad, 2007). This can partly be explained by early emphasis among medicalization scholars on the impact of a medical profession that was allowed to operate almost entirely through market dynamics. Consequently, early theories viewed medicalization as being driven by the market and the medical profession. However, this conceptualization may be as much a result of the unique position that the American medical profession found itself in (or forced itself into) as a real reflection of the relationship between the medical profession and medicalization processes. This relationship has always been more complex in other national settings, yet only recently has the potential impact of the state been theorized in medicalization research (Conrad and Leiter, 2004; Olafdottir, 2007) as well as the changes in the doctor-patient relationship in the US (McLeod et al., 2004). However, while this focus has broadened from just the medical profession to changes in delivery of health services more generally, most notably through managed care organizations, the fact remains that these relationships have been primarily theorized within one context, rather than comparing across societies. Pharmaceutical AdvertisingThe medical-industrial complex has transformed health care into medical product linesConrad and Leiter 04 (Peter Conrad and Valerie Leiter, “Medicalization, Markets and Consumers “Journal of Health and Social Behavior Vol. 45, pg. 160, 2004,) JohnsonThe use of advertising, the development of specific medical markets, and the standardization of medical services into product lines have contributed to an increased commodification of medical goods and services. Advertising of health care has become more commonplace (Dyer 1997), and new medical markets have emerged, particularly for specialty services. Imershein and Estes (1996) argue that medical services are increasingly organized into product lines (with attached payment schemes), consistent with a market-based approach to exchange. Cosmetic surgery is the most commodified of medical specialties, offering treatments that are often not covered by insurance, such as liposuction and breast augmentation (Sullivan 2001). Cosmetic surgeons advertise to stimulate demand for their services, for which patients pay cash (or borrow from finance companies that partner with cosmetic surgeons, much like purchasing a car). In the last five years, a loosened regulatory environment has given pharmaceutical and biotechnology companies more freedom in advertising their wares, both to physicians and consumers. The Federal Drug Administration Modernization Act of 1997 made several changes that have facilitated medicalization. Most relevant to our analysis, the act loosened the restrictions placed on the kind of information that pharmaceutical companies could share with physicians regarding “off-label” uses of their drugs, and subsequently, the information that must be included in direct-to-consumer advertisements.Pharmaceutical advertising creates new medical markets by pushing a normalized worldview of healthConrad and Leiter 2004 (Peter Conrad and Valerie Leiter, “Medicalization, Markets and Consumers “Journal of Health and Social Behavior Vol. 45, pg. 160, 2004,) JohnsonMedicalization narrows the definition of health and widens the definition of sickness. The direct-to-consumer advertising focuses on “help seeking” advertisements (Lyles 2002), which try to create an “awareness” of symptoms or conditions among consumers. “Consumer education campaigns” are used to introduce new products or extended applications, essentially bringing new people into a market by creating a previously unrecognized demand for a product (Applbaum 2000). The marketing of Viagra expands the bounds of erectile dysfunction, implying that it is not “healthy” or “normal” to have variation in penile erections. Paxil ads emphasize that it may be pathological to be anxious or shy in social situations and that this can be changed by using the drug. Employing human growth hormone to treat short stature indicates a narrowing of the range of normal height as well as reinforcing the notion that shortness is deviant and undesirable, and that it should be altered. The marketing of Paxil, Viagra and, to a lesser degree, human growth hormone targets relatively healthy people. Drug companies ‘search for markets creates broader disease definitions for their products, indirectly reducing what is “normal.” We highlight the increasing importance of pharmaceutical companies, insurers, and consumers for medicalization as they are involved in the creation of medical markets. The medical profession has a diminished but still key role in medicalization. Given the changes in medicine and its organization, important arenas of medicalization are moving from professional to market domains. It is not new knowledge or technology that engenders medicalization but how they are used. Corporate and medical promotion of products, treatments, and drugs underlies the emergence of new medical markets. With our corporatized medical-industrial complex, the creation or expansion of medical markets becomes an important conduit to medicalization. Consumer demand is not simply unfettered desire for medical solutions, but it is shaped by the availability and accessibility of medical interventions. This creates a new set of relationships among corporate entities, insurers, physicians, and consumers. In the context of the changing balance of power among the medical profession and related institutions, the engines of medicalization are found in the marketplace nexus of the biotechnology industry and rising consumerism. The brakes take the form of insurers, including private and government sponsored managed care. As corporate entities and consumers pursue the goals of promotion or reception of new medical interventions, we are likely to see the development of new medical markets along with a growing pressure to medicalize the troubles and problems of everyday life.ScientismSupposedly “rational” discourses abstract outside their historical contingency, and function to legitimize and operationalize oppressionRacevskis 1983 [Karlis Recevskis, Michel Foucault and the Subversion of the Intellect, Cornell University Press in 1983.] Karlis Racevskis is an emeritus professor of French at Ohio State University.The human sciences, which have been instrumental in setting up specific models of behavior and social organization, are characterized, we have seen, by a basically circular epistemological pattern already highlighted in The Order of Things. They have functioned to determine a certain truth of man by creating an image of his humanity; however, they have been bound to an analytic of finitude that leads them to posit their truths on the basis of their own inherent limitations. Truth in this regard has not set man free but has instituted subjection, since “the man described for us, whom we are invited to free, is already himself the effect of a subjection more profound than himself. A ‘soul inhabits him and brings him to existence, which is itself a factor in the mastery that power exercises over the body. The soul is the effect and instrument of a political anatomy; the soul is the prison of the body” (DP. Pg. 30). This effect of scientifically oriented humanistic discourses is particularly evident in modern penal systems, whose institution is predicated on a “humanization” but whose function is to define the limits of both the law and humanity: “Humanity in the sentences was the rule given to a system of punishment that must fix their limits on both. The ‘man’ that must be respected in the sentence was the juridical and moral form given to this double delimitation” (DP. P. 89). As we saw in the preceding chapter, Foucault’s analyses effectively bring out the dual functioning of discourses which, on the one hand, socialize bodies by making them tame and amenable to the effects of the second purpose— which is the definition and organization of the restraints and coercions to be applied. What is noteworthy in this process is the relation the two discursive effects maintain with each other, whereby one serves to hide the activity of the other. Such a strategy is not intentionally deceptive but is required by the very nature of power, whose success “is proportional to its ability to hide its own mechanisms” (HS, p. 86). The interaction of the two modes of discursive agency is successful to the extent that it manages to conceal the basically disinterested and contingent nature of its operations. This basic process of socialization does not require an a priori subjectivity to be effective, it is always already in effect. Obviously, there are also certain interests that seek to profit from this process by subsuming it under the overriding authority of certain truths. This is accomplished through an appeal to reason capable of disclosing truths by virtue of its disinterested “objective” nature. At the same time, such discourses of truth are neither interested nor capable of taking into consideration the Symbolic dimension of discursive activity in which they are integrated. Consequently, in order to accomplish their aims, they must inevitably rely on strategies of domination or oppression.Statistical demography, which is necessary for the management of insurance products, is the key development in the history of modernity’s harmful ontologies.Harding 16 [Harding, Ian. 2016, University of Chicago Press. Pgs: 65-81. “Biopower and the Avalance of Printed Numbers”] IAN HACKING is a University Professor Emeritus at the University of Toronto and a Professor Emeritus of the chair of Philosophy and History of Scientific Concepts at the Collie de France. Yet there is a quite unintended effect of enumerating, and I call this subversive. Enumeration demands kinds of things or people to count. Counting is hungry for categories. Many of the categories we now use to describe people are byproducts of the needs of enumeration. What could be more inevitable than the class struggle about which Marx hectored us? Yet the social classes are not something into which a society is intrinsically sorted. On the contrary, it is the early nineteenth-century counting-bureaucracies that designed the class structure in terms of which we view society. After 1800, there was a radical shift in the ways in which people were classified in terms of occupation. You might say that came because new occupations arose with the new industrialization. Of course. But that they should be classified in the ways in which we group them was not some inevitable feature of the factories' organization. On the contrary, bureaucrats—even the very factory inspectors or people from the Board of Trade—designed easily countable classifications into which everybody had to fall—and thenceforth did. Nothing was left untouched by the statistician. Nothing is as certain as death and taxes, and though you readily grant that tax brackets are an artifact, ways to die, you will think, are a pan of nature. On the contrary. It is illegal to die, nowadays, of any cause except those prescribed in a long list drawn up by the World Health Organization (WHO).^ This is inherited from the nosology of William Farr, who throughout the middle of the nineteenth century ran the Registrar-General's Office for England and Wales, the dominant fact-gathering institution of its day. As for taxes: taxation was among the earliest motives for counting a people, but if individuals are not to be taxed equally by a poll tax, distinctions must be made. In the beginning, it was deemed impossible to number the people. Only the permanent fixtures of their dwellings would stay still long enough to be counted, and so hearths and windows were the basis of taxation—incidentally, a far more "progressive" mode of taxation than modern income tax, for the rich were soaked vastly more than the poor. Hearths and windows were for long not only the basis of taxation but also the most reliable estimator of the size of the population. One can tell the story of biopolitics as the transition from the counting of hearths to the counting of bodies. The subversive effect of this transition was to create new categories into which people had to fall, and so to create and to render rigid new conceptualizations of the human being.Social MovementsMedicalization operates through social movements as well as doctors and health institutions Conrad 7 (Peter, PhD, Harry Copeland Professor of Social Sciences, “The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders. Johns Hopkins University Press, 2007. ProQuest Ebook Central, . Page 5) carlosThe key to medicalization is definition. That is, a problem is defined in medical terms, described using medical language, understood through the adoption of a medical framework, or “treated” with a medical intervention. While much writing, including my own, has been critical of medicalization, it is important to remember that medicalization describes a process. Thus, we can examine the medicalization of epilepsy, a disorder most people would agree is “really” medical, as well as we can examine the medicalization of alcoholism, ADHD, menopause, or erectile dysfunction. While “medicalize” literally means “to make medical,” and the analytical emphasis has been on overmedicalization and its consequences, assumptions of overmedicalization are not a given in the perspective. The main point in considering medicalization is that an entity that is regarded as an illness or disease is not ipso facto a medical problem; rather, it needs to become defined as one. While the medical profession often has first call on most maladies that can be related to the body and to a large degree the psyche (Zola, 1972 ), some active agents are necessary for most problems to become medicalized (Conrad, 1992 ; Conrad and Schneider, 1992). Many of the earliest studies assumed that physicians were the key to understanding medicalization. Illich ( 1976 ) used the catchy but misleading phrase “medical imperialism.” It soon became clear, however, that medicalization was more complicated than the annexation of new problems by doctors and the medical profession. In cases like alcoholism, medicalization was primarily accomplished by a social movement (Alcoholics Anonymous), and physicians were actually late adopters of the view of alcoholism as a disease (Conrad and Schneider, 1992 ). And even to this day, the medical profession or individual doctors may be only marginally involved with the management of alcoholism, and actual medical treatments are not requisite for medicalization (Conrad, 1992 ; Appleton, 1995 ).ImpactsAbleismThe medical model’s emphasis on individual culpability for disability leads to psychic violenceLang 01 (Dr. Raymond Lang, Senior Research Associate Overseas Development Group University of East Anglia, “THE DEVELOPMENT AND CRITIQUE OF THE SOCIAL MODEL OF DISABILITY”, January 2001, pg. 3-5, Rawle)2. The Origin and Basic Tenets of the Social Model of Disability The social model arose in response to the critique of the medical model of disability. It has generated a caucus of academic writing, predominantly written by academics and activists who themselves have disabilities and is the total antithesis to the medical model. It is not intended to provide a comprehensive review of the medical model within this paper, but to refer to it in relates to the social model. The primary focus of analysis is the manner in which the social model shifts away from consideration of the deficits of the functional, physiological and cognitive abilities of the impaired individual, to the ability of society to systematically oppress and discriminate against disabled people, and the negative social attitudes encountered by disabled people throughout their everyday lives. Disability is therefore situated in the wider, external environment, and is not explicable as a consequence of an individual’s physical and/or cognitive deficiencies. Thus, in focusing upon the manner in which disability is socially produced, the social model gives precedence to the importance to politics, empowerment, citizenship and choice. Furthermore, disability is the result of society’s failure to provide adequate and appropriate services. Consequently, the needs of disabled people are not adequately accounted for within the contemporary social organization of society. It is perceived in attitudinal terms - as a socio-cultural rather than a biological construct. Harlan Hahn, writing within the North American context, stated that disability stems from:- “the failure of a structured social environment to adjust to the needs and aspirations of citizens with disabilities rather than from the inability of the disabled individual to adapt to the demands of society.” (Hahn, H. 1986:128) A further central tenet of the social model is that, irrespective of the political, economic and religious character of the society in which they live, disabled people are subject to oppression and negative social attitudes, that inevitably undermine their personhood and their status as full citizens. Underlying the notion that disabled people are oppressed is the assumption that all societies are characterized by conflict between two competing groups; the dominant and the subordinate. Writing within the context of the politics of disability, James I. Charlton defined oppression as follows:- “Oppression is a phenomenon of power in which relations between people and between groups are experienced in terms of domination and subordination, superiority and control. Those with power control; those without power lack control. Power presupposes political, economic and social hierarchies, structured relations of groups of people, and a system or regime of power. This system, the existing power structure, encompasses the thousand of ways some groups and individuals impose control over others.” (Charlton, J. 1998:30) Charlton also maintains that the majority of disabled people have been so psychologically oppressed by society that their oppression has become internalised. As a result, they have developed a Marxian notion of “false consciousness”, whereby they come to believe that they are less capable than others. Consciousness can be defined as an awareness of oneself in the world. It is a process of awareness that is influenced by social conditions, chance and innate cognition. With regard to “false consciousness”, as a lethal mixture of self pity, self-hate and shame, this state of awareness can:- “… prevent people with disabilities from knowing their real selves, their real needs, and their real capabilities and from recognising the options they in fact have. False consciousness and alienation also obscure the real source of oppression. They cannot recognise their self-perceived pitiful lives are simply a mirroring of a pitiful world order. In this regard people with disabilities have much in common with others who have internalised their own oppression”. (Charlton, J. 1998:27)Medicalization’s ideological dominance renders disabled populations utterly dependent on state control.Lang 01 (Dr. Raymond Lang, Senior Research Associate Overseas Development Group University of East Anglia, “THE DEVELOPMENT AND CRITIQUE OF THE SOCIAL MODEL OF DISABILITY”, January 2001, pg. 12-15, Rawle)Oliver maintained that the economic structure and ideological hegemony of modern western society have had a major detrimental impact upon the lives of disabled people, and also other marginalised groups such as those with differing ethnic affiliations, or those with homosexual orientations. The rise of the factory system and the introduction of individual wage labour transformed the “means of production”, resulting in the separation of the home from the workplace, and in the marginalisation of disabled people, because they were unable to meet the demands of capitalist society. Disabled people have become further isolated from their family communities through the establishment of closed and segregated institutions, (which first came into existence in the late 19th century), whose function was to act as a mechanism for social control. In the latter half of the 20th century, closed and socially isolating institutions still exist which “warehouse” disabled people - for example, within many so called “special schools” and sheltered training workshops. However, during the past 20 years, throughout western-democratic societies, there has been a shift in government policy towards ensuring that disabled people live in community settings, where the package of “care” is bespoked to the individual needs. Within the UK context, this is referred to as the “care in the community programme”, (Priestley, 1999). Oliver further argued that in the wake of capitalism, dominant ideological presuppositions and modes of thought became commonly accepted, which again had detrimental consequences for the lives of disabled people. Analogous to Gramsci’s distinction between “organic” and “arbitrary” ideologies, He distinguished between “core” and “peripheral” ideologies, the latter being derived from the former. In relation to ideology, it was argued that the rise of capitalism necessitated the separation of work from home (as stated above), which in turn gave rise to the ideological construction of individualism, which became the “core” ideology vis-a-vis disability. Consequently, the rise of capitalism gave rise to the premise that disability is in essence an individual pathology, since a distinction needed to be drawn between those considered “ablebodied”, (and by implication able to work), and those who were considered disabled. Hence, within the modern capitalist era, “disabled people could not meet the demands of individual wage labour and so became controlled through exclusion”. This process of individualism gave rise to the peripheral ideologies of categorization and medicalisation of disability. In order to make a valid distinction between the deserving and undeserving poor, the agencies of the state assigned the medical profession the role of deciding who was disabled and who was not. This process, initiated during the 19th century, continues to have important ramifications for contemporary service provision, where it is commonly assumed that the greatest problems encountered by disabled people are directly related to their medical conditions. The medical profession still has a great deal of influence in the manner in which disabled people live, invariably being seconded by agencies of the state to make assessment of their needs and abilities, often in areas which have little to do with the application of medical science. Examples falling into this category would include the entitlement for financial grants, wheelchairs and other appliances, assessing the ability of a person to drive, and selecting appropriate educational provision. A possible explanation of the continued, and some would argue expanding, influence of the medical profession in the lives of disabled people is that the profession has widened its remit within the field of medical science to incorporate rehabilitation. Oliver, in support of this thesis, quoted Albrecht and Levy:- “As demand for rehabilitation services increased and insurance benefits expanded, there was an incentive for physicians to enter the rehabilitation field. Under the aegis of designing comprehensive medical rehabilitation programs, hospitals, and physicians began to incorporate rehabilitation services into the medical model. Definitions of disabling conditions and appropriate treatment were expanded to include medical interventions and physical control”. (Albrecht, G. and Levy J. 1981:22). Oliver continued his analysis by arguing that the economic and social structures of society, in combination with the dominant ideological hegemony, have resulted in disabled people being perceived as “dependent”. Consequently a great deal of the social welfare legislation enacted during the post-war period has compounded this notion. The term “dependency” is used in a two-fold manner. Firstly, welfare states have categorised entire groups of people, of which disabled people are but one, who have become dependent upon the state for the provision of education, health care, as well as financial support. Secondly, in specific relation to disability, attention has focussed upon the functional limitations of disabled people who are perceived to be unable to care for themselves.AutonomyPeople’s rightful autonomous ability to cope will be restored when the social workings behind overmedicalization are uncovered Illich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] I am much more concerned about the iatrogenic effects of the social structure, social behaviour, the social rituals built around the application of medical technology to people who are supposedly sick or who might become sick and to their environment. I started out with a definition of what health means for me: an ordinary language word to indicate the level of autonomy. I call 'overmedicalization' a level in a society of intensity of medical care so high that the ability of people to survive depends primarily on inputs from a specialized industry, and at the same time their environment is impoverished; a level of specific health-related devices and tools so that their willingness and intention to take care of their own health declines. Overmedicalization or the overexpansion of medicine will be diagnosed in a society when in that society the ability of people to deal on their own or in the primary group and in their natural unspecialized environment with pi, with disease, with incompetence or impairment, and with anguish, particularly the anguish of death, begins to decline thanks to increasing offers of heteronomous professional services in these areas. We must move away from seeing healthcare as a substitution of autonomous abilityIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] Health care can mean two things: an increase in this autonomy, or, and that is a very strange way of using the concept of health care, substituting for the autonomous ability to cope with changing environments and changing, decaying perhaps, internal states, engineered inputs which adapt that organism to its environment or which render the environment less trivial; decrease the level of noise in the environment and thereby make it supposedly more suitable for that organism. In thinking about these matters I come, therefore, to the conclusion that (at least if my starting point is not wrong) there must be some level beyond which any further attempt at improving health by transforming autonomous coping into heteronomous maintenance, what I originally called 'health', must decline. I start with a dilemma.BiopoliticsYour thesis of medicalization needs to be updated – modern technology has transformed medicalization into a necessary agent in protecting civil liberties.Nye 3 (Robert A. Nye, “THE EVOLUTION OF THE CONCEPT OF MEDICALIZATION IN THE LATE TWENTIETH CENTURY,” Journal of History of the Behavioral Sciences, Vol. 39(2), p. 123-125)It is tempting to draw the conclusion from these examples that there is an inverse relationship between the progress of the medicalization in the twentieth century and individual liberty—that a doctrine of the healthy citizen has displaced, in some degree, a regime of the citizen of rights. I think that this is what much of the early scholarship on the growth of medical power aimed to reveal. However, much recent work has argued for the complexity of this picture. The liberal state, in both its late nineteenth-century guise and its modern neoliberal incarnation, has proven more resistant than we might have thought to the triumph of a medical perspective over individual rights. As Graham Burchell has written, “. . . the state’s interventions in particular areas of life are brought under critical scrutiny in terms of their legitimacy (do they encroach on the necessary freedoms of individuals?) and the competence and cost-effectiveness of its methods (can the objectives be achieved without state intervention: that is by members of society themselves?)” (Burchell, 1991, p. 143). To be sure, in the twentieth century where the juridical institutions or procedures have been liquidated or crippled, the doctrine of the healthy body has been transformed into a justification for hygienic elimination of the weak and unfit, the medical sequestering of political and civil deviants, and a thoroughgoing control of reproduction and women’s bodies (Kater, 1989; Proctor, 1988; Weindling, 1989). We know about these examples only too well, but although they may serve to remind us of the dangers of the horrifically unfettered practice of a medicalized vision of the good society, they provide a distorted view of how the modern welfare state governs the bodies of people with sovereign rights. They also fail to appreciate the fact that the proliferation of medical knowledge itself has not always served the interests of medical authority but has also been used as a form of resistance and self-defense against it, indeed in precisely the way Foucault described knowledge – power reversals in the so called disciplinary society. Let me give a few examples. First, as Abram de Swaan has argued, although doctors are always on the lookout for personal and professional reasons to medicalize a condition the treatment of which will increase their power or income, in the modern state they often as not act as experts in conflict resolution between private individuals and insurors or between individuals and state entities. The expert medical witness has been performing such a service for many years. Today, however, medical opinion may have a bearing on matters ranging from the ability to hold down a job, be a good parent, receive injury compensation, and a host of other typical conflicts in the modern welfare state. Individuals at a legal disadvantage may find in medical expertise the leverage to turn matters in their favor or achieve a settlement that reaches a compromise (de Swaan, 1988, pp. 241 – 244). When matters of fact and opinion on health are themselves in conflict, say in the matter of medical marijuana, or in a number of issues in alternative or homeopathic medicine, a decisive appeal to some standard or authoritative medical model is less and less likely. The United States and some other Western countries are attempting, however awkwardly, to resolve these differences in the legal and administrative arena according to a doctrine of “best available information” mixed together with a strong dose of concern for legal rights and precedents. More interesting are direct conflicts between health authorities and defenders of individual rights. Even where a tradition of liberal rights has not been historically robust, defenders of patients’ rights have successfully used the courts to thwart internment of the insane, as Ann Goldberg has recently shown for Imperial Germany (Goldberg, 2002, 1999). Also, where such disputes are regularly mediated by the courts, as in the United States, there is little evidence that the medical perspective will prevail even in an unequal contest. In a recent case involving the Medical University of South Carolina, medical staff tested the urine of selected maternity patients for evidence of crack cocaine use. Thirty women were arrested, separated from their newborn children, and taken to jail. As the lawyer for the hospital said, “Law enforcement was not the purpose of this thing at all. All it did was help people get off cocaine and avoid the tragedy of these pathetic babies coming into the world” (a clearly disingenuous argument, since the testing took place shortly before birth). The U.S. Supreme Court seems to be ready to consider both health and rights together in this case, ruling that women’s rights were violated and that such measures will have a negative public health benefit in discouraging women to seek prenatal care (Greenhouse, 2000). Juridical eclecticism of this kind seems a more likely outcome of conflicts of this sort than the pitting of health “duty” versus individual “rights.” As I have suggested, in the modern Internet information age medical knowledge has helped undermine medical authority and has encouraged individuals to take more responsibility for their own health care. My mother-in-law often knows more about the contraindications of the drugs her doctor prescribes than he does himself. When medical knowledge has been more widely circulated it has usually served individual rather than state interest. The greatest irony of the huge public campaigns for increased reproduction in European states between the wars is the fact that teaching women more about the anatomy and physiology of reproduction by way of promoting healthy and numerous births, as occurred in Germany, Italy, and France, simply taught women how to control their fertility with greater assurance. Birthrates leveled off or declined at least partly as a result of this knowledge, and this trend continued into the last half of the twentieth century (Grossman, 1995; Horn, 1994; Roberts, Base of text 1994). Finally, we have seen in recent years the efficacy of civil resistance to heavy-handed public health initiatives. In response to the first stages of the HIV/AIDS epidemic, the American Center for Disease control issued its infamous 4-H list of high-risk categories, in reality straightforward “embodiments” of illness and/or deviance: homosexuals, hemophiliacs, heroin addicts, and Haitians. These individuals together with the “gay” lifestyle were marked out in advance for potential risk, if not outright quarantine. However, in the information age no one has a monopoly on the truth, or at least on public representations of it; gay activists like Larry Kramer and researchers throughout the West largely succeeded in not only resisting some further pathologization of homosexuality but helped set epidemiologists on a more productive track for research and treatment (Treichler, 1997). There are examples of other diseases—multiple sclerosis, polyposis coli, Huntingdon’s chorea, and in France myopathies, and the tainting of the blood supply of hemophiliacs—where an effort to medicalize a (usually genetic) condition has provoked the formation of a medical interest group that then relentlessly pressures medical researchers to work in behalf of its members.Medical and economic questions are so intertwined as to produce biopolitical control when using one to address the other; instead, we need to politicize questions concerning healthFox 77 (Renee C. Fox, PhD, “The Medicalization and Demedicalization of American Society,” Daedalus, Vol. 106, No. 1, Doing Better and Feeling Worse: Health in the UnitedStates (Winter, 1977), p. 15-16, The MIT Press) Talcott Parsons's well-known formulation of the "sick role" provides important insights into what these effects have been. According to him,11 the sick role consists of two interrelated sets of exemptions and obligations. A person who is defined as ill is exonerated from certain kinds of responsibility for his illness. He is not held morally accountable for the fact that he is sick (it is not considered to be his "fault"), and he is not expected to make himself better by "good motivation" or high resolve without the help of others. In addition, he is viewed as someone whose capacity to function normally is impaired, and who is therefore relieved of some of his usual familial, occupational, and civic activities and responsibilities. In exchange for these exemptions which are conditionally granted, the sick individual is expected to define the state of being ill as aberrant and undesirable, and to do everything possible to facilitate his recovery from it. In the case of illness of any moment, the responsibility to try to get well also entails the obligation to seek professionally competent help. In a modern Western society, such as the United States, this obligation involves a willingness to confer with a medically trained person, usually a physician, and to undergo the modes of diagnosis and treatment that are recommended, including the ministrations of other medical professionals and hospitalization. Upon entering this relationship with institutionalized medicine and its professional practitioners, an individual with a health problem becomes a patient. By cooperating and collaborating with the medical professionals caring for him, the patient is expected to work toward recovery, or, at least, toward the more effective management of his illness. The fact that the exemptions and the obligations of sickness have been extended to people with a widening arc of attitudes, experiences, and behaviors in American society means primarily that what is regarded as "conditionally legitimate deviance" has increased. Although illness is defined as deviance from the desirable and the normal, it is not viewed as reprehensible in the way that either sin or crime is. The sick person is neither blamed nor punished as those considered sinful or criminal are. So long as he does not abandon himself to illness or eagerly embrace it, but works actively on his own and with medical professionals to improve his condition, he is considered to be responding appropriately, even admirably, to an unfortunate occurrence. Under these conditions, illness is accepted as legitimate deviance. But this also implies that medical professionals have acquired an increasingly important social-control function in the society. They are the principal agents responsible for certifying, diagnosing, treating, and preventing illness. Because a greater proportion of deviance in American society is now seen as illness, the medical profession plays a vastly more important role than it once did in defining and regulating deviance and in trying to forestall and remedy it. The economic, political, and legal indicators of a progressive medicalization cited above also have complex origins and implications. For example, the fact that activities connected with health, illness, and medicine represent a rising percentage of the gross national product in the United States is a consequence of the fee-for-service system under which American health-care delivery is organized; the central importance of the modern hospital in medical care; the mounting personnel, equipment, and maintenance costs that the operation of the hospital entails; and the development of new medical and surgical procedures and of new drugs, most of which are as expensive as they are efficacious. Some of this increase in costs results from the desire for profits that medical professionals, hospital administrators, and members of the pharmaceutical industry share to varying degrees. But how much is difficult to ascertain, though radical ideological criticisms and defensive conservative statements on the point are both rife at present. In addition to such political and economic factors, the heightened commitment to health as a right and the medicalization of deviance have also contributed to the growth of health expenditures. Because health is both more coveted and more inclusively defined, and because a greater amount of medical therapeutic activity is applied to deviance-defined-as-illness, increasing economic resources are being invested in the health-illness-medicine sector of the society. The political and legal prominence of questions of health care and medicine in American society at the present time reflects in part a widespread national discontent with the way medical care is organized, financed, and delivered, and with some of the attitudes and behaviors of physicians. The inequities that exist in access to care, and in its technical and interpersonal excellence, are among the primary foci of political and legal activities. Another major area of current political and legal action concerns the internal and external regulation of the medical profession better to insure that it uses its knowledge and skill in a socially as well as medically responsible way, and that it is adequately accountable both to patients and to the public at large. Various new measures, which represent a mixture of controls from within the medical profession and from outside it, have been set into motion. For example, in 1972, the Professional Standards Review Organization was established through the passage of amendments to the Social Security Act which were designed to provide quality assessment and assurance, utilization review, and cost control, primarily for Medicare and Medicaid patients. Over the course of the years 1966 through 1971, a series of government regulations were passed which mandate peer review for all biom?dical research involving human subjects, supported by the Department of Health, Education, and Welfare (and its subunits, the National Institutes of Health and the Public Health Service), as well as by the Food and Drug Administration. In 1975, the American College of Surgeons and the American Surgical Association set forth a plan for systematically decreasing the number of newly graduated doctors entering surgical training. In part, this plan represented an organized, intraprofessional attempt to deal with what appears to be an oversupply of surgeons in the United States, and thereby to reduce the possibility that federal health manpower legislation would have to be passed to remedy this maldistribution.Biopolitics (Net-Widening)Internalization of oppressive values through society ignoring the claims of those who are effected by the medicineWardope 14 (Alistair Wardrope, Psychosomatic Medicine, Neurology, Philosophy of Science, “Medicalization and epistemic injustice”, Med Health Care and Philos, 11/09/2014, pg 348-349, Rawle)This range of negotiated responses to and engagement with the medicalization of conditions can be found in other classic controversial medicalization cases, in particular ADHD. As described above, many commentators are particularly critical of the medicalization of disruptive childhood conduct in the diagnosis of ADHD, and see its medical management as oppressive socialisation of children into conformity; these children are then either forced to take medication that subdues them and renders them incapable of resistance, or else come to internalise such oppressive values, embracing their use (Rose 2013; Fraser 2013). Once again, though, the testimonies of children with ADHD diagnoses exhibit a far greater range of stances toward the medicalization and medication of their condition than critics allow. In a remarkable study of the views of children with ADHD and their parents, Singh (2013b) explored these stances. A small minority of the cohort expressed views akin to those of critics, identifying with the untreated child, rejecting the diagnosis, and expressing sentiments like ‘‘I wasn’t myself’’; a few others partially endorsed this perspective, accepting a medicalized description of their behaviour but expressing concern regarding alienating ‘side-effects’ of stimulant medication. The majority, however, rejected the medicalization critique’s analysis—they did not lose themselves to medication, but could rather use it as a tool by which they were able to modify their behaviour as desired; some viewed this modification as one of modulating the degrees of influence of contrasting aspects of their character (‘‘When I’m on my medication I’m still [myself]. It’s just that I’m a bit more and a bit less of some of the things’’), while others looked on the ADHD as a straightforwardly pathological—and thus alien—influence (‘‘If you’re like driving in a car, and like, there’s two different ways, and you usually always go this way … and then one day you want to go the other way, but … the ADHD acts as like a blocker, so you can’t … [Medication] opens the blocker so that you can go [the other] way. But you still have the choice of going the wrong way.’’). Critiques of the medicalization of these conditions, then, fail to represent the testimony of many of these patients. Short of simple ignorance of this testimony (culpable, given the subject at hand), this suggests that critics do not accord such testimony high credibility, granting the first premise of the argument to testimonial injustice. The fourth premise— that of harm or disadvantage arising from others’ lack of belief in the testimony—follows straightforwardly insofar as the primary harms of testimonial injustice are intrinsic to one’s not being believed. If, as some of Karp’s interviewees suggest, ignorance of such testimony can contribute to a failure to understand the effects of psychiatric medication and consequent stigmatisation of psychiatric treatment seeking, it may also produce secondary harms. A credibility deficit that may in some sense be harmful establishes premises (1) and (4) of the argument to testimonial injustice. What remains is the question of whether the credibility deficit is unwarranted and thus unjust— more specifically, whether it is unwarranted because based on prejudice. Medicalization, medical subjectivity, and adaptive preference How might one justify assigning low credibility to such testimony without resorting to prejudice? Where this question is engaged with at all, the common strategy is to attribute this testimony to the social-constructive power of medicalization and its institutions. This may be soft-power coercion, where those making the testimony endorse a medicalized account due simply because to do otherwise might entail substantive material costs (even though a gun is not being held to one’s head)—Rose (2013), for example, suggests that Singh’s interviewees with ADHD respond less out of honest reflection than ‘‘in self-protection’’ when confronted with ‘‘yet another adult authority figure’’, while Morgan (1998, 92) highlights the material costs inherent in being labelled ‘‘non-compliant’’ by health care providers. Or it may be more insidious—involving not an external imposition of oppressive norms, but an internal one, variously described as ‘internalised oppression’, ‘oppressive socialisation’, ‘medicalized subjectivity’ or ‘adaptive preference’ (Morgan 1998; Cosgrove 2011; Rose 2013). This response argues that support for a norm, practice, or conceptualisation, while ‘freely’ expressed, may not be autonomously or authentically so, if the agent’s endorsement is itself a function of oppression. The overwhelming influence of oppressive practices within the environment of the agent’s moral and conceptual development predict that they would grow up to embrace their chains—but, if able to reflect properly on the influence of that environment on their development, they would, seeing clearly, cast them off. This may be compounded by distinctly epistemic features of the oppression—for example if (as with hermeneutical injustice) it deprives agents of the conceptual resources to express, let alone endorse, alternatives; or if (as with the much-discussed ‘gaslighting’), it centrally concerns undermining the agent’s self-trust in their capacities as an epistemic agent.Medicalization reaches all the way down into the construction of subjectivity – in a medicalized society, we discipline and normalize ourselvesWardope 14 (Alistair Wardrope, Psychosomatic Medicine, Neurology, Philosophy of Science, “Medicalization and epistemic injustice”, Med Health Care and Philos, 11/09/2014, pg 344, Rawle)The relationship between medical hermeneutical injustice and social control is explored further by those who develop a Foucauldian medicalization critique. Employing Foucault’s concept of ‘biopower’—the operation of power through distributed, self-enforced regulatory mechanisms—these accuse medicalization of being a tool of social control. Such critiques bring to the fore the ‘‘medicalized subjectivity’’ produced by medicine’s hermeneutical privilege. When available conceptual resources encourage us to perceive phenomena through a ‘medical gaze’, it is claimed that this both legitimises direct institutional intervention in those phenomena (Conrad 1992, 216), and enforces practices of self-policing and self-surveillance that constrain agents to opt for the ‘responsible’, ‘healthy’ course of action over nonconforming alternatives (Morgan 1998; Verweij 1999; Kukla 2005; Cosgrove 2011). This medicalized subjectivity, authors claim, can be seen at work not just in psychiatric diagnosis, but also in pregnancy and postnatal health care, and in preventive medicine and health promotion. Several ethical concerns are expressed with reference to this manifestation of medical authority: that it threatens patient autonomy in ways not adequately captured by the usual institutional means of protecting and respecting autonomy (Kukla 2005; Cosgrove 2011); that it amounts to an illiberal enforcement and dogmatic acceptance of a particular conception of what is valuable in life (Verweij 1999); or that, by emphasising self-surveillance and healthpromoting behaviours, it can individualise responsibility for complex social problems (Verweij 1999; Clark 2014).Clinical IatrogenesisThere are four types of clinical iatrogenesis we must focus on to expose their importance: malpractice, accidents, accepted risks, and defensive practiceIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] I suggest that we first focus on the kind of iatrogenesis about which I assume most of the other speakers intend to speak, namely, the clinically verifiable, specific health-denying or disease making effects of specific medical interventions, pathologies known in the classic notation of medicine which are increased through the practice of medicine. These are not my concern and I am not here for the remning 19 minutes of my paper in order to lose too much time over them, but I wish to focus on them so that it is very clear in what I am personally relatively uninterested. Because I consider it secondary, I consider it a little bit scandalous. I am in agreement with the saying that one should not wash one's dirty linen in public, and this is the dirty linen of doctors - not my business. And third, because I believe that the more we speak about it, the more people will think that that is the issue which makes the iatrogenic impact of medicine important. I distinguish four categories in clinical iatrogenesis. These are not medical categories; these are the categories which an outsider or a jurist or a philosopher finds. One is malpractice, negligence, professional callousness. These are matters between the doctor and his creator, if he has one, or the doctor and the law. These are matters for which we accuse a doctor or a nurse of guilt. We tell him, 'You are guilty'. A second category is accidents. Human error or systems break down. Increasingly, we have systems breaking down as medicine becomes more complex. Things which formerly would have been called callousness are now called inefficiency. Things which formerly would have been called lack of training, are now called a lack of engineering or underdevelopment of apparatus, or the need for further research funds ! I do not have to tell you of the evidence which exists in certain countries where one out of four or one out of five patients, depending upon whether the hospital is a university hospital or a simple general hospital to which he is admitted, acquires a specific new iatrogenic disease by hospitalization. The third category is the specific risks which are accepted. I am not saying whether they are acceptable or not. These are the diseases of medical progress inevitably connected with the administration of certain cures or certain diagnostic tools. And finally, the fourth type of clinical iatrogenic disease, which, for practical purposes I think one should see as clearly separate, is that which Dr Quentin Young from Chicago calls 'the damages resulting from the defensive practice of medicine'. This is a matter much more for certain countries, such as the United States, where malpractice suits are so common and where, Young believes, at this moment the major source of iatrogenic, of clinical iatrogenesis is medicine practised in a defensive way in order to protect doctor and hospital against the accusation of malpractice.The economic, divorced nature of medicine has created a Paradox of Conglomeration Illich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM]What is common to all these four subclasses of clinical iatrogenesis is what has been called 'the paradox of conglomeration'. We specialize functions, thereby we specialize measurements, series of interventions, each one judged by the relative specialist as a success conglomerate on a higher indicator as a loss, as direct counter-productivity in the area of health. When during the rush hour, I add my car to other thousands of cars on the highway, between entrance and exit, which normally would take me only 15 minutes, I might lose 45 minutes. I add 45 minutes to my traffic-related time investment in life, but while I lose half an hour, my presence on that highway has been calculated as creating a loss of at least 50 if not i5o hours to other cars which are on that highway, each a little retarded because of my presence there. Clinical iatrogenesis from this abstract, economic point of view seems to be nothing more exciting than the congestion effect appearing in medicine.Corporate CaptureMedicalization reifies corporate control over individuals’ self-determination Arunima 12 (Arunima, Sarvdeep Kohli Department of Psychology, M.D. University, Rohtak. “Medicalization : A Growing Menance.” DELHI PSYCHIATRY JOURNAL. October 2012). Social medicalization which has been described as a form of social control in which individuals and their problems are taken into the fold of the medical establishment and can be manipulated. Economic medicalization is the transformation of the process for doing clinical trials into exercises that are motivated more as marketing vehicles than needed. Dependence of medicine would make people obsessed about health as a value and lead to the “medicalization of life”, with a gradual loss of the right of people to self determinism. Medicalization contributes to the belief that people are not responsible for the actions. Medicalization; whose goal is to hold trouble makers blameless. It is often said that leading drug companies now spend more on marketing than on research and development this can lead to disastrous consequences. the biomedical profession is intruding upon the experience of everyday life and is doing so to increase its profit in the drug industry. Many believe that it jeopardizes medical/ Hippocratic professionalism and others opine that it undermines evidence- based medicine; it also alters the prescribing habits. In addiction, the label of disease or illness may attach a stigma of the individual being labelled, increasing the individual’s experience of life as “sick” or “disordered”.CounterproductivityParadoxical health-denying results from increased investment in med tech is a product of medicine we are obligated to faceIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] Finally, we observe - I observe at least - that increasingly the unwanted, non-technical effects which result from increased investment in medical technology produce directly health-denying results. This is no more a cost, or no more an external, which can be shifted from medicine, for instance, onto the education department. This is a paradoxical counter-product of medicine, a strange effect which we ought to face at this moment, because it appears to crop up in all other major enterprises in society and so far has left us confused because we have not named it. They are costs, they are externals. Costs are benefits which are shifted from one institution to another, and there are paradoxical counterproducts which our major institutions produce which no other institution produces, within which this counter-productivity remains locked. I consider that an institution has become counterproductive when its further development removes society from a purpose or a goal for which society originally had financed, established and organized that institution. When the acceleration of traffic becomes increasingly time-consuming, this is an effect which I call 'counter-productivity'. When legitimate learning becomes defined as only that which happens in a certain curriculum within schools and thereby autodidactic learning is devalued, very soon schools serve for training for specialized incompetents! This is specific counterproductivity in the field of education. When medi-cine reaches a certain point at which there is serious discussion as to whether its unwanted side effects are in the field of health or not, its healthdenying, health-destroying effects are not more important than its healing effects, then medicine is threatened by counter-productivity. The reason why I became involved in a study of medicine had nothing to do with helping other people, individuals, to be less sick as individuals. My interest in medicine was brought about entirely by my belief that in the case of medicine I can describe several different types of counter-productivity. I can develop a taxonomy of iatrogenic health-denial and disease which then helps me to develop very similar, almost identical, catalogues by which I can distinguish the different kinds of counterproductivity in traffic, urbanization, food production or educational institutions. DehumanizationBiomedicalization reduces the body to a merely physical and mechanistic phenomena that is best interpellated through highly expensive technology; this forces medical practices into positive feedback loops of uncertainty where the only constant is corporate profitSulik 11 (Gayle Sulik, PhD, “‘Our Diagnoses, Our Selves’: The Rise of the Technoscientific Illness Identity,” Sociology Compass 5/6 (2011), p. 467-469, State University of New York at Albany)Stakeholders in the medical profession such as health care providers, the health care industry, insurers, the state, and medical consumers, each hold competing interests in medicine that constrain the autonomy of the profession and enable contestation (Light 2000). Insurers and providers struggle to shape health care coverage (Quadagno 2004). Pharmaceutical organizations lobby professional medical societies, government agencies, and consumers through public awareness campaigns to gain buy-in for new drugs (Connell and Hunt 2010). Indeed the most powerful stakeholders within the medical system compete to influence standards and clinical guidelines, create policies and procedures, maintain internal controls, and produce professional knowledge (Clarke and Shim 2009; Fisher 2009; Freidson 1994; Parsons 1951). Importantly, the biomedical framework that underlies the system as a whole remains tantamount. The biomedical model relies on unique causality, consistent and recognizable symptoms, and scientifically determined diagnosis and treatment (Weitz 2010), suggesting that unruly body processes can be reduced to specific mechanisms that can be objectively identified, measured, treated, and (hopefully) fixed. Although there has been a shift toward more integrative approaches to treatment and healing, the biomedical model constructs the body rationally and mechanistically (Fries 2008; Hollenberg 2006). In turn, technoscientific biomedicine relies on high technology to reduce the body to smaller and smaller parts at a level far beneath human experience (i.e. cells, molecules, genes, etc.). Technoscientific advancements attempt to pinpoint, and keep track of, biological mechanisms at finer degrees of precision, and with greater accuracy and efficiency (Helman 2001). In the 21st century, technoscientific biomedicine has taken on a life of its own. Technoscientization refers to the ongoing process of understanding, diagnosing, monitoring, and treating biomedical processes through high technology (see Clarke and Shim 2009). The main areas of technoscientization involve molecularization and geneticization, computerization and data banking, and the design, development, and distribution of medical technologies (Clarke and Shim 2009, 215). New technologies, treatment modalities, and pharmaceuticals are constantly being developed, studied, and marketed to the general population (Light 2010; Loe 2006; Moynihan and Cassels 2005; Rosser 2000). Clinical trials require billions of dollars in medical equipment and new technologies to test new drugs and therapies (Fisher 2009; O’Meara 2009). All of these new advancements help to create new medical markets (Conrad and Leiter 2004), in which profit motives and proprietary interests, as opposed to intellectual curiosity, may be driving the research (Moynihan and Cassels 2005; Schafer 2009; Sulik 2010). In the United States, more than 75 percent of drug trials are now conducted in the private sector (Fisher 2009). The pharmaceutical industry, with global sales in the trillions of dollars, relies on high technology to be one of the most powerful and profitable industries in the world (Berkrot 2010). In addition to market incentives, the dependence upon technoscientific advancements in biomedicine creates a widening divide between basic and clinical research and a polarizing effect between those who would direct it (Schafer 2009). The knowledge and practices produced throughout technoscientific biomedical apparatuses are complex and highly specialized, requiring the expertise of a professional elite (Bryan et al. 2006; Henwood et al. 2003; Hollenberg 2006; Wathen et al. 2008). Our Diagnoses, Our Selves 467 ? 2011 The Author Sociology Compass 5/6 (2011): 463–477, 10.1111/j.1751-9020.2011.00374.x Sociology Compass ? 2011 Blackwell Publishing Ltd Exclusionary language helps to differentiate between specialists and other medical professionals, in particular creating a chasm between biomedical researchers and clinical practitioners. In The Vanishing Physician-Scientist, Andrew Schafer MD argues that there is such a ‘language barrier’ between basic scientists and clinical practitioners that, ‘the growing alienation of physicians from serious research careers largely parallels and reflects a widening schism between basic science and clinical medicine’ (2009, 7). The physician–scientist who once relied on clinical experience to develop new research and understanding of body processes, referred to as an ‘endangered species’, has given way to a cadre of nonphysician scientists who may have limited, if any, clinical experience. With the rapid increase in specialized techniques and biomedical language, it is increasingly challenging for specialists to stay current amid the complex and rapidly changing areas of biomedical research and the development of new technologies (Callahan 2009; Hunter and Cohen 2006). According to Hunter and Cohen (2006), the National Library of Medicine’s PubMed database is expanding at a compounded annual growth rate of about 4.2 percent, which is contributing to ‘literature overload’ (589). With over 16 million publications in the system, over 3 million were published in the last 5 years. Running parallel to the production of specialized knowledge, specialist doctors now comprise about 80 percent of total physicians in the United States (Callahan 2009). Unfortunately, the substantial increases in biomedical research, knowledge, technoscientific advancements, and specialists do not necessarily reduce biomedical uncertainty – the gap between biomedical knowledge and diagnostic, treatment, and prognostic practices. Biomedical uncertainty is a primary concern of the biomedical age. It affects how knowledge translates to clinical practice and doctor–patient communications as well as patients’ functional awareness and decision-making. The three dimensions of biomedical uncertainty explored in medical sociological research are defined as clinical, functional, or existential. Clinical uncertainty is related to limitations to what is known about a particular condition, how to deal with it, or to practitioners’ mastery of the existing knowledge base (Adamson 1997; Fox 1999; Parsons 1951). Functional uncertainty shapes doctor–patient interactions, such as when medical practitioners know and understand the signs of a terminal illness but patients themselves have little to no awareness about the probability or timing of their own death (Glaser and Strauss 1965). When the cause of one’s illness is unknown, treatment is indeterminate, or there is a misdiagnosis or incorrect treatment, patients may experience existential uncertainty (Adamson 1997; Weitz 1989). It is likely that all three types of uncertainty operate at once in many medical encounters. The incessant advancement of science and medicine is especially likely to increase uncertainty at the clinical and existential levels. Parson’s (1951) argued that as doctors relied more completely on specialized scientific technology to consult with patients and construct diagnostic and treatment protocols. The implications are far ranging, including: not knowing which people with a genetic predisposition will get a particular disease, not knowing which biomedical information will be reliable (e.g. excessive false positives on a mammogram), not knowing how to interpret particular biomedical data (e.g. whether to classify abnormal cells that do not have the capacity to spread as a carcinoma), not knowing the shelf life of biomedical information (e.g. high recurrences of certain cancers following a cancer free period), and having difficulty gaining a command of the technological skills and knowledge bases that are continually changing (e.g. implications of the latest clinical trials or accuracy in reading mammograms) (see Fisher and Ronald 2008; Fox 1999; Partridge et al. 2008; Rosser 2000; Rothman 2006; Sulik 2010). 468 Our Diagnoses, Our Selves ? 2011 The Author Sociology Compass 5/6 (2011): 463–477, 10.1111/j.1751-9020.2011.00374.x Sociology Compass ? 2011 Blackwell Publishing Ltd Even in the face of biomedical uncertainty, health practitioners are charged with processing, interpreting, communicating, and acting upon biotechnological information. Biomedical specialists routinely rely on high tech histological representations and biochemical markers to determine etiology, diagnosis, treatment, and aftercare for an increasing number of medicalized conditions and health? body enhancements (Conrad and Potter 2004). Since the language needed to understand biomedical technoscience is complex, esoteric, and virtually incomprehensible for those without scientific backgrounds, this exclusivity grants authority to biomedical knowledge and positions as experts those who produce and communicate it (Kerr et al. 2007). Thus, the rapid expansion of, and reliance upon, biomedical technoscience influences the means through which medical consumers gain access to specialized biomedical information, the kinds of information they obtain, and their capacity to understand and use it (Halfon 2010; Henwood et al. 2003; Wathen et al. 2008). Highly specialized biomedical language and increased biomedical uncertainty contributes to the re-mystification of modern medicine and erodes to some degree the empowerment potential of medical consumers in more cooperative doctor? patient relationships (Sulik 2009).DepoliticizationMedicalization depoliticizes healthBambra et al. 5 (Clare Bambra, PhD; Debbie Fox and Alex Scott-Samuel; Department of Sociology and Social Policy, Sheffield Hallam University and Department of Public Health, University of Liverpool; “Towards a politics of health,” Health Promotion International, Vol. 20 No. 2, Oxford University Press, p. 191)The conceptualization of health as non-political is also in part due to medicalization—the transfer of power over and responsibility for health from individuals, the public and therefore political life, to powerful elites, namely the medical and health professions and the multinational pharmaceutical companies. When we conceive of ill-health as episodes of disease manageable by the delivery of healthcare, we are . . . transferring the responsibility for health from society as a whole to an elite possessing what we define as the necessary professional and technical expertise for the management of disease (ScottSamuel, 1979). However, unlike the impression given in the above quote, this transfer of responsibility is not always voluntary. Drug companies and the medical profession have taken the power and responsibility for health for themselves (Illich, 1977). They have thus been able to determine what health is and therefore, how political it is (or, more usually, is not). Their historic power over the definition and management of health has contributed substantially to its depoliticization: health is something that doctors are responsible for, they are the providers, and we are the recipients. Their authority and responsibility over health has further emphasized its commodity status—when ill, an individual visits a doctor and/or purchases drugs (commodity) to regain health (another, albeit less obvious commodity). Ill-health is a transient state caused by the presence of disease. It can be ended by the appropriate application of medical technology. This depoliticization of health, via the transfer of power and responsibility to these professional and/or commercial groups, means that we do not acknowledge our power over our own health or our autonomy over our own bodies.Health Care CostsMedicalization expands the functions of normalization which require that more and more social problems are viewed medically; this exponentially increases the costs of health carePackham 2010 [John, Director of Health Policy Research at the University of Nevada School of Medicine and Past President of the Nevada Public Health Association “The medicalization of society” Reno Gazette-Journal / ]In 1970, Americans spent about $75 billion on health care or $356 per resident. We currently spend over $2.5 trillion on health care services and products, or $8,160 per person. The percent of U.S. gross domestic product spent on health care has grown from 7.2% in 1970 to 17.6% in 2009. Numerous factors are responsible for increased spending on health care, including an aging population, growing per capita income and national wealth, and the expansion of both public health insurance programs and employer-sponsored health coverage. Partly motivated by a desire to “bend the cost curve” via improved access to primary care and preventive health services over the long run, national health insurance reforms will undoubtedly produce additional demand for health services from historically underserved populations and, thus, result in even more spending on health care in the short term. Greater spending on health services is also clearly a function of increasingly technologically intensive medical care and our society’s penchant toward “gizmo idolatry.” Writing in the medical journal JAMA, Drs. Bruce Leff and Thomas Finacune describe gizmo idolatry as the willingness of clinicians, patients, policymakers, and importantly, health insurers “to accept, in fact to prefer, unproven, technologically oriented medical measures” over less technological (and less costly) measures. One explanation for increasing health care costs that has received comparatively little attention, though, is the phenomenon of medicalization. Sociologist Peter Conrad defines medicalization as the “process whereby non-medical problems becomes defined and treated as medical problems, usually in terms of illnesses and disorders.” He argues that the transformation of human conditions into treatable disorders is largely a social process, not unlike globalization, secularization and other trends accompanying the evolution of modern society over the past half century. Examples of “medicalized” conditions include menopause, alcoholism and substance related disorders, attention deficit/hyperactivity disorder (ADHD), the expansion of depression to include normal sadness, post traumatic stress disorder (PTSD), anorexia, infertility, sleep disorders, erectile dysfunction, panic disorder, male pattern baldness, obesity, social anxiety disorder or social phobia, chronic fatigue syndrome, and all sorts of body image conditions, among others. And the medicalization of new conditions marches on. The New York Times recently reported that the German pharmaceutical giant Boehringer is seeking approval from the Food and Drug Administration for a drug that it claims will treat “hypoactive sexual desire disorder” (low libido) in women. Boehringer’s medical director, Dr. Peter Piliero, maintains that “this is a real disease” and that “there’s an unmet medical need among premenopausal women to have a treatment.” Conrad insists that the medicalization of society does not imply a change that is good or bad, or that the medical treatment of these conditions does not confer real benefits to many individuals. Rather, he simply maintains that, over the last four or five decades, medicine’s reach has been extended to formerly non-medical problems and life experiences and, consequently, has contributed to spiraling health care costs in the US and other rich societies. In a recent report published in Social Science and Medicine, Conrad and colleagues conservatively estimate that spending on twelve specific medicalized conditions alone totals $77 billion. While this represents only 3.9 percent of total domestic expenditures on health care, these figures exceed what local and state governments in the US annually spend on routine public health services. Dr. H. Gilbert Welch, an internist for the Department of Veteran Affairs, goes one step further contending that “the most fundamental life events – birth and death – increasingly involve more and more medical care ... my profession has gotten pretty good at terrifying (and operating on) pregnant women during what should be one of the great experiences in life. And we are equally proficient at dragging the elderly through all sorts of misery on the road to death.” On the front end of life, he cites the ubiquitous use of ultrasound and electronic fetal monitoring – tests that have been shown to have had no effect on identifying the need for neonatal intensive care or infant survival, yet have been a key factor for why the beginning of life now involves major surgery (Cesarean sections) one third of the time. On the back end of life, he notes that, while most Americans say they would like to die at home, the most common place of death is still the hospital or, to be more precise, in a costly hospital intensive care unit. Like most commentators on medicalization, Welch concludes that medical care has a great deal to offer. Nonetheless, medicalization of society continues to turn more and more people into patients and it expands what is a treatable medical condition. He adds “everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed, and our ability to affect the normal course of aging get exaggerated.” The proliferation of medical categories and treatments for human problems and common life conditions thus represents another important reason why health care costs so much. Medicalization poses serious problems for health care reform—explosion of insurable problems deprives universal health care of all meaning and prevents implementationConrad and Barker 2010 [Peter Conrad and Kristin Barker, The Social Construction of Illness: Key Insights and Policy Implications, Journal of Health and Social Behavior 51(S) S67 –S79, DOI: 10.1177/0022146510383495] Peter Conrad is a professor of social science at Brandeis University. Kristin Barker is an associate professor of sociology at the University of New Mexico.Finally, medicalization itself raises concerns about the possibility of meaningful health care reform. Creating an ever larger jurisdiction of medical problems that are subject to potential insurance or public reimbursement may be a serious impediment to providing comprehensive and universal health care coverage. What is comprehensive coverage in the context of the successful commercialization of “elective” medicine, as in the case of cosmetic surgery or anti-aging medicine? Is it possible to provide universal coverage given our cultural predisposition for “a pill for every ill,” amplified by the pharmaceutical industry’s promotion of an “ill for every pill” (Mintzes 2002:909)? Are there are any limits to what can be medicalized, or are all human problems and variations in socially desirable characteristics fodder for medical diagnoses and treatments? In sum, the fiscal costs of run-away medicalization may significantly impede any effort to reform health care (Conrad, Mackie, and Mehrotra, 2010).Hermeneutic Closure (Net-Widening)Medical institutions wield epistemic privilege allowing those parties who are systematically advantaged to grow at the expense of marginalized communities in attempts to remedy “undesirables”Wardope 14 (Alistair Wardrope, Psychosomatic Medicine, Neurology, Philosophy of Science, “Medicalization and epistemic injustice”, Med Health Care and Philos, 11/09/2014, pg 343-344, Rawle)The concept of hermeneutical injustice provides a means of elucidating the recurring strand of critique within medicalization discourse identified in the introduction. This critique holds that medical institutions wield a high—significantly, disproportionately high—epistemic privilege,4 such that when a medical perspective is voiced on a given issue, it is taken to be the authoritative one. They contend that this perspective does not tell the entire story, and allowing it to become dominant at the expense of others distorts our understanding of the world. Injustice arises because it systematically advantages certain parties—the health sector itself, the pharmaceutical industry and the beneficiaries of entrenched capitalism are the usual suspects here—at the expense of others—social nonconformists, free-spirited children, marginalised communities and cultures. For Ivan Illich, the harm is one of undermining the cultural significances of pain, sickness, and death that both bind communities together and enable autonomous coping with these trials of human existence. Medicalization, as he sees it, renders these mere technical problems, to be dealt with individually by the appropriate engineer (where the ‘appropriate’ engineers are strictly those of the medical establishment); it replaces the health ‘‘of autonomous and live reaction to an experienced reality’’ (Illich 2003) with an absence of suffering and prolongation of life by any means and at any cost. This loss of the appropriate response to our social environment and life experience is a theme that is developed in critiques directed specifically at psychiatric medicalization, holding that we have pathologized reactions that are not merely understandable, but appropriate and even desirable. Carl Elliott expresses this view in reference to alienation from the material realities of modern (Western, consumer–capitalist) existence, maintaining that to view this simply as ‘depression’ is to lose sight of the value of the experience: [T]he medical standpoint looks at the man who feels bad and doesn’t know why and says: this fellow is in a fix. He’s in bad shape. What he needs is to get in therapy, develop his self-esteem, get a prescription for Prozac. Whereas what the novel says, more often than not, is sure, this guy is in a bad shape; but doesn’t it look better than the alternative? … The novel says, of course you’re depressed. Take a look around you; it would take a moron not to be depressed (Elliott 1998, 183). Elliott suggests that viewing alienation from the standpoint of the DSM rather than the novel both perpetrates an evaluative harm—while painful, it may nonetheless be better than the alternative, whereas medicine’s implicit normativity holds pathology to be definitionally undesirable and necessitating medical remedy—and engenders harmful political consequences, insofar as it ‘‘seems to be a way of accommodating to conventional ways of life’’ (Elliott 1998, 186) rather than resisting them.Hermeneutical injustice grants the social license for the use of medication as a tool of oppressive socialization to prevent those affected from fighting backWardope 14 (Alistair Wardrope, Psychosomatic Medicine, Neurology, Philosophy of Science, “Medicalization and epistemic injustice”, Med Health Care and Philos, 11/09/2014, pg 344, Rawle)The political concern, meanwhile, is that medicalization of depression is ‘‘helping to police the established values of consumer capitalism, and reinforcing the very unhappiness that they purport to cure’’ (Fraser 2013). This worry is also expressed in relation to other psychiatric diagnoses, notably attention-deficit hyperactivity disorder (ADHD), with medicalization (and medication) used as a tool of oppressive socialisation; medication is a tool ‘‘to reinforce generally conservative norms of social behaviour,’’ (Fraser 2013) while the hermeneutical injustice both grants the social licence for this use of medication and deprives children of the means of articulating resistance—they are ‘‘oppressed … rendered incapable of protest, and condemned to conformity’’ (Singh 2013a).NormalizationThe medicalization of sexual behavior has deemed certain behaviors to be abnormal and encouraged torturous forms of treatmentHart and Wellings, 2002 (Graham Hart, Professor of Social and Public Health Sciences Unit at University of Glasgow, Kaye Wellings, Director of the Centre for Sexual Health Research at The HALondon School of Hygiene and Tropical Medicine ,“Sexual Behaviour and Its Medicalisation: In Sickness and in Health.” BMJ?: British Medical Journal, ) P.M.Psychiatry, as the moral arm of medicine, played a major role in developing the idea that some sexual behaviours are expressions of disease. The Diagnostic and Statistical Manual of Mental Disorders, first published by the American Psychiatric Society in 1952, described “treatable” behaviours that previously had been seen as morally inadmissible. This book was hugely influential in defining and sustaining judgments regarding the sexual behaviours that required medical intervention.12 For example, homosexuals, formerly considered to be sinners, were labelled as ill—not bad, but mad. Commitments to mental institutions, hormonal treatments, and castrations were used to deal with unwanted sexual behaviour. This process has taken a new form recently, with the search for the “gay gene” and the continuing refusal of some to see sexual expression as historically variable and socially constructed.13, HYPERLINK "" \l "B16" 16 In the years before the second world war, pregnant, unmarried young women could still be sent to and indefinitely detained in psychiatric institutions. Treatments for homosexual men—such as aversion therapy—continued until, and beyond, 1973, when the American Psychiatric Association redesignated homosexuality as non-pathological. Even venereology (later genitourinary medicine)—the specialty specifically responsible for treating sexually transmitted infections—was marked throughout the 20th century by an uneasy truce between medical moralists and those promoting practical public health measures to prevent infection.14 R C L Batchelor, Physician in Charge of Edinburgh's venereal disease services until 1954, often described people who transmitted infections as “moral defectives” who should be confined.15No SolvencyReplicating the illness/disease dichotomy by failing to ground sociology of medicine in biological principles deprives theory of necessary nuance and applicabilityTimmerman and Haas 2008 [Stefan Timmerman and Steven Haas, Towards a sociology of disease, Sociology of Health & Illness, Vol. 30 No. 5, pp. 659–676, doi: 10.1111/j.1467-9566.2008.01097.x] Stefan Timmerman is a professor of sociology at UCLA. Steven Haas is a professor of sociology at ASU.While the focus on illness has allowed sociologists to claim a subject matter, a price was paid for the restriction of a sociological perspective and of ignoring the ‘technical’ or ‘biological’ aspects of health care. Sociologists often make a case for studying health and illness holistically rather than with a narrow focus on biological factors but an aversion to taking the ‘disease’ aspects of medicine into consideration results in gaping analytical holes. In effect, social scientists grant health professionals, many health researchers and, increasingly, epidemiologists the clinical facts, leaving themselves no choice either to accept clinical parameters at face value, tirelessly denounce the ‘construction’ of factual knowledges, or, more often, to ignore such factors. In addition, fundamental questions remain unasked: we may have established the strati?cation of longevity and health, but rarely explain how this longevity is socially achieved. We may know much about the effects of chronic illness on identity but fail to establish the health consequences of this identity formation. An observation of a decade ago still rings true, all too often ‘the [social] investigator stood with his or her back to the heart of medicine and studied the “social phenomena” surrounding it’ (Berg and Casper 1995: 397). This ignored ‘heart’ of medicine consists of three crucial aspects that sociologists routinely bracket. First, social scientists rarely make speci?c diseases central to their inquiries. Instead, sociologists tend to study health conditions at an abstract level of conceptual aggregation, or, alternatively, focus on the multiple ambiguities of disease diagnosis. In everyday life, however, most patients and health professionals deal with speci?c diseases (Rosenberg 2003). Secondly, social scientists rarely include clinical markers of disease in their analyses. Speci?cally, we rarely ?nd out how the processes that social scientists explore affect actual health outcomes. Thirdly, social scientists also tend to ignore the normative purpose of health interventions. An extensive literature analysing patient-doctor encounters, for example, documents studies more concerned with patient satisfaction than with the actual health outcomes (Heritage and Maynard 2006). Taken together, these omissions re?ect a social science studying medicine pragmatically as a site of social action while ignoring what makes medicine medicine: its existential, ontological, and purposeful dimension of diminishing human and social suffering. OvermedicalizationIatrogenesis has two sides of causation ultimately rooted in scientific progress, knowledge, and technologyIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] Now this non-clinical iatrogenic impact of medical endeavour inevitably has two sides. It has a social side and an intimate structural or symbolic side, if you want to call it so. Socially, overmedicalization manifests itself by architecture changing because of the existence of hospitals. This is the hospitalization of social space; when apartments become such that the young and those to be born and those who are sick or those who are crippled or those who are dying do not fit in there. The medicalization of family structure takes place at the point when dying at home becomes socially inconceivable, when schedules are so arranged and life is so arranged that aging at home becomes increasingly more painful rather than more beautiful, thanks to our progress in scientific knowledge and technology.PainMedicine as a practice trivializes the subjective element of human painConrad and Barker 2010 [Peter Conrad and Kristin Barker, The Social Construction of Illness: Key Insights and Policy Implications, Journal of Health and Social Behavior 51(S) S67 –S79, DOI: 10.1177/0022146510383495] Peter Conrad is a professor of social science at Brandeis University. Kristin Barker is an associate professor of sociology at the University of New Mexico.Despite its vast technical arsenal, medicine is simply unable to see or measure pain. For this reason, physicians have often trivialized the pain of patients who lack a visible injury to account for their suffering. More aggressive pain management may be mandated, however, once we take seriously and develop appropriate means of evaluating the vivid accounts of chronic pain sufferers. The current interest in narrative medicine is in large part predicated on the work of sociologists and others who were among the first to listen to illness stories (Frank 1995). As a window into subjective experience, illness narratives are now used as a means of bringing the person back into medicine, both as an end in itself and for potential therapeutic benefits. Again, chronic pain is illustrative: When it comes to affirming the humanity of the sufferer and authenticating the existence of pain, patient narratives are a tool for overcoming the limitations of high-tech medicine (Kleinman 1988).RacializationMedicalization racializes subjects in order to extract additional profits from providing health care – pharmaceuticals proveDuster 2013 [Troy, professor at New York University, “The molecular reinscription of race: unanticipated issues in biotechnology and forensic science,” Race in Contemporary Medicine ed. Sander Gilman, pp. 122.137]Biotechnology firms have found an unusual and effective way around the problem of confronting the issue of race as a biological category. The strategy does not deal with the notion in a systematic full-scale case-control design, but uses a clinical study that was not intended to test whether race plays any part–only to discover later that the race of the clinical population, however defined, bears some unknown relation to drug efficacy. The reinterpretation of already obtained data sets by racial categories thereby conveniently circumnavigates the problem of having to define what is meant by race. By sharp contrast, a case-control study that categorised participants according to race would require the researcher to specify the boundaries of the relevant populations. The story of how the first racial drug was approved by the US Food and Drug Administration (FDA) is a remarkable tale of the racialisation of medicine. BiDil (NitroMed, Lexington, MA, USA) is a combination drug (isosorbide dinatrate and hydralazine) designed to restore low or depleted blood nitric oxide concentrations to treat or prevent congestive heart failure. The drug was originally designed without racial specification. But early clinical studies showed no compelling efficacy,2 and a US Food and Drug Administration advisory panel voted 9 to 3 against approval.3In a remarkable turn of fate, however, one of the investigators looked at the data again, and found that a small sub-sample of African Americans in the original clinical trial seemed to have fared better than did white people.2 Because the study was not designed to compare efficacy of BiDil in people of different races, a new clinical trial would have had to be approved to investigate such a hypothesis. However, rather than setting up a study design to test this hypothesis, in March, 2001, the FDA approved a full-scale clinical trial, undertaken only in black men and women with heart disease.4 In June, 2005, after a hearing in which an FDA committee reviewed reports that BiDil was significantly more effective than a placebo, the drug’s patent was approved for another 15 years as a race-specific drug.5 Indeed, the race-specific claim was what made the drug patentable.6 The use of black participants only in this BiDil trial is indicative of three problematic assumptions about race and medicine. The first is that African Americans’ risk of developing and dying from heart failure is substan- tially greater than that of white people. An investigation by the Hamline University, St Paul, MN, USA, legal scholar Jonathan Kahn seriously challenges this assertion.7 Kahn’s work shows that claims made by NitroMed, the company that developed BiDil, about the extent of differences in efficacy between black and white people are untrue. Kahn traced the citation sources used to substantiate that claim back nearly two decades, and showed that the difference in mortality between black and white people is not the often quoted 2 to 1, but instead closer to 1·2 to 1.6 The second problematic assumption is that BiDil has a greater effect on African Americans than on white people.7 But as mentioned, none of the clinical trials of the drug were designed to test that hypothesis. By concentrating only on black people, the study by Taylor and colleagues yielded no compelling evidence for this claim. Thus, substantial scaffolding of the BiDil clinical trial is based on non-existent statistical data regarding racial disparities. The third problematic assumption concerns the presentation of data for the age-specific disparities in mortality, for which there is some evidence. In the early spring of 2005, anticipating FDA approval, NitroMed released the following statement: “The African American community is affected at a greater rate by heart failure than that of the corresponding Caucasian population. African Americans between the ages of 45 and 64 are 2·5 times more likely to die from heart failure than Caucasians in the same age range.”8 The figures are technically correct, but as I have shown elsewhere, the 45–64 year age-group accounts for only about 6% of deaths from heart failure, whereas people older than 65 years constitute 93·7% of the deaths. More- over, for people older than 65 years, the differences between African Americans and white people mostly disappear.9 Why the focus on race, and what is at stake? Part of the answer almost certainly lies in the role of prospective markets. The original BiDil patent, non-race specific, will expire in 2007. By making the drug race-specific, the patent extends another 13 years giving NitroMed exclusive rights to market the drug until 2020. Yet marketing is only part of the story. The BiDil example also provides an updated chapter in the medicalisation of race. In a classic 1991 study, Michael Klag and his associates10 showed that, in general, within the African-American community, the darker the skin colour, the higher the rate of hypertension. Klag argued that the correlation between skin colour and hypertension was not biological or genetic in origin, but biological in effect due to stress-related outcomes of reduced access to valued social goods, such as employ- ment, promotion, housing stock, etc.10 Consistent with this finding, a recently published study by Cooper and colleagues examined prevalence of hypertension in 85 000 participants. Their research compared racial groups; sampling white people from eight surveys completed in Europe, the USA, and Canada, and contrasting these results with those from three surveys undertaken in black people from Africa, the West Indies, and the USA. According to the authors, data from Brazil, Trinidad, and Cuba showed a significantly smaller racial disparity in blood pressure than that in North America. Tellingly, the authors conclude: “These data demonstrate that the consistent emphasis given to the genetic elements of the racial contrasts may be a distraction from the more relevant issue of defining and intervening on the preventable causes of hyper- tension, which are likely to have a similar impact regard- less of ethnic and racial background.”11 Despite these clear refutations of genetic racial differences in hypertension, BiDil’s approval for use only in black people encourages further racialisation of pharmacology and promotes the view that racial differences in health are attributable to biological causes. For example, the British drug manufacturer AstraZeneca did a large clinical trial in patients with advanced lung cancer to test the efficacy of one of its most promising drugs, Iressa (Gefitinib, AstraZeneca, Luton, UK).12 First introduced in 2002, more than 45 000 patients have taken the drug worldwide.11 Iressa works by blocking carcinogenic-cell proliferation. In the original study, the difference between patients given placebo and those taking Iressa was insignificant. When these results were announced, the FDA began a review to assess whether the drug should be pulled from the market. However, when the data were re-assessed by race and ethnicity, scientists found that “Asians” had a 9·5 month prolongation of life on the medication, nearly double the 5·5 month average for the general population. As widely reported in the popular press, AstraZeneca touted the findings as significant, and began their marketing strategies and sales to Asian countries. The appearance of racialised drugs on pharmacists’ shelves only increases the need to attend to the myriad social sources of disparities in morbidity and mortality. Although to turn a profit from fighting racial discrimination is difficult, effective medical care demands continued awareness of the complex social dimensions of diseases, such as hypertension and cancer.Current health insurance emphases on treatment rather than prevention produces racial and ethnic disparities in the distribution of health careCDC 09 (National Center for Chronic Disease Prevention and Health Promotion. The Centers for Disease Control and Prevention (CDC) is a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health. 2009. “The Power of Prevention Chronic disease . . . the public health challenge of the 21st century”) The United States spends significantly more on health care than any other nation. In 2006, our health care expenditure was over $7,000 per person, more than twice the average of 29 other developed countries. We also have one of the fastest growth rates in health spending, tripling our expenditures since 1990. Yet the average life expectancy in the United States is far below many other nations that spend less on health care each year. As a nation, more than 75% of our health care spending is on people with chronic conditions. These persistent conditions—the nation’s leading causes of death and disability—leave in their wake deaths that could have been prevented, lifelong disability, compromised quality of life, and burgeoning health care costs. The facts are arresting, 7 out of 10 deaths among Americans each year are from chronic diseases. In 2005, 133 million Americans—almost 1 out of every 2 adults—had at least one chronic illness. About one-fourth of people with chronic conditions have one or more daily activity limitations. Health disparities in chronic disease incidence and mortality are widespread among members of racial and ethnic minority populations. For example, heart disease death rates are higher among African Americans than whites, and diabetes rates are substantially higher among American Indians and Alaska Natives than whites. Mental illnesses and chronic diseases are closely related. Chronic diseases can exacerbate symptoms of depression, and depressive disorders can themselves lead to chronic diseases. The scope and severity of the chronic disease problem has not escaped the public’s attention. More than two-thirds of all adults believe that the U.S. health care system should place more emphasis on chronic disease preventive care, and more than 4 in 5 Americans (84%) favor public funding for such prevention programs. Heart disease and stroke: The good news is that since 1999, death rates for coronary heart disease and stroke have declined 20.8% and 24.4%, respectively. In addition, the percentage of adults with high cholesterol, a major risk factor for heart disease, has been cut by almost half since the early 1960s. YET . . . Heart disease and stroke remain the first and third leading causes of death, accounting for more than 30% of all mortality, and are among the leading causes of disability. 1 million Americans are disabled from strokes; many can no longer perform daily tasks, such as walking or bathing, without help. In 2003, approximately 37% of adults reported having two or more of the major risk factors for heart disease and stroke (high blood pressure, high cholesterol, diabetes, current smoking, physical inactivity, and obesity). Many disparities persist—for example, age-adjusted stroke death rates for 2005 were 31% higher for African Americans than for whites, and heart disease death rates were 23% higher. Cancer During the past two decades, tremendous progress has been made in developing and using effective cancer prevention strategies, early detection interventions, and cancer treatments. Largely through public health efforts targeting screening, breast cancer deaths among women decreased by 2% per year from 1998 to 2005, and deaths from colorectal cancer decreased among both men and women by 4% per year from 1995 to 2005. YET . . . Cancer continues to claim more than half a million lives each year and remains the nation’s second leading cause of death. Cancer does not affect all races equally in the United States. African Americans are more likely to die of cancer than people of any other racial or ethnic group. The total number of Americans living with a previous diagnosis of cancer, currently estimated at 11 million, is on the rise. The most commonly diagnosed cancers are prostate, female breast, lung and bronchus, and colorectal cancers. Lung cancer remains the leading cause of cancer death in both men and women. More than 80% of lung cancers are due to smoking or exposure to secondhand smoke. Four modifiable health risk behaviors—lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption—are responsible for much of the illness, suffering, and early death related to chronic diseases. Chronic diseases and their major risk factors place huge economic demands on our nation. For example, from 1987 through 2001, increases in obesity prevalence alone accounted for 12% of the growth in health spending. Without concerted interventions, these and other costs can be expected to increase in the years ahead. Americans are living longer than ever before. In 30 years, the number of Americans aged 65 years or older is expected to double, generating a 25% increase in health care spending before taking inflation or new technologies into account.SexismMedical discourse about female bodies is key to the social control of womenConrad and Barker 2010 [Peter Conrad and Kristin Barker, The Social Construction of Illness: Key Insights and Policy Implications, Journal of Health and Social Behavior 51(S) S67 –S79, DOI: 10.1177/0022146510383495] Peter Conrad is a professor of social science at Brandeis University. Kristin Barker is an associate professor of sociology at the University of New Mexico.A number of feminist scholars have shown how gender meaning is inscribed onto women’s bodies and minds through past and present medical discourse and practice, and, in turn, functions to naturalize gender inequality (Clarke 1998; Ehrenreich and English 1978; Lorber 1997). For example, embedded within medical knowledge about pregnancy, premenstrual syndrome (PMS), childbirth, and menopause, one finds clear ideas about women’s “proper” (i.e., subordinate) place in society, as well as moral assumptions about women’s sexuality and femininity more generally. In the early twentieth century, pregnant women were advised against driving an automobile or dancing, on grounds that these activities threatened the health of their unborn child. Today, pregnant women are endlessly warned about the risks of drinking alcohol (Armstrong 2003). In both periods, the medical advice reflects marked cultural anxieties about women’s sexual and social freedoms; and, in both periods, when pregnant women follow the prescribed medical advice, they enact the dominant cultural ideals of femininity. Medical knowledge about PMS provides another interesting case. Precisely because some of the symptoms of PMS (e.g., frustration, aggression, anger) defy norms about how women ought to behave, they become prima facie evidence of a disorder (Markens 1996). Thus, not only can medical ideas result in the social control of women’s behavior, but they also contribute to our cultural beliefs concerning the existence of unalterable differences between men and women. These beliefs, in turn, can be used to justify gender inequality within intimate relationships, families, institutions, and society.StigmaFailing to recognize the cultural origin of disease classification creates classes of stigmatized and contested illnesses, and sufferers of this illness often fail to receive the appropriate treatment. Conrad and Barker 2010 [Peter Conrad and Kristin Barker, The Social Construction of Illness: Key Insights and Policy Implications, Journal of Health and Social Behavior 51(S) S67 –S79, DOI: 10.1177/0022146510383495] Peter Conrad is a professor of social science at Brandeis University. Kristin Barker is an associate professor of sociology at the University of New Mexico.As we have noted, certain illnesses come to have cultural meanings that are not reducible to biology, and these cultural meanings further burden the afflicted. At a general level, insights from this line of research suggest a shift in emphasis away from an exclusive focus on biomedically fixing individuals and toward changing the social and cultural context that gives particular illnesses their negative meaning. For example, there are policy implications of both stigmatized illness and contested illness. Stigmatized illness can make an illness much more difficult to treat and manage. For example, if an illness such as epilepsy or HIV/AIDS has a powerful stigma, it can make people less likely to seek treatment for fear of being mistreated by health care providers and publicly associated with a tainted condition. Obese women report avoiding routine gynecological exams, despite having higher rates of gynecological cancers than non-obese women, because of the stigma of obesity and the corresponding negative attitudes of health care professionals toward overweight people (Amy, Aalborg, Lyons, and Keranen 2006). Therefore, an effective policy based on early cancer screening must overcome this barrier. In the case of contested illnesses, the fact that sufferers’ symptoms are not readily associated with a discernable biomedical abnormality often makes it difficult for them to have their symptoms acknowledged or treated, and often raises suspicions that their problems are “all in their heads.” Some physicians refuse to treat patients diagnosed with contested illnesses, and some insurance companies will not reimburse for such treatment. On the other hand, patients’ desires for a medical diagnosis as confirmation that their symptoms are “real” often lead to excessive demand for unnecessary and costly diagnostic procedures. Faced with this situation, health organizations may find that giving patients a contested illness diagnosis and providing them with inexpensive palliatives is the most effective means of cost containment. Consequently, there are real concerns that these diagnoses are being overused to manage difficult and potentially expensive patients (Barker 2005). This may be one factor behind the growing prevalence of contested illnesses. Another may be the rise and spread of Internet support groups as alternative arenas for legitimating such illnesses. Despite the widespread use of these diagnoses, sufferers of contested illnesses only infrequently receive disability benefits, even when they meet the stated criteria regarding the inability to do “usual and customary work.” Funds for medical research to find solutions for the putative problems that underlie contested illnesses are also scarce relative to the number of individuals afflicted. In each of these areas, effective medical practice and policy are likely to be enhanced by a greater appreciation of the behavioral consequences of cultural meanings that grant legitimacy to the symptoms of some sufferers and not to those of others.Trans ExclusionMedicalization causes stigma and actively enforce the gender binary among trans folkLee, Alvin. "TRANS MODELS IN PRISON: THE MEDICALIZATION OF GENDER IDENTITY AND THE EIGHTH AMENDMENT RIGHT TO SEX REASSIGNMENT THERAPY."?Harvard Journal of Law & Gender?31 (2008): 447-71. Web. 21 July 2017.?Alvin has represented a wide range of industry-leading clients at all stages of litigation, including high-stakes commercial disputes and products liability, securities, and appellate litigation. He also has significant experience in international arbitration and complex, multi-party actions, including mass tort litigation and class actions. In 2010, Alvin was a Fulbright Scholar in Seoul, Korea, where he conducted research on Korean human rights practices.C. Criticisms of the Medical Model The medicalization of gender identity that has occurred over the past several decades has caused considerable controversy within the trans community and among advocates and scholars of trans rights.65 Those who are opposed to widespread use of the medical model offer several criticisms of it, most of which align with one of the following four arguments: 1) the medical model pathologizes and thus stigmatizes trans people; 2) the medical model heavily disfavors low-income trans people; 3) the medical model is diagnostically and descriptively underinclusive; and 4) the medical model reinforces the oppressive gender binary. The rest of this section will elaborate on each of these criticisms in turn. The most prominent of these criticisms from within the trans community is that the medicalized discourse surrounding gender identity implies that trans individuals “are somehow flawed people.”66 Being labeled disabled or disordered is deeply offensive to many67 and can be especially objectionable to those who do not feel physically or mentally limited in any way.68 As described by some, “[t]o be diagnosed with [GID] is to be found, in some way, ill, sick, wrong, out of order, abnormal . . . .”69 Scholars have described a diagnosis of GID as “an instrument of pathologization” that ultimately results in “a certain stigmatization as a consequence of the diagnosis being given at all.”70 A second criticism of the medical model that has emerged is that it heavily disfavors low-income trans people because they do not have the economic means to access the sophisticated health care involved with diagnosing and treating GID.71 the economic access criticism thus has special significance in the context of legal rights that are conditional upon medical evidence: for example, if a trans individual cannot afford gender-related surgery, then she is most likely legally forbidden from changing the sex designation on her birth certificate72 or marrying her opposite-sex partner.73 Thus, requirements of medical evidence in order to obtain basic legal rights place low-income trans people “in a particularly precarious situation” given that they will “have limited recourse to [certain] legal protections . . . .”74 Scholars have articulated a third criticism of the medical model that it is diagnostically and descriptively underinclusive; this underinclusivity argument is, at least conceptually, based on the broader criticism that GID itself is grounded in overly rigid and formalistic diagnostic standards.75 The argument goes that, given this rigidity, trans people are forced to perform rehearsed narratives that may not accurately depict their experiences,76 and any failure to perform such a narrative will result in a denial of trans-specific health care.77 Even medical professionals have acknowledged this tension in noting that the provision of trans health care often involves an adversarial element between the patient and the caregiver, mostly stemming from mental-health professionals’ roles as “gatekeepers” to gender-related treatment.78 The obvious legal concern stemming from the underinclusivity argument is that those trans people who do not perfectly fit the DSM-IV’s precise definition of GID, as well as those trans people who do not wish to undergo any sex reassignment therapy, will, like low-income trans people, have limited access to all rights conditioned upon medical proof.79 A fourth criticism that has emerged from scholarly discourses is that, given that gender is socially constructed, the medical model actually works to reinforce the oppressive gender binary.80 The scholars who set forth this postmodern criticism are, in many ways, synthesizing the pathology and underinclusivity criticisms: the argument goes that the medical model pathologizes gender nonconformity while at the same time creating only a small, insular diagnostic category for certain trans individuals who, if treated, will ultimately end up in one gender category or the other.81 These scholars point out that, as a consequence, the medical model “hold[s] transgender people to hyper-normative standards of masculinity or femininity,”82 such that GID actually serves as an instrument for funneling trans people into one gender or the other rather than allowing them to exist somewhere in between.83Alternatives/FrameworksGender HackingGender hacking is the only political strategy left – politics that ruptures conventional medical and political practice in favor of multiplicity, reclaiming gender and subjectivity through disidentification Preciado 13 (Paul Preciado, PhD, "Gender and Sex Hackers", Testo Junkie: Sex, Drugs, and Biopolitics in the Pharmacopornographic Era, p. 394-398, Feminist Press at the City University of New York)The cis-males and cis-females (indiscriminately heterosexual or homosexual), as well as transsexuals, who have access to surgical, endocrinological, or legal techniques of the production of identity, are not simple economic classes in the Marxist sense of the term, but genuine “pharmacopornographic factories”—existing simultaneously as raw materials, producers (but rarely proprietors) of biocodes of gender, and pharmacopornographic consumers. Porn actors; whores; the transgender; genderqueers; and producers, traffickers, and consumers of illegal drugs inhabit different cultures, but all are used as living pharmacoporn laboratories. All of them sell, buy, or get access to their biocodes as pharmacopornographic property. The sudden emergence of new gender statuses is creating a novel type of conflict between owners and managers of the patents of the microtechnologies of subjectification (sex hormones, psychotropic molecules, audiovisual codes, etc.) and the producers and traffickers of these techno-biocodes. The pharmacopornographic entrepreneurs, who are among the contemporary leaders of global capitalism, are trying to restrict and privatize the biocodes of gender and convert them into rare and naturalized objects by means of legal and market techniques. Computer hackers use the web and copyleft programs as tools of free and horizontal distribution of information and claim that they should be in reach of everyone. The pharmacopornographic gendercopyleft movement has a technoliving platform that is a lot easier to gain access to than the Internet: the body, the somathèque. Not the naked body, or the body as unchanging nature, but the technoliving body as a biopolitical archive and cultural prosthesis. Your memory, your desire, your sensibility, your skin, your cock, your dildo, your blood, your sperm, your vulva, your ova . . . are the tools of a potential gendercopyleft revolution. The various producers of sexual biocodes are very different from one another. Some get off on economic and social privileges, such as the models through whose bodies the dominant codes of male and female beauty are produced. Others, such as porn actors or sex workers, suffer from the lack of regulations for the open market of their biocodes. But all of them depend on the pharmacopornographic industry and its local alliances with the police forces of the nation-states. One day, they will all become hackers. Agnes, mother of all the techno-lambs: Del LaGrace Volcano, Kate Bornstein, Jacob Hale, Dean Spade, Mauro Cabral, Susan Stryker, Sandy Stone, King Erik, Moises Martínez—all are master hackers of gender, genuine traffickers of semiotico-technological flux, producers and tinkers of copyleft biocodes. Gender copyleft strategies must be minor but decisive: the survival of life on the planet is at stake. For this movement, there will be no single name that can be transformed into a brand. It will be our responsibility to shift the code to open the political practice to multiple possibilities. We could call this movement, which has already begun, Postporn, Free Fuckware, BodyPunk, OpenGender, FuckYourFather, PentratedState, TotalDrugs, PornTerror, AnalInflation, UnitedUniversalTechnoPriapism . . . This book, a legacy of Agnes’s self-experimentation politics, is a protocol for self-tests carried out with testosterone in gel form, exercises of controlled poisoning on my own body. I am infecting myself with a chemical signifier culturally branded as masculine. Vaccinating yourself with testosterone can be a technique of resistance for bodies that have been assigned the status of cis-females. To acquire a certain political immunity of gender, to get roaring drunk on masculinity, to know that it is possible to look like the hegemonic gender. Little by little, the administration of testosterone has ceased to be a simple political test and has molted into a discipline, an asceticism, a way of restoring my spirit by means of the down growing on my arms, an addiction, a form of gratification, an escape, a prison, a paradise. Hormones are chemical prostheses. Political drugs. In this case, the substance not only modifies the filter through which we decode and recodify the world; it also radically modifies the body and, as a result, the mode under which we are decoded by others. Six months of testosterone, and any cis-female at all, not a should-have-been-boy or a lesbian, but any girl, any neighborhood kid, a Jennifer Lopez or a Rihanna, can become a member of the male species who cannot be told apart from any other member of the hegemonic class. I refuse the medico-political dose, its regime, its regularity, its direction. I demand a virtuosity of gender; to each one, its dose; for each context, its exact requirement. Here, there is no norm, merely a diversity of viable monstrosities. I take testosterone like Walter Benjamin took hashish, Freud cocaine, or Michaux mescaline. And that is not an autobiographical excuse but a radicalization (in the chemical sense of the term) of my theoretical writing. My gender does not belong to my family or to the state or to the pharmaceutical industry. My gender does not belong to feminism or to the lesbian community or to queer theory. Gender must be torn from the macrodiscourse and diluted with a good dose of micropolitical hedonist psychedelics. I don’t recognize myself. Not when I’m on T, or when I’m not on T. I’m neither more nor less myself. Contrary to the Lacanian theory of the mirror state, according to which the child’s subjectivity is formed when it recognizes itself for the first time in its specular image, political subjectivity emerges precisely when the subject does not recognize itself in its representation. It is fundamental not to recognize oneself. Derecognition, disidentification is a condition for the emergence of the political as the possibility of transforming reality. The question posed by Deleuze and Guattari in 1972 in Anti-Oedipus remains stuck in our throat: “Why do the masses desire fascism?” It’s not a question here of opposing a politics of representation to a politics of experimentation, but of becoming aware of the fact that the techniques of political representation always entail programs of the somatic production of subjectivity. I’m not opting for any direct action against representation, but for a micropolitics of disidentification, a kind of experimentation that doesn’t have faith in representation as an exteriority that will bring truth or happiness. In order to accomplish the work of therapy for the multitudes that I have begun with these doses of testosterone and with writing, I now need only to convince you, all of you, that you are like me, and not the opposite. I am not going to claim that I’m like you, your equal, or ask you to allow me to participate in your laws or to admit me as a part of your social normality. My ambition is to convince you that you are like me. Tempted by the same chemical abuse. You have it in you: you think that you’re cis-females, but you take the Pill; or you think you’re cis-males, but you take Viagra; you’re normal, and you take Prozac or Paxil in the hope that something will free you from your problems of decreased vitality, and you’ve shot cortisone and cocaine, taken alcohol and Ritalin and codeine . . . You, you as well, you are the monster that testosterone is awakening in me.HealthRethink health: rather than a biological property of things, think health of a property of aliveness itselfIllich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] I begin by saying that I am not a doctor; I have no clinical experience. I am a philosopher. I must therefore ask myself what I am talking about. I am speaking in some way related to health. I find out that health is, as far as I can understand, an ordinary language word referring to what theoretical biologists would call 'the level of autonomy with which an organism adapts its internal states to the conditions of the environment, and ... (in the case of human health) consciously engages in changing some of these conditions in order to make adaptation more pleasurable or more effective.' Health therefore refers to something which is a property of aliveness -it is related to the aliveness of that organism or of that primary group.Medicalization must be understood not just on a small scale, but as well as its structural health-denying effects that overflow into other agencies of society Illich 75 [Ivan Illich; “Clinical damage, medical monopoly, the expropriation of health: Three dimensions of iatrogenic tort”; Centro Intercultural de Documentacion, Cuernavaca, Mexico; Journal of Medical Ethics, 1975, I, 78-80; BPM] I am suggesting to you very strongly the necessity to study, while looking at iatrogenesis, not only clinical iatrogenesis (which as I have said, I call the 'dirty linen' of your own profession, and is really none ofmy business) but also a much more profound structurally health-denying, health-disabling effect which overgrowth in the medical profession and in medical endeavour inevitably produces in society. This counter-productivity of medicine on a general level is parallel, is thoroughly consistent with, the paralysis of autonomy and the blockage through internal congestion in most other major production agencies in society today.Solvency – Corporate InfluenceThe alternative can recognize the way in which corporate interest has contributed to medicalization in ways that undermine the influence of research and social movementsConrad, P. (2005). The Shifting Engines of Medicalization. Journal of Health and Social Behavior, 46(1), 3-14. doi:10.1177/002214650504600102 He has been a member of the faculty at Brandeis University since 1979 and since 1993 has been the Harry Coplan Professor of Social Sciences. He received his B.A. in Sociology at State University of New York at Buffalo (1967), M.A, from Northeastern University (1970) and Ph.D. in Sociology from Boston University in 1976. Prior to Brandeis, he taught at Suffolk University in Boston, Massachusetts (1971–75) and Drake University in Des Moines, Iowa (1975–78). At Brandeis he served as chair of the Department of Sociology for nine years and since 2002 as chair of the interdisciplinary program “Health: Science, Society and Policy” (HSSP). He has also been a visiting professor at New York University, Gadjah Mada University (Yogyakarta, Indonesia), University of London, Royal Holloway, and Queen’s University Belfast (Northern Ireland)Most of the early sociological studies took a social constructionist tack in investigating the rise of medicalization. The focus was on the creation (or construction) of new medical categories with the subsequent expansion of medical jurisdiction. Concepts such as moral entrepreneurs, professional dominance, and claims-making were central to the analytical discourse. Studies of the medicalization of hyperactivity, child abuse, menopause, post-traumatic stress disorder (PTSD), and alcoholism, among others, broadened our understanding of the range of medicalization and the attendant social processes (see Conrad 1992). If one conducted a meta-analysis of the studies from the 1970s and 1980s several social factors would predominate. At the risk of oversimplification, I suggest that three factors underlie most of those analyses. First, there was the power and authority of the medical profession, whether in terms of professional dominance, physician entrepreneurs, or, in its extremes, medical colonization. Here, the cultural or professional influence of medical authority is critical. One way or another, the medical profession and the expansion of medical jurisdiction was a prime mover for medicalization. This was true for hyperactivity, menopause, child abuse, and childbirth, among others. Second, medicalization sometimes occurred through the activities of social movements and interest groups. In these cases, organized efforts were made to champion a medical definition for a problem or to promote the veracity of a medical diagnosis. The classic example here is alcoholism, with both Alcoholics Anonymous and the “alcoholism movement” central to medicalization (with physicians reluctant, resistant, or irresolute). But social movements were also critical in the medicalization of PTSD (Scott 1990) and Alzheimer’s disease (Fox 1989). Some efforts were less successful, as in the case of multiple chemical sensitivity disorder (Kroll-Smith and Floyd 1997). In general, these were organized grassroots efforts that promoted medicalization. Third, there were directed organizational or inter or intra professional activities that promulgated medicalization, as was the case with obstetricians and the demise of midwives (Wertz and Wertz 1989) or the rise of behavioral pediatrics in the wake of medical control of childhood diseases (Pawluch 1983; Halpern 1990). To be sure, there were other contributing factors that were implicated in the analyses. Pharmaceutical innovations and marketing played a role with Ritalin and hormone replacement therapy (HRT) in the medicalization of hyperactivity and menopause. Third-party payers were factors in the medicalization in terms of whether insurance would pay for surgery for “gender dysphoria,” obesity, or detoxification and medical treatment for alcoholism. However, it is significant that in virtually all studies where they were considered, the corporate aspects of medicalization were deemed secondary to professionals, movements, or other claimsmakers. By and large, the pharmaceutical and insurance industries were not central to the analyses.Solvency – MovementsHealth social movements are successful insofar as they engage the political sphere. Brown and Zavestoski 4 (Phil Brown, PhD; Stephen Zavestoski, PhD; “Social movements in health: an introduction,” Sociology of Health and Illness, Volume 26, Issue 6 September 2004, p. 691-692)Studying health social movements offers insight into an innovative and powerful form of political action aimed at transforming the health care system, modifying people's experience of illness and addressing broader social determinants of health and disease of diverse communities. Health social movements challenge state, institutional and cultural authorities in order to enhance public participation in social policy and regulation, and to democratise the production and dissemination of scientific knowledge in medical science and public health research. In order to achieve their goals, HSMs deploy an array of strategies and are nimble in the way they shift arenas of struggle. The inter-sectoral nature of HSMs strengthens their capacity to impact on scientific and policy realms as they forge strategic alliances with movements targeting other sectors, such as the environmental movement. Finally, HSMs utilise a broad range of tactics: they engage in the legal realm, shape public health research, employ cultural resources such as popular gender norms, promote new approaches to medical science, employ creative media tactics to highlight the need for structural social change and true disease prevention and engage within the policy arena to enhance public power to monitor and regulate industrial production. HSM activism in scientific knowledge production may also introduce potential contradictions. Although engaging in scientific endeavours is important, this process can also sap energy and staff time that might otherwise be directed toward political and community organising. Engaging in scientific activities may cause dissension among movement groups, especially if those working on collaborations with academic researchers begin to attain far more resources and institutional access than other groups. Thus, it is important to keep in mind that as activists begin to take science into their own hands, they must grapple directly with some of the same polemical issues and contradictions that they had previously criticised. For example, some health movement groups have major disagreements over whether to take corporate funding to support their work. This issue has been particularly controversial for the environmental breast cancer movement, where groups have debated whether to accept funding from major pharmaceutical firms. Some activists have argued that accepting such corporate funding can create a real or perceived conflict of interest and undermine the credibility of an organisation reliably to analyse and disseminate scientific information, especially data regarding clinical trials for new drug protocols. Other groups must address ethical quandaries, such as Native American groups that work with scientists to analyse the presence of persistent contaminants in human breast milk. In carrying out this research, activists have sought to develop informed consent procedures that address the needs of the community and not just individual community members, and they must negotiate appropriate ways to report individual and collective study results to the community (Schell and Tarbell 1998). Despite these challenges, HSMs have successfully leveraged their embodied experience of illness and forged a new path for how social movements can effectively engage in scientific knowledge production. Thus, HSMs serve as a critical counter-authority aimed at democratising and reshaping social policy and regulation in a way that transforms the socioeconomic and political conditions that underlie distributions of health and disease among populations.Solvency – Trans ExclusionsThe alternative’s emphasis on autonomy is a method of reconstructing the medicalized control of sexualityLee, Alvin. "TRANS MODELS IN PRISON: THE MEDICALIZATION OF GENDER IDENTITY AND THE EIGHTH AMENDMENT RIGHT TO SEX REASSIGNMENT THERAPY."?Harvard Journal of Law & Gender?31 (2008): 447-71. Web. 21 July 2017.?Alvin has represented a wide range of industry-leading clients at all stages of litigation, including high-stakes commercial disputes and products liability, securities, and appellate litigation. He also has significant experience in international arbitration and complex, multi-party actions, including mass tort litigation and class actions. In 2010, Alvin was a Fulbright Scholar in Seoul, Korea, where he conducted research on Korean human rights practices.D. The Self-Determinative Model Stemming from the perceived inadequacy of the medical model,84 trans scholars and advocates have articulated a more flexible discursive framework of trans identity that can be coined the “self-determinative model.”85 The self-determinative framework generally envisions what its term implies: that an individual should decide for herself whether she is trans rather than being forced to have doctors and scientists decide for [them] her.86 Proponents of the self-determinative model conceive of a world in which gender transgression is regarded as “freeing [trans people] to express more of themselves, and enabling more comfortable and exciting self-understandings and images.”87 Trans scholars have devised innovative legal frameworks consistent with the self-determinative model, and such frameworks can form the basis of workable legal theories that do not necessarily employ medical evidence. Many of these theories involve substantive due process protection of some sort of constitutional liberty or privacy right. For example, Laura Langley argues for a fundamental liberty right “to gender self-determination, rooted in the Due Process Clause of the Fourteenth Amendment.”88 Franklin Romeo makes a similar argument, stating that “[a]nalogizing gender self-determination to the right to determine reproductive choices may provide an opportunity for courts to consider a self-determination model of gender.”89 Other scholars have articulated legal theories grounded in the Equal Protection Clause,90 and still others have begun developing the notion that the First Amendment’s free speech protections encompass gender-expressive activity.91 Trans advocates have begun employing these self-determinative legal theories in court, and there is at least some evidence that such efforts have met with success. For example, in a New York case involving trans women’s bathroom use, the judge, in ruling on a discovery motion, stated that information about the plaintiff’s anatomical sex was irrelevant to her status as a trans person.92 It should be noted, however, that medicine and self-determination are not always antithetical, mutually exclusive frameworks. Indeed, an example of an area in which self-determination intersects with, and perhaps trumps, medical judgment involves the administration of contraceptive hormones. Birth control pills are largely given upon patient demand without extensive examination or inquiry by health care professionals.93 Thus, one could say that patients who seek birth control largely self-determine, or more specifically self-diagnose, their need for particular medical treatment.Framework – State Focus FailsReducing debates about health care to more versus less state intervention questions elides the social dimension of healthBambra et al. 5 (Clare Bambra, PhD; Debbie Fox and Alex Scott-Samuel; Department of Sociology and Social Policy, Sheffield Hallam University and Department of Public Health, University of Liverpool; “Towards a politics of health,” Health Promotion International, Vol. 20 No. 2, Oxford University Press, p. 189-190)Health is often reduced and misrepresented as health care (or in the UK, as the National Health Service). Consequently, the politics of health becomes significantly misconstructed as the politics of health care—see for example Freeman (Freeman, 2000). As an illustration, the majority of popular UK political discussions about health concern issues such as the ‘State or the market?’ debate about National Health Service (NHS) funding, organization and delivery, or the demographic pressures on the future provision of healthcare facilities (Rhodes, 1997). The same applies in most other—especially ‘developed’—countries. The limited, one-dimensional (Carpenter, 1980) nature of this political discourse surrounding health can be traced back to two ideological issues: the definition of health and the definition of politics. The definition of health that has conventionally been operationalized under Western capitalism has two interrelated aspects to it: health is both considered as the absence of disease (biomedical definition) and as a commodity (economic definition). These both focus on individuals, as opposed to society, as the basis of health: health is seen as a product of individual factors such as genetic heritage or lifestyle choices, and as a commodity that individuals can access either via the market or the health system (Scott-Samuel, 1979). This remains the case despite our sophisticated understanding of health promotion—as is evident if one ignores the rhetoric of the governments of ‘developed’ nations and looks instead at their health policies. Health in this sense is an individualized commodity that is produced and delivered by the market or the health service. Inequalities in the distribution of health are therefore either a result of the failings of individuals through, for example, their lifestyle choices; or of the way in which health care products are produced, distributed and delivered. In order to tackle these inequalities, political attention is directed towards the variable that is most amenable to manipulation—the healthcare system. It is important to note that this limiting, one-dimensional view of health is common across the ideological spectrum, with left-wing versus right-wing health debates usually consisting of a more versus less state intervention dichotomy. Orthodox UK left-wing politics is guilty of placing health care and the NHS at the centre of its discussions and struggles about health. This ‘NHS illusion’ has resulted in the naive perspective amongst health activists that societal ill-health can be cured by more and better NHS services. At best, this perspective is slowly changing, as is shown by the enthusiasm of some in the UK for New Labour's emphasis on tackling health inequalities through the NHS—while it simultaneously widens them through its neo-liberal macroeconomic, trade and foreign policies (Bambra et al., 2003).Aff AnswersLink DebateReformInsurance and coverage reform can check the worst aspects of medicalization while furthering the causes of social justiceChodoff, P. (2002). The Medicalization of the Human Condition. Psychiatric Services, 53(5), 627-628. doi: Dr. Chodoff taught and consulted at George Washington University, St. Elizabeths Hospital, Walter Reed Army Medical Center and the National Institute of Mental Health. He served as president of the Washington Psychiatric Society and the organization known today as the American Academy of Psychoanalysis and Dynamic Psychiatry. As a member of the American Psychiatric Association, Dr. Chodoff worked to stop the practice in the former Soviet Union of using psychiatry to quell political dissidents.Second, the motivations and experience of the diagnosing psychiatrist must be taken into account in cases in which the clinical picture is equivocal. An important incentive for making a DSM diagnosis is to qualify the patient for insurance reimbursement, which is otherwise unavailable. Another incentive might be to justify prescribing a drug rather than taking a primarily psychotherapeutic approach when a psychiatrist is skilled in the former but not the latter modality. Other, less obvious but significant motivations may play a role. To summarize my thesis, I believe that in pursuing the Holy Grail of remedicalization, psychiatry has corrected an error in one direction but has gone too far in the other. The result has been not only the excessive emphasis on medical-model diagnosis but also a related "furor psychopharmacologus" (7) that seeks a specific drug for every aberrant feeling or behavior as if we were in quest of a society tranquilized by "Soma" as in the dystopia described in Aldous Huxley's Brave New World (8). Another consequence has been the downgrading of psychotherapy except when it is used in conjunction with drug treatment. Patients who seek psychotherapy often experience what can be called "problems of living," which are defined as conditions that produce psychopathological symptoms that are sufficient to negatively influence a person's well-being and relationships but not to justify a diagnosis of illness or disorder. Such patients are often best treated with psychotherapy alone and not with drugs. Under the tyranny of "medical necessity," an outmoded and no longer effective gatekeeper, these patients must either pay for treatment out of pocket or be smuggled into insurance coverage by gaming the system with an inaccurate diagnosis, subjecting the therapist to moral risk (9,10). This group of patients, sometimes rather patronizingly referred to as the "worried well," has constituted a component of my more than 50 years of practice and of the practices of colleagues, and we have helped many achieve beneficial results. Rather than continue the charade I have described, the alternative course, as I see it, is for psychiatry to recognize and try to deal with the fact that ours is a profession that, while it has one foot firmly planted in medicine, is also deeply involved in other aspects of the human condition. To this extent it transcends the medical model. The integrity of the profession of psychiatry as well as that of other helping professions such as psychology and social work that also now operate uneasily under the constraints of a sometimes inappropriate illness model depends on the acceptance of both aspects of this identity.Although political action can’t resolve all of the impacts of medicalization, regulation and reform are a step in the right direction. Fox 77 (Renee C. Fox, PhD, “The Medicalization and Demedicalization of American Society,” Daedalus, Vol. 106, No. 1, Doing Better and Feeling Worse: Health in the UnitedStates (Winter, 1977), p. 20-22, The MIT Press)Dissatisfaction with the distribution of professional medical care in the United States, its costs, and its accessibility has become sufficiently acute and generalized to make the enactment of a national health-insurance system in the foreseeable future likely. Exactly what form that system should take still evokes heated debate about free enterprise and socialism, public and private regulation, national and local government, tax rates, deductibles and co-insurance, the right to health care, the equality principle, and the principle of distributive justice. But the institutionalization of a national system that will provide more extensive and equitable health-insurance protection now seems necessary as well as inevitable even to those who do not approve of it. There is still another change in the health-illness-medicine area of the society that seems to be forthcoming and that, like national health insurance, would alter the structure within which care is delivered. This is the movement toward effecting greater equality, collegiality, and accountability in the relationship of physicians to patients and their families, to other medical professionals, and to the lay public. Attempts to reduce the hierarchical dimension in the physician's role, as well as the increased insistence on patient's rights, self-therapy, mutual medical aid, community medical services and care by non-physician health professionals, and the growth of 21 legislative and judicial participation in health and medicine by both federal and local government are all part of this movement. There is reason to believe that, as a consequence of pressure from both outside and inside the medical profession, the doctor will become less "dominant" and "autonomous," and will be subject to more controls. This evolution in the direction of greater egalitarianism and regulation notwithstanding, it seems unlikely that all elements of hierarchy and autonomy will, or even can, be eliminated from the physician's role. For that to occur, the medical knowledge, skill, experience, and responsibility of patients and paramedical professionals would have to equal, if not replicate, the physician's. In addition, the social and psychic meaning of health and illness would have to become trivial in order to remove all vestiges of institutionalized charisma from the physician's role. Health, illness, and medicine have never been viewed casually in any society and, as indicated, they seem to be gaining rather than losing importance in American society. It is significant that often the discussions and developments relevant to the destratification and control of the physician's role and to the enactment of national health insurance are accompanied by reaffirmations of traditional American values: equality, independence, self-reliance, universalism, distributive justice, solidarity, reciprocity, and individual and community responsibility. What seems to be involved here is not so much a change in values as the initiation of action intended to modify certain structural features of American medicine, so that it will more fully realize long-standing societal values. In contrast, the new emphasis on health as a right, along with the emerging perspective on illness as medically and socially engendered, seems to entail major conceptual rather than structural shifts in the health-illness-medical matrix of the society. These shifts are indicative of a less fatalistic and individualistic attitude toward illness, increased personal and communal espousal of health, and a spreading conviction that health is as much a consequence of the good life and the good society as it is of professional medical care. The strongest impetus for demedicalization comes from this altered point of view. It will probably contribute to the decategorization of certain conditions as illness, greater appreciation and utilization of non-physician medical professionals, the institutionalization of more preventive medicine and personal and public health measures, and, perhaps, to the undertaking of non-medical reforms (such as full employment, improved transportation, or adequate recreation) in the name of the ultimate goal of health. However, none of these trends implies that what we have called cultural demedicalization will take place. The shifts in emphasis from illness to health, from therapeutic to preventive medicine, and from the dominance and autonomy of the doctor to patient's rights and greater control of the medical profession do not alter the fact that health, illness, and medicine are central preoccupations in the society which have diffuse symbolic as well as practical meaning. All signs suggest that they will maintain the social, ethical, and existential significance they have acquired, even though by the year 2000 some structural aspects of the way that medicine and care are organized and delivered may have changed. In fact, if the issues now being considered under the rubric of bioethics are predictive of what lies ahead, we can expect that in the future, health, illness, and medicine will acquire even greater importance as one of the primary symbolic media through which American society will grapple with fundamental questions of value and belief. What social mechanisms we will develop to come to terms with these "collective conscience" issues, and exactly what role physicians, health professionals, biologists, jurists, politicians, philosophers, theologians, social scientists, and the public at large will play in their resolution remains to be seen. But it is a distinctive characteristic of an advanced modern society like our own that scientific, technical, clinical, social, ethical, and religious concerns should be joined in this way.Permutation – Do BothTheir link arguments are so broad as to be about nothing in particular. The permutation resolves their links because the alternative reminds about the importance of definitional precision regarding medicalization phenomena.Conrad, P. (2005). The Shifting Engines of Medicalization. Journal of Health and Social Behavior, 46(1), 3-14. doi:10.1177/002214650504600102 He has been a member of the faculty at Brandeis University since 1979 and since 1993 has been the Harry Coplan Professor of Social Sciences. He received his B.A. in Sociology at State University of New York at Buffalo (1967), M.A, from Northeastern University (1970) and Ph.D. in Sociology from Boston University in 1976. Prior to Brandeis, he taught at Suffolk University in Boston, Massachusetts (1971–75) and Drake University in Des Moines, Iowa (1975–78). At Brandeis he served as chair of the Department of Sociology for nine years and since 2002 as chair of the interdisciplinary program “Health: Science, Society and Policy” (HSSP). He has also been a visiting professor at New York University, Gadjah Mada University (Yogyakarta, Indonesia), University of London, Royal Holloway, and Queen’s University Belfast (Northern Ireland)In a recent paper, Adele Clarke and her colleagues (2003) argue that medicalization is intensifying and being transformed. They suggest that around 1985 “dramatic changes in both the organization and practices of contemporary biomedicine, implemented largely through the integration of technoscientific innovations” (p. 161) coalesced as an expanded phenomena they call biomedicalization. By biomedicalization they mean “the increasingly complex, multisited, multidirectional processes of medicalization that today are being reconstituted through the emergent social forms and practices of a highly and increasingly technoscientific biomedicine” (Clarke et al. 2003:162). Clarke et al. paint with a very broad brush and create a concept that attempts to be so comprehensive and inclusive—incorporating virtually all of biotechnology, medical informatics and information technology, changes in health services, the production of technoscientific identities, to name just a few—that the focus on medicalization is lost. This new conception, in my judgment, loses focus on the definitional issues, which have always been a key to medicalization studies.1 Along with Clarke et al. (2003), I see some major changes in medicalization in the past two decades (cf. Gallagher and Sionean 2004). I see shifts, where they see transformations. I see medicalization as expanding and, to a degree, changing, but not morphing into a qualitatively different phenomena. My task remains narrower and more focused on the medicalization process.Permutation – Informed CultureWe can check medicalization by creating better informed consumersConrad 7 (Peter, Ph.D, Harry Copeland Professor of Social Sciences, “The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders. John Hopkins University Press, 2007. ProQuest Ebook Central, . Page 10,11)carlosCritiques argued that the medicalization case has been overstated and constraints limit rampant medicalization (R. Fox, 1977 ; Strong, 1979 ). critiques conflated deprofessionalization with demedicalization (R. Fox, 1977 failed to recognize that most studies of medicalization adopt a historical, social-constructionist perspective. This perspective focuses on the emergence of medical categories and how problems entered the medical domain, bracketing whether a phenomenon is “really” a medical problem (Bury, 1986 ; see Conrad, 1992 : 212 ). From a sociological perspective, case studies of medicalization have created a new understanding of the social process involved in the cultural production of medical categories or knowledge; however, these investigations do not necessarily contain a mandate as to how the categories and knowledge are to be evaluated. In the 1990 s several writers suggested ways of “rethinking” or “reconsidering” medicalization. For example, some noted how changes in society and medicine may place new constraints on medicalization. Simon Williams and Michael Calnan ( 1996 ) contended that most studies of medicalization viewed individuals or the lay public as largely passive or uncritical of medicine’s expansion. They suggested that a better-informed public would create a “challenge of the articulate consumer.” Barsky and Boros ( 1995 ) noted that despite a growing medicalization of bodily distress (e.g., somatization), managed care creates great incentives to reduce utilization, therefore placing new constraints on medicalization. While it remains questionable whether most studies of medicalization see the public as passive (“medical dupes,” as Vicente Navarro [ 1976 ] put it many years ago), it seems clear that culture and medicine may limit medicalization. But as I endeavor to demonstrate in this book, perhaps especially in chapter 7 , both articulate consumers and managed care incentives may promote as well as constrain medicalization. It is important to recognize that problems can still be medicalized, even in the face of skeptical members of the public or a medical system that resists treating them. For example, the fact that insurance companies won’t pay for treatment of certain medical diagnoses limits medicalization but doesn’t necessarily undermine it, so long as medical categories are accepted and applied to problems. It may, however, affect the degree of medicalization. Much of what is called self-care involves the use of medical approaches by lay people in the absence of professional medical treatment.Permutation – Preventative MeasuresPreventative measures are better overall for the well-being of impoverished populationsLantz et al., 2007 (Paula M. Lantz, Associate Dean for Academic Affairs and a professor of public policy at the Ford School with a masters in Epidemiology and PhD in Social Demography, Richard L. Lichtenstein, Professor of Health Management and Policy with a M.P.H. and Ph.D. from the University of Michigan in medical care organization and a B.S. from Cornell University in industrial and labor relations, Harold A. Pollack, Professor at The University of Chicago School of Social Service Administration, “Health Policy Approaches To Population Health: The Limits Of Medicalization”, Health Affairs, ) PMCurrent public policy responses to health vulnerability focus primarily (although not exclusively) on the procurement of medical care services, with a reduction in access barriers proffered as the central benchmark for success. Although policies that address financial and geographic barriers to health care bring important services to populations in need, many such policies establish and reinforce a two-tier “safety-net” system in which vulnerable populations primarily go to separate institutions or providers for their health care. These separate programs are viewed as necessary as a result of the dominant system’s failure to provide adequate access for those who are marginalized and vulnerable. These programs, however, are not well funded, and the services provided are neither adequately paid for nor completely covered.12 This leaves safety-net providers and programs plagued by financial pressures and often unable to deliver high-quality medical care to the populations they serve.13 A second, less noticed consequence of medicalized perspectives is a conflation between health status disparities and health care disparities. Medicalization encourages the view that one can solve socioeconomic and racial/ethnic health status disparities through initiatives and policies that reduce disparities in health care access, use, and quality. This conflation, for example, can be seen in some aspects of the Health Disparities Research Plan of the National Institutes of Health (NIH) and also in the National Action Agenda of the Department of Health and Human Services (HHS) Office of Minority Health.14 In turn, when health vulnerability and disparities are medicalized, health care access becomes overvalued and overemphasized as the most promising policy path. It is also an easier path, politically, than are fundamental social and economic reforms. The result is our current situation, in which an estimated 95 percent of U.S. health services spending goes toward direct medical services, and only 5 percent is invested in population or community approaches for prevention and health status improvement.15 Medicalized framing of health vulnerability can be an effective strategy to defend policy benefits/transfers to the disadvantaged by sidestepping social and political debates over the deservingness or worthiness of vulnerable populations. The Supplemental Security Income and Social Security Disability Insurance programs are examples of how a medicalized approach to complex social problems can bring valuable income support and other benefits to people living with disabilities.16 Similarly, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides housing and social services that extend beyond the domain of medical care to people living with HIV and AIDS. In addition, Medicaid provides a funding umbrella under which many states finance expanded services and social supports that extend beyond medical treatment and care. Nonetheless, these types of social services and interventions tend to become available only after a person is diagnosed as sick or disabled, and they focus on individuals and families rather than on the social and economic conditions of communities that are the fundamental drivers of poor health over the life course.Permutation Solves – Trans ExclusionThe medicalization of sex and sexuality can be transformed in ways that affirm human self-determinationLee, Alvin. "TRANS MODELS IN PRISON: THE MEDICALIZATION OF GENDER IDENTITY AND THE EIGHTH AMENDMENT RIGHT TO SEX REASSIGNMENT THERAPY."?Harvard Journal of Law & Gender?31 (2008): 447-71. Web. 21 July 2017.?Alvin has represented a wide range of industry-leading clients at all stages of litigation, including high-stakes commercial disputes and products liability, securities, and appellate litigation. He also has significant experience in international arbitration and complex, multi-party actions, including mass tort litigation and class actions. In 2010, Alvin was a Fulbright Scholar in Seoul, Korea, where he conducted research on Korean human rights practices.A. Refuting the Criticisms of the Medical Model As already mentioned, the primary criticism of the medical model from within the trans community is that it is pathologizing and stigmatizing.118 This criticism, however, is largely the product of ableist attitudes that have been adopted from society’s unjust biases against disabilities in general.119 The label “disabled” in a vacuum is itself not stigmatizing; instead, it is the negative association that society imposes upon disabilities that is stigmatizing. Indeed, the entire aim of disability advocacy in this country has been to demonstrate that “disabled people are capable of equal participation” but for the ableist attitudes that unfairly deny them access to such participation.120 As trans scholars and advocates have begun to point out, the conceptual overlap between the trans community and the disability community should not in and of itself be troubling and should, instead, unite the two communities toward the common cause of reducing ableist stigmas associated with disabilities generally.121 The second criticism of the medical model discussed earlier is that it largely disfavors low-income trans people.122 Although it is difficult to imagine a wholesale refutation of the economic access criticism,123 especially as applied to the predication of basic rights such as legal sex designation upon a showing of medical evidence,124 the criticism is largely irrelevant in the prison context: the provision of health care in prisons is predicated not upon the ability to purchase it but upon its objective seriousness for a particular patient.125 This is because Eighth Amendment jurisprudence indicates that prisoners have a right to health care for objectively serious medical needs without making any reference to prisoners’ ability to pay for it.126 Indeed, given that inmates are in fact incarcerated and, thus, unlikely to be able to purchase outside health care even if they want to, an argument that economic considerations advantage or disadvantage otherwise similarly situated prisoners is conceptually unsound with regard to health care. This is not to suggest that prisoners, whether trans or not, receive excellent or even adequate health care while incarcerated, but it is to suggest that any deficiency in the provision of health care in prison is likely not attributable to differences in wealth from inmate to inmate. The third aforementioned criticism, that the medical model is diagnostically and descriptively underinclusive,127 is somewhat belied by the fact that self-determinative principles are built into the definitions of transsexualism and GID: Harry Benjamin originally stated that desire for sex reassignment therapy is one of the central signifiers of transsexualism,128 and the DSMIV’s diagnostic criteria explicitly state that a “request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex” is probative of the existence of GID.129 Indeed, trans-specific health care specialists have noted that such self-determinative principles are to be honored and respected in the responsible administration of sex reassignment therapy.130 Thus, the argument that a diagnosis of GID is inaccessible to a significant segment of trans people who wish to access it is not very forceful. The claim that adherence to strict diagnostic criteria and rehearsed narratives dictates who can and cannot access a diagnosis of GID seems somewhat inconsistent with the fact that, to a large extent, merely requesting sex reassignment therapy is seen as a central, probative indication that an individual has GID. Indeed, in this sense, GID and access to sex reassignment therapy share much in common with the birth control example outlined earlier:131 people with GID play a large role in self-determining, or more specifically in self-diagnosing, their need for sex reassignment therapy by initially requesting it. In fact, if desire for birth control were deemed a mental health condition called “Contraceptive Need Disorder” and access to it were predicated upon a showing of diagnostic evidence that the patient actually wanted it, then the birth control example would be almost identical to the provision of GID-related health care.132 Further, the underinclusivity criticism seems to operate on the assumption that the medical model is inherently rigid and inflexible.133 This assumption, however, is simply not supported by the medical model’s textual underpinnings: the introduction to the DSM-IV states that its diagnostic definitions are to be used as mere guidelines and should not be applied mechanically or in “cookbook fashion.”134 Similarly, the Standards of Care state that they are “intended to provide flexible directions” for trans-related health care and that they should be departed from when an individual’s unique health concerns necessitate such particularized decision-making.135 Given that the medical model calls for such individualized discretion, responsible health care practitioners are ethically charged with individually assessing each patient’s unique medical concerns rather than relying on overly strict, textualist readings of GID.136 Thus, in the prison context, it makes little sense to argue that inmates will be precluded from receiving trans-specific health care because of some broad-based underinclusivity inherent in a medicalized conception of gender identity. Indeed, for those trans prisoners who do request sex reassignment therapy but are nonetheless denied access, such problems could very well be caused not by the medical model’s underinclusivity but, instead, by systemic or institutional problems with the administration of health care in prisons.137 Trans health experts have frequently noted that misinformed, transphobic doctoring has permeated the history of trans-specific medical care in this country.138 So to the extent that systemic or institutional problems with prison health care stem from misinformed doctoring by prison personnel, one could argue that the medical model, and proper education surrounding it, would actually help trans prisoners gain access to sex reassignment therapy. Finally, with regard to the postmodern argument that the medical model stems from and ultimately reinforces the oppressive gender binary,139 it should be pointed out that, regardless of the medical model’s origins or its effect in the abstract, there are trans people who believe that it accurately describes their experiences.140 There are undoubtedly members of the trans community for whom the medical model is inaccurate or inadequate,141 but dismissing the medical model simply because it stems from or bolsters a fictional gender binary disserves those trans people who believe that the gender-related discomfort they have felt throughout their lives is best described in medicalized terms. In other words, discounting the medicalization of gender identity would discount the medicalized narratives of anxiety and discomfort to which many people with GID lay claim. Indeed, some trans rights advocates have characterized the postmodern criticism as, when “taken to its logical conclusion, [positing] that transsexualism does not exist.”142 These advocates have fundamentally rejected this criticism as well as “the premise that there is nothing essential about gender identity.”143 Arguing that GID is diagnostically and descriptively accurate for a significant subsection of the trans community, trans rights lawyers such as Jennifer Levi have pointed out that postmodern skepticism over the legitimacy of GID is both unfair for those who feel it accurately describes their experiences as well as “deeply offensive to many transsexuals.”144Permutation Solves – Link CategoriesTheir link arguments are about treatment practices rather than the nature and structure of insurance in the abstract; the permutation can solve the worst abuses of medicalization by transforming the kinds of treatment that we emphasize while also affirming the importance of expanding coverageParens, E. (2013). ON GOOD AND BAD FORMS OF MEDICALIZATION. Bioethics, 27(1), 28-35. doi:10.1111/j.1467-8519.2011.01885.x Parens leads The Hastings Center’s new National Endowment for the Humanities-funded Humanities Research Initiative. He is also a member of Columbia University’s National Institutes of Health-funded Center for Excellence in Ethical, Legal, and Social Implications of the Human Genome Project. He is a Fellow of the Center for Neuroscience and Society at the University of Pennsylvania, and has served as a consultant to several government and nongovernmental bodies, including the American Academy of Arts and Sciences, the Institute of Medicine, of the National Academy of Sciences, and the Presidential Commission for the Study of Bioethical Issues.In principle, the medicalization charge can be used to criticize the use of any means to achieve what is construed to be a non-medical purpose. But in our current context, with the avalanche of ever more pharmaceuticals, the medicalization charge often refers to the use of pharmacological means to deal with some normal human problem. When enthusiasts about self-shaping hear the medicalization charge, they sometimes exasperatedly counter that the critics suffer from ‘pharmacological Calvinism.’ Gerald Klerman first used that now-famous phrase in the early 1970s, in an article in the Hastings Center Report.20 According to Klerman, pharmacological Calvinists think that ‘if a drug makes you feel good, it not only represents a secondary form of salvation but somehow it is morally wrong and the user is likely to suffer retribution with either dependence, liver damage, . . . , or some other form of medical-theological damnation.’ Klerman continues, ‘Implicit in the theory of therapeutic change is the philosophy of personal growth, basically a secular view of salvation through good works.’21 As Klerman was a psychiatrist, not a theologian, we can set aside his unconventional understanding of Calvinism and try to understand the insight at work in his charge. A less snarky version might read: ‘If pharmacological and psychotherapeutic means can both achieve the same end – improving how one experiences herself and the world – then it is irrational and perhaps inhumane to prefer the more strenuous and expensive means. It’s irrational not to take a shortcut when improving human well-being is the destination. We should be slower to imagine that suffering leads to growth and understanding, and quicker to remember that sometimes it just crushes human souls.’ Even if the chances of finding a ‘pharmacological Calvinist’ in the USA today are about as good as spotting a bald eagle in Manhattan, Klerman was surely right to observe that we come from long and particular traditions (originating in both Jerusalem and Athens), which have taught that with suffering comes understanding. Those traditions have valorized the suffering that goes with large and small normal human problems.22 Insofar as those traditions celebrated suffering for which there were no medical remedies, Klerman must be right that at least to some extent those traditions made a virtue of necessity. But he must be wrong to the extent that his charge invites us to ignore the respect in which suffering can be a crucial element in a good human life. To take but one example, which I mentioned above: even the staunchest self-shaping enthusiasts acknowledge the respect in which suffering from the loss of someone we love is ‘proper’ – and as such should be endured rather than erased. (Yes, I did suggest above that the notion of ‘the proper’ can obfuscate and here I am suggesting that it can illuminate.) Moreover, the charge of pharmacological Calvinism must be wrong to the extent that it ignores how the means we use to reduce the suffering associated with normal problems can matter morally. As critics of medicalization argue, using medical means to solve normal human problems can lure us into thinking that the individual rather than her social context is the source of the problem. It can lure us into attending only to the respect in which we are objects – and ultimately to forgetting that we are also subjects, who can remedy some problems by giving and taking reasons to change our minds and contexts. Klerman’s charge can also obfuscate the fact that different means can emphasize different values in an even more obvious sense. Insofar as means like medications can be cheaper or work more quickly than, say, means like words, they can emphasize the value of efficiency. Insofar as means like words require the giving and taking of reasons between persons, they can emphasize the value of engagement. So, like the medicalization charge, the ‘pharmacological Calvinism’ charge can both help us to think and give us an excuse to stop thinking. If that’s right, we are saddled with a daunting ethical responsibility. By ‘we’ I mean those who think it is important to respond to the suffering of individuals and that it is important to attend to the social roots of that suffering; those who think it is important to consider ourselves as subjects and that we should be grateful for the ways in which considering ourselves as objects can help us to diminish human suffering; and those who worry that medicalization can be bad and believe that choosing for or against ‘medicalization’ full stop could be lazy or unhelpful. By ‘ethical responsibility’ I refer to the responsibility to attempt to distinguish between good and bad forms of medicalization.Impact DebateMedicalization Good – AutonomyTechnological treatments increase individual autonomyParens, E. (2013). ON GOOD AND BAD FORMS OF MEDICALIZATION. Bioethics, 27(1), 28-35. doi:10.1111/j.1467-8519.2011.01885.x Parens leads The Hastings Center’s new National Endowment for the Humanities-funded Humanities Research Initiative. He is also a member of Columbia University’s National Institutes of Health-funded Center for Excellence in Ethical, Legal, and Social Implications of the Human Genome Project. He is a Fellow of the Center for Neuroscience and Society at the University of Pennsylvania, and has served as a consultant to several government and nongovernmental bodies, including the American Academy of Arts and Sciences, the Institute of Medicine, of the National Academy of Sciences, and the Presidential Commission for the Study of Bioethical Issues.To start, it helps to remember the respect in which we already do embrace some forms of medicalization. When for example Dostoyevsky wrote The Idiot, the cluster of traits that today we call epilepsy was called a divine gift. In the beginning of the 20th century, that cluster of traits was construed as a ‘psychological’ disorder, and today we are confident that ‘it’ is a proper medical disorder. None of us criticizes the process whereby that particular constellation of traits was transformed from a divine gift into a medical problem. Nor does any of us criticize the process whereby what today we call Alzheimer’s disease went from being interpreted as the moral problem of ‘senility’ to being interpreted as a medical problem. One could counter that these aren’t examples of ‘good’ medicalization. Rather, they are only examples of us overcoming past mistakes: calling epilepsy a disease instead of a divine gift is just an example of aligning our everyday practice with our deeper scientific or medical knowledge. Mistaking epilepsy for a divine gift, goes this argument, is no more interesting than mistaking whales for fish. Fair enough. But this brings us to straightforward, harder-to-dismiss examples to support my suggestion that we should be skeptical about assuming that medicalization is bad, full stop. Many feminists and fellow travelers have in the past, with good reason, lamented the medicalization of everything from childbirth, to menstruation, to menopause.23 More recently, the institution of medicine has brought within its purview ‘labia-plasty,’ which its practitioners say can be used to treat ‘emotional problems such as embarrassment, anxiety, and loss of self-esteem’24 related to the shape of one’s labia minora. The profound, amplysupported concern is that, by bringing ever more normal features of women’s bodies and lives within the purview of medicine, disease mongers diminish women’s power to control their own bodies and, more generally, diminish their ability to flourish. While there may be no better arena than what gets called ‘women’s health’ to witness dis-empowering forms of medicalization, there may also be no better place to see empowering forms. As feminist philosopher Laura Purdy has argued in this journal25 – and others have argued elsewhere26 – a blanket condemnation of medicalizing ‘normal facets’ of women’s (and men’s) lives fails to acknowledge the respect in which women (and men) use medical technologies to gain control over their lives to promote their own flourishing.27 Consider for example the normal human capacity of producing eggs (or sperm), or the normal capacity of bringing a fertilized egg to term. Given that those capacities can’t be construed as symptoms of disease, and given that becoming pregnant when one doesn’t want to is a perennial human problem, we must grant that using medical technologies to control those capacities (from birth control pills, to vasectomies, to IUDs) are forms of medicalization – forms of medicalization that seem good to many of us. Even many of us who are in general deeply, wholeheartedly critical of the idea that more control is always better, embrace technologies that allow women to determine if and when they will become pregnant. We embrace those technologies not only because we believe that women have a right to self-determination, but because we know that women who cannot control if and when they become pregnant are at significantly increased risk of living (along with their children) lives blighted by poverty. For this observer, fertility control counts as a good form of medicalization. Of course, ‘many of us’ isn’t all of us. Who, though, objects to the process whereby what once was considered chronic pain associated with normal aging came to receive labels like Complex Regional Pain Syndrome (CRPS)?28 Before we could do anything to treat such pain, we construed it as a normal, if difficult part of the aging process. But once it’s technically feasible for healthcare professionals to reduce such pain, the door swings wide open to new diagnostic labels and ‘treatments’. What was once a problem of everyday living becomes a medical problem. It is a classic example of the medicalization process – but, I am suggesting, an example of ‘good’ medicalization.Alternative/Framework DebateFramework Solves – Health LiteracyHealth literacy obtained through civic engagement is more important than philosophical pronouncements regarding the nature of health in the abstractFreedman et al. 9 (Darcy A. Freedman, PhD, MPH, Kimberly D. Bess, PhD, Holly A. Tucker, PhD, David L. Boyd, PhD, Arleen M. Tuchman, PhD, Kenneth A. Wallston, PhD; “Public Health Literacy Defined,” American journal of preventive medicine, June 2009, p. 447-448)It is proposed that health literacy be reconceptualized to include two broad components: individual-level health literacy, which is already well developed, and public health literacy, as defined in this paper. The definition of public health literacy, as well as the corresponding dimensions and competencies, emerged through an inductive analytic process conducted in 2007 by a multidisciplinary research team. Building on the principles of Rudolf Virchow, a nineteenth-century German physician and public health official who understood disease to be fundamentally a social problem,30 –32 the team first evaluated concepts from the health literacy movement through the lenses of public health, social determinants of health, and population health. These three terms were operationalized to refine the scope of the analytic process. Public health was defined as: the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries.33 The social determinants of health are defined as: the “causes of the causes”—the fundamental structures of social hierarchy and the socially determined conditions these structures create in which people grow, live, work, and age.34 Population health is defined as: the health outcomes of a group of individuals, including the distribution of such outcomes within a group.22 After reviewing the health literacy literature, the research team developed a preliminary definition of public health literacy and its dimensions and competencies. Two expert-panel sessions were convened to assess the consensual validity of the preliminary definition. The experts included public health officials, global health researchers, biologists, virologists, advanced practice nurses, community health workers, and physicians. Existing scholarship broadens the concept of health literacy to account for the social, environmental, and systemic forces affecting the health of individuals and the public. Zarcadoolas et al.,6 for example, speak of civic literacy as the “skills and abilities that enable citizens to become aware of public issues, participate in critical dialogue about them, and become involved in decision making processes.” Nutbeam5 defines critical health literacy as the “cognitive and skills development outcomes which are oriented towards supporting effective social and political action, as well as individual action.” Gazmararian et al.29 have drawn attention to the concept of public health literacy and have called for a more precise definition of “what it means to be public health literate.” They present public health literacy as an ethical imperative and suggest that people who are public health literate will be better able to appreciate the ways that health issues “affect themselves, their community, and society at large.”29 More recently, Pleasant and Kuruvilla15 have emphasized that health literacy should include knowledge of public health concepts. Unfortunately, this clear academic shift in focus from the individual to the public has not taken hold in research initiatives, clinical interactions, or public messages related to health concerns. The dominance of the biomedical model may be a barrier to the adoption of broader conceptualizations of health literacy, situating disease and illness within individual bodies and focusing on treatment of acute conditions rather than on strategies of prevention.35,36 An additional barrier may be the term “public.” Public health literacy is often interpreted as health literacy for the public (or the mass distribution of individual-level health literacy) rather than literacy about public health. An example is May 2009 Am J Prev Med 2009;36(5) 447 the American Medical Association’s commentary on the recent call for improving public health literacy in America, which responded to the call by underscoring the need for better communication mechanisms between patients and providers.37 Notwithstanding the importance of promoting individual-level health literacy at the population level, this strategy alone is too narrow. Public health literacy is defined here as the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community. Although it parallels the IOM’s definition of health literacy, the definition of public health literacy differs in the following ways: ● An emphasis on evaluation underscores the importance of being able to judge or determine the significance, worth, or quality of information related to the health of the public. ● The addition of action assumes that individuals and groups have agency and thus the power to organize activities to accomplish public health goals and objectives through civic engagement. ● An emphasis on public health decisions goes beyond the set of health literacy skills related to accessing, interpreting, and using health information for individual health purposes. These individual-level skills contribute to, but are insufficient for, the societal level perspective public health literacy requires. ● An emphasis on community acknowledges that individuals are embedded in environmental and social contexts. This emphasis differs from the conceptualization of individual-level health literacy, which most often treats individuals, and even their families, as decontextualized units. In this definition, public health literacy is purported to be distinct from, but related to, individual-level health literacy. Together, the two types of literacy form an expanded framework for health literacy. Table 1 depicts health literacy as a broader concept inclusive of two unique types of literacy that converge to achieve the broader goal of promoting health and reducing health disparities among individuals, families, communities, and societies.Restoring health literacy is key to repoliticization of educational spheres and its impact on social change. Nutbeam 2000 (Don Nutbeam, “Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century,” Health Promot Int (2000) 15 (3), p. 265-267)Health literacy is a concept that is both new and old. In essence it involves some repackaging of established ideas concerning the relationship between education and empowerment. Education for health directed towards interactive and critical health literacy is not new, and has formed part of social mobilization programs for many years. There are many contemporary examples of education being used as a powerful tool for social mobilization with disadvantaged groups in both developed and developing countries. Indeed those in developed countries may do well to retrace the roots of contemporary health education in community development programs, and learn from their current application in health development projects in developing countries. Disappointingly, the potential of education as a tool for social change, and for political action has been somewhat lost in contemporary health promotion. Close attention to the impact of public policy decisions on health, and the need to create supportive environments for health may have had the unintended consequence of leading to structural interventions ‘on behalf’ of people —health promotion which is done ‘on’ or ‘to’ people, rather than ‘by’ or ‘with’ people. In turn, health education has been limited to interpersonal communication and media campaigns directed towards individual behavioural outcomes and health services use. If achieving health literacy as defined by WHO is to be a goal, some rediscovery of the importance of health education needs to occur, together with a significant widening of the content and methods used. This poses a real challenge for contemporary health education and the type of information/education/communication programs which are widely supported by development and donor agencies—many of which are directed only towards achieving functional health literacy as described above. Pursuing the goal of improved health literacy will also require more overt alliances between health and education sectors in pursuing the goal of improved literacy levels in the population. This applies at local, national and international levels—emphasizing, e.g. the need for improved alliances between WHO and UNESCO, at an international level, and clearer understanding between agencies at the most local level (St Leger and Nutbeam, 2000). Improving health literacy in a population involves more than the transmission of health information, although that remains a fundamental task. Helping people to develop confidence to act on that knowledge and the ability to work with and support others will best be achieved through more personal forms of communication, and through community-based educational outreach. If we are to achieve the ultimate goal that is reflected in that definition of health literacy—trying to promote greater independence and empowerment among the individuals and communities we work with—we will need to acknowledge and understand the political aspects to education, focused on overcoming structural barriers to health.Knowledge of the intricacies of health and health care promotes social change and results in healthier people. S?rensen et al. 12 (Kristine S?rensen, Stephan Van den Broucke, James Fullam, Gerardine Doyle, Jürgen Pelikan, Zofia Slonska, Helmut Brand, Consortium Health Literacy Project European, “Health literacy and public health: A systematic review and integration of definitions and models,” BMC Public Health 12:80, p. 7-8)Apart from the dimensions of health literacy, the conceptual models summarized in Table 3 also give the main antecedents and consequences of health literacy outlined in the literature. For the antecedents, most authors refer to demographic, psychosocial, and cultural factors, as well as to more proximal factors such as general literacy, individual characteristics and prior experience with illness and the healthcare system. Among the demographic and social factors which impact on health literacy one notes socioeconomic status, occupation, employment, income, social support, culture and language [40], environmental and political forces [35], and media use [50]. In addition, peer and parental influences may impact on the health literacy of adolescents. In terms of personal characteristics, health literacy is predicted by age, race, gender and cultural background [50]; as well as by competences such as vision, hearing, verbal ability, memory and reasoning [40], physical abilities and social skills [50], and meta-cognitive skills associated with reading, comprehension, and numeracy [4, 48, 50]. The latter refers to the level of overall literacy, defined as the capacity to use printed and written information to function in society, achieve one's goals, and develop one's knowledge and potential. Finally, Nutbeam [36] points out that health literacy is also a result of health promotion actions such as education, social mobilization and advocacy. In terms of the consequences, a number of researchers pointed out that health literacy leads to improved self-reported health status, lower healthcare costs, increased health knowledge, shorter hospitalization, and less frequent use of healthcare services [43, 48, 50, 53]. According to Baker [49], these better health outcomes are caused by the acquisition of new knowledge, more positive attitudes, greater self-efficacy, and positive health behaviors associated with higher health literacy. Paashe-Orlow and Wolf [40] posit that health literacy influences three main factors which in turn have an impact on health outcomes: (1) navigation skills, self-efficacy and perceived barriers influence the access and utilization of healthcare; (2) knowledge, beliefs and participation in decision-making influence patient/provider interactions; and (3) motivation, problem-solving, self-efficacy, and knowledge and skills influence self care. The relationship of health literacy to health outcomes according to these authors must be conceived as a step function with a threshold effect, rather than in a simple linear fashion. People generally exist within a web of social relationships; and below a certain level of function, much of the day-to-day detail of chronic disease management often needs to be facilitated by others. While the interaction between health literacy and social support is likely to have complicated and subtle implications, the health impact of social effects has not been fully elucidated in the context of health literacy [54]. Nutbeam [36] distinguishes between individual and community or social benefits of health literacy. In terms of individual benefits, functional health literacy leads to an improved knowledge of risks and health services, and compliance with prescribed actions; interactive health literacy to an improved capacity to act independently, an improved motivation and more self-confidence; and critical health literacy to improved individual resilience to social and economic adversity. In terms of community and social benefits, functional health literacy increases the participation in population health programs; interactive health literacy enhances the capacity to influence social norms and interact with social groups; and critical health literacy improves community empowerment and enhances the capacity to act on social and economic determinants of health. Nutbeam's conceptual framework has been applied in case studies focusing on topics of diarrhea [55], self-management in diabetes [56] and health promoting schools [57]. Ratzan [58] links health literacy in the community to the concept of social capital, arguing that health literate people live longer and have stronger incentives to invest in developing their own and their children's knowledge and skills. Healthier populations tend to have higher labor market productivity contributing to, rather than withdrawing from, pension schemes. Similarly, healthier people use the health system less, and coupled with education and cognitive function, appropriately demand fewer health services.Health literacy skills foster greater personal autonomy and promote actions that overcome institutional barriers to health.S?rensen et al. 12 (Kristine S?rensen, Stephan Van den Broucke, James Fullam, Gerardine Doyle, Jürgen Pelikan, Zofia Slonska, Helmut Brand, Consortium Health Literacy Project European, “Health literacy and public health: A systematic review and integration of definitions and models,” BMC Public Health 12:80, p. 8-10)Whereas a number of conceptual models of health literacy have been presented in the literature, none of these can be regarded as sufficiently comprehensive to line up with the evolving health literacy definitions and with the competencies they imply [59]. This is probably due to the fact that attempts to conceptualize health literacy have thus far failed to integrate the existing knowledge encompassing different perspectives on health literacy. Firstly, most of the existing conceptual models are not sufficiently grounded in theory in terms of the notions and concepts included. Secondly, very few models have integrated the components included in "medical" and "public health" literacy models. The only models which explicitly try to bridge the difference between both views are Nutbeam's [36] and Manganello's [50], whose dimension of functional literacy corresponds with the cognitive skills of medical health literacy. Thirdly, while acknowledging that health literacy entails different dimensions, the majority of the existing models are rather static and do not explicitly account for the fact that health literacy is also a process, which involves the consecutive steps of accessing, understanding, processing and communicating information. Fourthly, while most conceptual models identify the factors that influence health literacy and mention its impact on health service use, health costs and health outcomes, the pathways linking health literacy to its antecedents and consequences are not very clear. Researchers could link conceptual models of health literacy more explicitly to established health promotion theories and models [59]. Finally, very few conceptual models of health literacy have been empirically validated. To address these shortcomings, we propose an integrated model of health literacy which captures the main dimensions of the existing conceptual models reviewed above (Figure 1). The model combines the qualities of a conceptual model outlining the main dimensions of health literacy (represented in the concentric oval shape in the middle of Figure 1), and of a logical model showing the proximal and distal factors which impact on health literacy, as well as the pathways linking health literacy to health outcomes. The core of the model shows the competencies related to the process of accessing, understanding, appraising and applying health-related information. According to the 'all inclusive' definition this process requires four types of competencies: (1) Access refers to the ability to seek, find and obtain health information; (2) Understand refers to the ability to comprehend the health information that is accessed; (3) Appraise describes the ability to interpret, filter, judge and evaluate the health information that has been accessed; and (4) Apply refers to the ability to communicate and use the information to make a decision to maintain and improve health. Each of these competences represents a crucial dimension of health literacy, requires specific cognitive qualities and depends on the quality of the information provided [60]: obtaining and accessing health information depends on understanding, timing and trustworthiness; understanding the information depends on expectations, perceived utility, individualization of outcomes, and interpretation of causalities; processing and appraisal of the information depends on the complexity, jargon and partial understandings of the information; and effective communication depends on comprehension. The competences also incorporate the qualities of functional, interactive and critical health literacy as proposed by Nutbeam [36]. This process generates knowledge and skills which enable a person to navigate three domains of the health continuum: being ill or as a patient in the healthcare setting, as a person at risk of disease in the disease prevention system, and as a citizen in relation to the health promotion efforts in the community, the work place, the educational system, the political arena and the market place. Going through the steps of the health literacy process in each of these three domains equips people to take control over their health by applying their general literacy and numerical skills as well as their specific health literacy skills to acquire the necessary information, understanding this information, critically analyzing and appraising it, and acting independently to engage in actions overcoming personal, structural, social and economical barriers to health. As contextual demands change over time, and the capacity to navigate the health system depends on cognitive and psychosocial development as well as on previous and current experiences, the skills and competencies of health literacy develop during the life course and are linked to life long learning. The frameworks associated with the three domains represent a progression from an individual towards a population perspective. As such, the model integrates the "medical" conceptualization of health literacy with the broader "public health" perspective. Placing greater emphasis on heath literacy outside of healthcare settings has the potential to impact on preventative health and reduce pressures on health systems. The combination of the four dimensions referring to health information processing with the three levels of domains yields a matrix with 12 dimensions of health literacy as illustrated in Table 4. Four dimensions of health literacy in the domain of healthcare, i.e., the ability to access information on medical or clinical issues, to understand medical information, to interpret and evaluate medical information, and to make informed decisions on medical issues and comply with medical advice. Four dimensions of health literacy in the domain of disease prevention, notably the ability to access information on risk factors for health, to understand information on risk factors and derive meaning, to interpret and evaluate information on risk factors, and to make informed decisions on risk factors for health. Four dimensions in the domain of health promotion, notably the ability to regularly update oneself on determinants of health in the social and physical environment, to comprehend information on determinants of health in the social and physical environment and derive meaning, to interpret and evaluate information on determinants, of health in the social and physical environment, and the ability to make informed decisions on health determinants in the social and physical environment. Health literacy is in our understanding regarded an asset for improving people's empowerment within the domains of healthcare, disease prevention and health promotion. In addition to the components of health literacy proper, the model in Figure 1 also shows the main antecedents and consequences of health literacy. Among the factors which impact on health literacy, a distinction is made between more distal factors, including societal and environmental determinants (e.g., demographic situation, culture, language, political forces, societal systems), and proximal factors, which are more concerned with personal determinants (e.g., age, gender, race, socioeconomic status, education, occupation, employment, income, literacy) and situational determinants (e.g. social support, family and peer influences, media use and physical environment). Health literacy is strongly associated with educational attainment [50], as well as with overall literacy [34, 38, 39]. Fundamental literacy affects a wide range of cognitive, behavioral, and societal skills and abilities. It should be distinguished from other specific literacy, such as science literacy (i.e., the ability to comprehend technical complexity, understanding of common technology, and an understanding that scientific uncertainty is to be expected), cultural literacy (i.e., recognizing and using collective beliefs, customs, world-views, and social identity relationships) and civic literacy (i.e., knowledge about sources of information and about agendas and how to interpret them, enabling citizens to engage in dialogue and decision-making). According to Mancuso [43], an individual must have certain skills and abilities to obtain competence in health literacy, and identifies six dimensions that are considered as necessary antecedents of health literacy, namely operational, interactive, autonomous, informational, contextual, and cultural competence. Health literacy in turn influences health behavior and the use of health services, and thereby will also impact on health outcomes and on the health costs in society. At an individual level, ineffective communication due to poor health literacy will result in errors, poor quality, and risks to patient safety of the healthcare services [61]. At a population level, health literate persons are able to participate in the ongoing public and private dialogues about health, medicine, scientific knowledge and cultural beliefs. Thus, the benefits of health literacy impact the full range of life's activities--home, work, society and culture [34, 38, 39]. Advancing health literacy will progressively allow for greater autonomy and personal empowerment, and the process of health literacy can be seen as a part of an individual's development towards improved quality of life. In the population, it may also lead to more equity and sustainability of changes in public health. Consequently, low health literacy can be addressed by educating persons to become more resourceful (i.e., increasing their personal health literacy), and by making the task or situation less demanding, (i.e., improving the "readability of the system").Health literacy is necessary to socio-cultural and political change – educators have a unique role in facilitating its development. S?rensen et al. 12 (Kristine S?rensen, Stephan Van den Broucke, James Fullam, Gerardine Doyle, Jürgen Pelikan, Zofia Slonska, Helmut Brand, Consortium Health Literacy Project European, “Health literacy and public health: A systematic review and integration of definitions and models,” BMC Public Health 12:80, p. 1-2)Health literacy is a term introduced in the 1970s [1] and of increasing importance in public health and healthcare. It is concerned with the capacities of people to meet the complex demands of health in a modern society [2]. Health literate means placing one's own health and that of one's family and community into context, understanding which factors are influencing it, and knowing how to address them. An individual with an adequate level of health literacy has the ability to take responsibility for one's own health as well as one's family health and community health [3]. It is important to distinguish health literacy from literacy in general. According to the United Nation Education, Science and Culture Organization (UNESCO) during its history in English, the word 'literate' mostly meant to be 'familiar with literature' or in general terms 'well educated, learned'. While maintaining its broader meaning of being knowledgeable or educated in a particular area, during the late nineteenth century it has also come to refer to the abilities to read and write text. In recent years four understandings of literacy have appeared from the debate of the notion: 1) Literacy as an autonomous set of skills; 2) literacy as applied, practiced and situated; 3) literacy as a learning process; and 4) literacy as text. The focus is furthermore broadening so that literacy is not only referring to individual transformation, but also to contextual and societal transformation in terms of linking health literacy to economic growth and socio-cultural and political change [4]. The same development can be traced in the realm of health literacy. For some time most emphasis was given to health literacy as the ability to handle words and numbers in a medical context, and in recent years the concept is broadening to also understanding health literacy as involving the simultaneous use of a more complex and interconnected set of abilities, such as reading and acting upon written health information, communicating needs to health professionals, and understanding health instructions [5]. American studies in the 1990s linked literacy to health, showing an association between low literacy and decreased medication adherence, knowledge of disease and self-care management skills [6]. The 2003 National Assessment of Adult Literacy (NAAL), which measured the English literacy of American adults (people age 16 and older) included questions related to health, and revealed the consequences of limited literacy on health and healthcare [7]. A report from the Institute of Medicine indicates that nearly half of the American adult population may have difficulties in acting on health information [8]. This finding has been referred to as the "health literacy epidemic" [9]. In response, measures have been taken to ensure better health communication through establishing health literacy guidelines [10], and a trans-disciplinary approach has been encouraged to improve health literacy [11]. To support this approach, the American Medical Association recommends four areas for research: health literacy screening; improving communication with low-literacy patients; costs and outcomes of poor health literacy; and causal pathways of how poor health literacy influences health [12, 13]. The research literature on health literacy has expanded exponentially, with nearly 5,000 PubMed-listed publications to date (Primo November 2011), the majority of which have been published since 2005 [5, 14] and is evident that health literacy is being explored within different disciplines and with different approaches, e.g. looking at the role of health educators in promoting health literacy [15]; public health literacy for lawyers [16], health communication [17], the prevalence of limited health literacy [18], and health literacy as an empowerment tool for low-income mothers [19]. While until recently the interest in health literacy was mainly concentrated in the United States and Canada, it has become more internationalized over the past decade [20]. Research on health literacy has taken place in e.g. Australia [21, 22], Korea [23], Japan [24], the UK [25], the Netherlands [26], and Switzerland [27]. Although the EU produced less than a third of the global research on health literacy between 1991 and 2005 [28, 29], the importance of the issue is increasingly recognized in European health policies. As a case in point, health literacy is explicitly mentioned as an area of priority action in the European Commission's Health Strategy 2008-2013 [30]. It is linked to the core value of citizen empowerment, and the priority actions proposed by the European Commission include the promotion of health literacy programs for different age groups. However, with the proliferation of health literacy research and policy measures, it becomes clear that there is no unanimously accepted definition of the concept. Moreover, the constituent dimensions of health literacy remain disputed, and attempts to operationalize the concept vary widely in scope, method and quality. As a result, it is very difficult to compare findings with regard to health literacy emerging from research in different countries. The current article aims to address this issue by offering a systematic review of existing definitions and concepts of health literacy as reported in the international literature, by identifying the central health literacy dimensions, the target group as well as antecedents and consequences if explained. in order to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.Framework Solves – PolicyThe process of debating a variety of policies about health care is necessary to foster the kind of health literacy that transforms health care into health justice.Freedman et al. 9 (Darcy A. Freedman, PhD, MPH, Kimberly D. Bess, PhD, Holly A. Tucker, PhD, David L. Boyd, PhD, Arleen M. Tuchman, PhD, Kenneth A. Wallston, PhD; “Public Health Literacy Defined,” American journal of preventive medicine, June 2009, p. 448-450)Three dimensions of public health literacy are identified: conceptual foundations, critical skills, and civic orientation. Each dimension has corresponding competencies. Public health literacy is socially, spatially, and temporally located. It consists of various types of knowledge and skills, including experience and oral traditions, as well as reading, writing, arithmetic, and higher education. Public health literacy is as much citizenbased as it is expert-driven, and it can take multiple forms, from voting to organizing grass-roots initiatives to establishing healthy policies and structures. The target population for promoting public health literacy is the entire public, not just public health and medical officials. The competencies within each dimension are not hierarchic, but rather summative: The greater the number of competencies, the higher the level of public health literacy and the greater the capacity to improve public health outcomes. Dimension 1: Conceptual Foundations The conceptual foundations dimension includes the basic knowledge and information needed to understand and take action on public health concerns. An individual or group demonstrating public health literacy at a conceptual level is able to define and discuss: ● core public health concepts such as primary prevention, health promotion, and population health; ● public health constructs such as prevalence, risk factors, probability, and ORs, and the relationship of each of these to morbidity and mortality; and ● ecologic perspectives and the multiple pathways through which disease is transmitted and health is promoted. Conceptual foundations of public health literacy call for a different kind of knowledge than that needed to promote individual health— knowledge that may be gained from sources ranging from classroom sessions to folklore. Such knowledge may or may not be technical in nature, but in all cases it is focused on health promotion and disease prevention at the population level. People or groups with high levels of public health literacy would focus on prevention rather than treatment and would take into account the multiple factors affecting health, including the role of community settings and structures, as well as individual behaviors and lifestyles. Dimension 2: Critical Skills The critical skills dimension relates to the skills necessary to obtain, process, evaluate, and act upon information needed to make public health decisions that benefit the community. An individual or group demonstrating public health literacy on this dimension is able to: ● obtain, evaluate, and utilize public health information from a variety of sources (e.g., health practitioners, media, social networks); ● identify public health aspects of personal and community concerns (e.g., urban planning, agricultural practices, violence); ● communicate information about health conditions and actions (e.g., smoking, obesity, handwashing) not only as a personal concern but also as a problem affecting the larger community; and ● assess who is naming and framing public health problems and solutions and describe the ways in which such framing is biographically, culturally, spatially, temporally, and institutionally bounded. Critical skills focus on promoting the health of the community rather than the health of individuals. In doing so, citizens are able to understand public health aspects of personal and community concerns. In addition, people or groups with high levels of public health literacy have the skills to communicate personal health conditions in terms of problems affecting the broader community and to shift conversations and actions about public health concerns from individual-level to community-level change. These skills tend to refocus discourse about public health problems as well as corresponding actions to reveal the biographic, cultural, spatial, temporal, and institutional constraints on understandings of public health. Dimension 3: Civic Orientation The civic orientation dimension ensures that “the public” remains at the center of public health literacy and includes the skills and resources necessary to address health concerns through civic engagement. An individual or group demonstrating public health literacy from a civic perspective is able to: ● articulate that the burdens and benefits of society are not fairly distributed; ● evaluate who benefits and who is harmed by public health efforts or lack thereof; ● communicate that current public health problems are not inevitable and can be changed through civic action; and ● address public health problems through civic action, leadership, and dialogue. Civic engagement calls for awareness of the ways that public goods, resources, burdens, and benefits are distributed; it is the first step toward civic action to advocate on behalf of the public’s health. Creating a population that is public health literate is critical, and the potential pathways for achieving this goal are numerous. First, efforts ought to focus on formal educational systems, including elementary and high schools, junior colleges, and 4-year colleges and universities. This type of training would be aimed at preparing people to become not necessarily public health professionals but rather more informed members of the public, and would thus prepare students to effectively address public health concerns from myriad perspectives (e.g., at work, as a voter, as a parent). Examples of this type of approach are already being developed.38,39 Second, there is a need to increase levels of public health literacy among the public at large. This increase may occur through the media (e.g., newspapers, magazines, television, radio, websites), along with communitybased or work-based initiatives. Recent efforts related to the 2008 PBS TV documentary series Unnatural Causes: Is Inequality Making Us Sick? () are exemplary of this type of training. This seven-part series has been used by government agencies, communitybased organizations, faith-based groups, and others to explore racial and socioeconomic inequities in health and inspire groups to take action in an effort to redress these injustices. Finally, targeted training may be needed for professionals not formally trained in public health but whose work influences the health of the public. Efforts may target a specific health concern, such as childhood obesity, and then work to ensure relative stakeholders (e.g., school administrators, grocery store owners, legislators, media) are provided with opportunities to become more public health literate. An Agenda for the Future Public health literacy is important, and the challenge is to identify effective strategies for increasing it. A fivepart agenda for future public health literacy research and action is proposed. First, as advocated by Gazmararian et al.,29 measures of public health literacy should be developed. The three dimensions outlined above may be useful in the development of effective assessment instruments that would identify the extent to which individuals and groups are public health literate. Research would also explore the relationship between individual-level health literacy and public health literacy. Second, investigators should explore the full impact of low levels of public health literacy on both society and the decisions of various stakeholders in the healthcare system— consumers, providers, advocates, educators, administrators, policymakers, and elected officials. Third, efforts should be made to promote the incorporation of public health literacy into health literacy programs, formal educational systems, and informal educational networks. Interventions aimed at helping the public become more public health literate should be developed, implemented, and evaluated. Fourth, individuals and groups need to be empowered to translate increased public health literacy competencies into actions that will help resolve some of society’s more pressing health issues and alleviate social injustices. Finally, a broader model of health literacy should be put into practice. This expanded model would emphasize the interconnections between individual-level and societal-level constructs and highlight the ways that these constructs combine to influence the health and well-being of individuals and communities. This interactive model would enlarge the set of tools for devising short- and long-term health solutions for both individuals and the public.Concrete political action is key to demedicalization. Fox 77 (Renee C. Fox, PhD, “The Medicalization and Demedicalization of American Society,” Daedalus, Vol. 106, No. 1, Doing Better and Feeling Worse: Health in the UnitedStates (Winter, 1977), p. 18-19, The MIT Press)The criticism of medicalization and the advocacy of demedicalization have not been confined to rhetoric. Concrete steps have been taken to declassify certain conditions as illness. Most notable among these is the American Psychiatric Association's decision to remove homosexuality from its official catalogue ("Nomenclature") of mental disorders. In addition, serious efforts have been made to heighten physicians' awareness of the fact that because they share certain prejudiced, often unconscious assumptions about women, they tend to over-attribute psychological conditions to their female patients. Thus, for example, distinguished medical publications such as the New England Journal of Medicine have featured articles and editorials on the excessive readiness with which medical specialists and textbook authors accept the undocumented belief that dysmenorrhea, nausea of pregnancy, pain in labor, and infantile colic are all psychogenic disorders, caused or aggravated by women's emotional problems. Another related development is feminist protest against what is felt to be a too great tendency to define pregnancy as an illness, and childbirth as a "technologized" medical-surgical event, prevailed over by the obstetrician-gynecolo gist. These sentiments have contributed to the preference that many middle-class couples have shown for natural childbirth in recent years, and to the revival of midwifery. The last example also illustrates an allied movement, namely a growing tendency to shift some responsibility for medical care and authority over it from the physician, the medical team, and hospital to the patient, the family, and the home. A number of attempts to "destratify" the doctor's relationships with patients and with other medical professionals and to make them more open and egalitarian have developed. "Patients' rights" are being asserted and codified, and, in some states, drafted into law. Greater emphasis is being placed, for example, on the patient's "right to treatment," right to information (relevant to diagnosis, therapy, prognosis, or to the giving of knowledgeable consent for any procedure), right to privacy and confidentiality, and right to be "allowed to die," rather than being "kept alive by artificial means or heroic measures ... if the situation should arise in which there is no reasonable expectation of. . . recovery from physical or mental disability."15 In some medical milieux (for example, community health centers and health maintenance organizations), and in critical and self-consciously progressive writings about medicine, the term "client" or "consumer" is being substituted for "patient." This change in terminology is intended to underline the importance of preventing illness while stressing the desirability of a non-supine, non-subordinate relationship for those who seek care to those who provide it. The emergence of nurse-practitioners and physician's assistants on the American scene is perhaps the most significant sign that some blurring of the physician's supremacy vis-?-vis other medical professionals may also be taking place. For some of the responsibilities for diagnosis, treatment, and patient management that were formerly prerogatives of physicians have been incorporated into these new, essentially marginal roles.16 Enjoinders to patients to care for themselves rather than to rely so heavily on the services of medical professionals and institutions are more frequently heard. Much attention is being given to studies such as the one conducted by Lester Breslow and his colleagues at the University of California at Los Angeles which suggest that good health and longevity are as much related to a self-enforced regimen of sufficient sleep, regular, well-balanced meals, moderate exercise and weight, no smoking, and little or no drinking, as they are to professionally administered medical care. Groups such as those involved in the Women's Liberation Movement are advocating the social and psychic as well as the medical value of knowing, examining, and caring for one's own body. Self-therapy techniques and programs have been developed for conditions as complicated and grave as terminal renal disease and hemophilia A and B. Proponents of such regimens affirm that many aspects of managing even serious chronic illnesses can be handled safely at home by the patient and his family, who will, in turn, benefit both financially and emotionally. In addition, they claim that in many cases the biom?dical results obtained seem superior to those of the traditional physician administered, health-care-delivery system. The underlying assumption in these instances is that, if self-care is collectivized and reinforced by mutual aid, not only will persons with a medical problem be freed from some of the exigencies of the sick role, but both personal and public health will thereby improve, all with considerable savings in cost. This point of view is based on the moral supposition that greater autonomy from the medical profession coupled with greater responsibility for self and others in the realm of health and illness is an ethically and societally superior state.No Solvency – GeneralAlternatives to medicalization ignore pragmatic and institutional realities which everyday people need in order to surviveOmahony, S. (2016). Medical Nemesis 40 years on: the enduring legacy of Ivan Illich. Journal of the Royal College of Physicians of Edinburgh, 46(2), 134-139. doi:10.4997/jrcpe.2016.214 Dr Seamus O’Mahony has been a consultant physician since 1996, and is a Fellow of the Royal Colleges of Physicians of London and Edinburgh. His has published extensively in the fields of endoscopy, coeliac disease and inflammatory bowel disease, and was awarded the MD in 1991. His current main academic interest is medical humanities, and has written extensively in this field. He is associate editor for medical humanities of the Journal of the Royal College of Physicians of Edinburgh, and is a regular contributor to the Dublin Review of BooksIllich’s diagnosis of medicine’s woes was astute, but his prescriptions were risible. He argued, for example, for ‘more public support for alpha waves, encounter groups and chiropractic.’ He advanced rather vague proposals of handing back to lay people responsibility for their health, and limiting the power of doctors, insurance companies and pharmaceutical firms. Medical Nemesis is resistant to medical remedies. It can be reversed only through a recovery of the will to self-care among the laity, and through the legal, political and institutional recognition of the right to care, which imposes limits upon the professional monopoly of physicians. Perhaps it is unreasonable to expect Illich to provide practical solutions to what he viewed as a spiritual, rather than an organisational, or societal, malaise. Medicalization is an example of ivory tower theory that in and of itself pushes lay people out of the discussion.Omahony, S. (2016). Medical Nemesis 40 years on: the enduring legacy of Ivan Illich. Journal of the Royal College of Physicians of Edinburgh, 46(2), 134-139. doi:10.4997/jrcpe.2016.214 Dr Seamus O’Mahony has been a consultant physician since 1996, and is a Fellow of the Royal Colleges of Physicians of London and Edinburgh. His has published extensively in the fields of endoscopy, coeliac disease and inflammatory bowel disease, and was awarded the MD in 1991. His current main academic interest is medical humanities, and has written extensively in this field. He is associate editor for medical humanities of the Journal of the Royal College of Physicians of Edinburgh, and is a regular contributor to the Dublin Review of BooksMedical Nemesis is not an easy read. The prose is dense, and at times, impenetrable. Illich drew not only from the medical literature, but also history, philosophy, sociology and anthropology. His use of footnotes is even greater than the late David Foster Wallace: one 39-word sentence has eight footnotes. He defended this use of footnotes: ‘The footnotes reflect the nature of this text. I assert the right to break the monopoly that academia has exercised over all small print at the bottom of the page. Illich employed this particular style deliberately: he wanted lay people (who, after all, he argued, should take responsibility for their own health) to have access to an extensive bibliography and he wanted to impress medical readers with as much evidence as possible. I suspect that Illich also simply wished to show off: he did not wear his learning lightly. If Medical Nemesis had been stripped of repetition, footnotes and irrelevancies, it might have been a readable long essay. Unreadability, however, is not an insuperable obstacle to success for a book; Medical Nemesis was a bestseller and established Illich as a star public intellectual in the Christopher Hitchens mould. Illich was a charismatic and accomplished public speaker; I suspect that many bought the book after hearing him speak, and gave up after the first few pages.Medicalization has always been a parable for corruption in the Catholic Church rather than the healthcare systemOmahony, S. (2016). Medical Nemesis 40 years on: the enduring legacy of Ivan Illich. Journal of the Royal College of Physicians of Edinburgh, 46(2), 134-139. doi:10.4997/jrcpe.2016.214 Dr Seamus O’Mahony has been a consultant physician since 1996, and is a Fellow of the Royal Colleges of Physicians of London and Edinburgh. His has published extensively in the fields of endoscopy, coeliac disease and inflammatory bowel disease, and was awarded the MD in 1991. His current main academic interest is medical humanities, and has written extensively in this field. He is associate editor for medical humanities of the Journal of the Royal College of Physicians of Edinburgh, and is a regular contributor to the Dublin Review of BooksA reader unfamiliar with Illich would not guess that the author of Medical Nemesis was a Catholic priest. Apophasis may be defined as a kind of theological or philosophical thinking that reveals its true subject by not mentioning this subject.1 The original Greek word means ‘denial’ or ‘negation’. There is a long tradition of Christian apophatic theology, including Meister Eckhart and St John of the Cross. In later life, Illich told his friends that his personal theology was ‘apophatic’. His biographer, Todd Hartch, argues that Illich’s books, including Medical Nemesis, were really about the corruption of Christianity: To Illich, the history of the West was thus the tragedy of the institutionalization of Christianity, as the Church, truly the Body of Christ, adopted the false and dangerous guise of an institution…If the Church had not succumbed to institutionalization, those other institutions would not even have come into existence. Illich’s apophasis, therefore, had two levels. He denied that mandatory schooling was true learning or teaching, that modern medicine was true healing, and that economic development was true compassion; at the deeper level he denied that the Church was a bureaucracy, that the human body was a machine, and that death and suffering could be avoided. Many years after the publication of Medical Nemesis, Illich told his friend, the historian Barbara Duden, that the subject of the book ‘could as easily have been the postal service because the underlying corruption of the West, not medicine itself, was the true object of his study.’1 Illich, like the Biblical prophets, often spoke in riddles and parables.No Solvency – BiopoliticsFoucauldian power analysis is insufficient to capture the nature of actuarial theory in social insurance, which is necessary for uniting disparate interests on a stable platform for actionLengwiler 2003 [Martin Lengwiler, Technologies of trust: actuarial theory, insurance sciences, and the establishment of the welfare state in Germany and Switzerland around 1900, Information and Organization vol. 13, pages 131-150.] Martin Lengwiler is a professor of modern history at the University of Basel.The purpose of this article was to examine the history of actuarial theory in order to understand historically the relation between transformations in information systems, like actuarial theory, and changing organizational contexts, notably German and Swiss social insurances around 1900. These transformations should be seen as co-dependent. As JoAnne Yates cautioned against a technological determinism when examining the rise of information systems, we should also beware of any epistemological determinisms. The rise of actuarial theory is not driven by its scientific progress, it has to be understood in a wider social and institutional context. The institutional rise and significance of actuarial theory is based upon organizational needs, particularly the need for a seemingly objective, disinterested and independent knowledge in the politically highly disputed field of welfare policy and social insurances. Thus, organizational conditions, like the centralized bureaucracy of Wilhelmine, Germany, with its large university system, shaped the emergence of new informational practices, like the rise of actuarial theory as an academic discipline and its subsequent implementation in social insurances. The article also cautions against an exclusive focus on the hegemonic and controlling aspects of information systems, stressed for example in the critical histories of information technologies (Yates, 1989; Beniger, 1986) or by the studies using the Foucauldian concept of governmentality to interpret accounting or insurance practices (Foucault, 1991; Ewald, 1986; Power, 1994). We should refrain from monistic concepts of power, especially of the Foucauldian tradition, and specify them by a heterogeneous multiplicity of interests. Given the variety of strategical policies of insurance companies, government authorities, academics, employers and employees, it is inappropriate to reduce them to one technology of power or one form of government. The history of actuarial theory in Germany and Switzerland for example shows, that information, particularly scientific knowledge, can be used to integrate different parties on a seemingly disinterested and objective point of view. In the institutional context of social insurances, the universalistic approach of scientific experts provided a common reference point for employers and trade unionists when dealing with controversial issues. Thus, in social insurances around 1900, actuarial knowledge is less a coercive power instrument but rather a mediating and integrating conceptual platform within organizations marked by deep antagonisms. Actuarial science was not a pure instrument of power but rather a subtle technology of trust (Porter, 1995).No Solvency – PoliticizationThe shortcomings of health care are only solved through politicization – power is exercised over it as part of a wider bureaucratic and economic system. Bambra et al. 5 (Clare Bambra, PhD; Debbie Fox and Alex Scott-Samuel; Department of Sociology and Social Policy, Sheffield Hallam University and Department of Public Health, University of Liverpool; “Towards a politics of health,” Health Promotion International, Vol. 20 No. 2, Oxford University Press, p. 187-188)It is time that the implicit, and sometimes explicit but unstated politics within and surrounding health were more widely acknowledged. Health, like almost all other aspects of human life, is political in numerous ways: Health is political because, like any other resource or commodity under a neo-liberal economic system, some social groups have more of it than others. Health is political because its social determinants are amenable to political interventions and are thereby dependent on political action (or more usually, inaction). Health is political because the right to ‘a standard of living adequate for health and well-being’ (United Nations, 1948) is, or should be, an aspect of citizenship and a human right. Ultimately, health is political because power is exercised over it as part of a wider economic, social and political system. Changing this system requires political awareness and political struggle. Health inequalities Evidence that the most powerful determinants of health in modern populations are social, economic and cultural (Doyal and Pennell, 1979; Townsend and Davidson, 1992; Whitehead, 1992; Blane et al., 1996; Acheson, 1998) comes from a wide range of sources and is also, to some extent, acknowledged by governments and international agencies (Townsend and Davidson, 1992; Acheson, 1998; Department of Health, 1998; Social Exclusion Unit, 1998). Yet inequalities in health continue, within countries (on the basis of socio-economic class, gender or ethnicity) and between them (in terms of wealth and resources) (Davey Smith et al., 2002; Donkn et al., 2002). How these inequalities in health are approached by society is highly political: are health inequalities to be accepted as ‘natural’ and inevitable results of individual differences both in respect of genetics and the silent hand of the economic market, or are they social and economic abhorrences that need to be tackled by a modern state and a humane society (Adams et al., 2002)? Underpinning these different approaches to health inequalities are not only divergent views of what is scientifically or economically possible, but also differing political and ideological opinions about what is desirable. Health determinants Causes of, and genetic predispositions to ill-health are becoming increasingly well understood. However, it is evident that in most cases, environmental triggers are equally if not more important and that the major determinants of health or ill-health are inextricably linked to social and economic context (Acheson, 1998; Marmot and Wilkinson, 2001). Factors such as housing, income and employment—indeed many of the issues that dominate political life—are key determinants of our health and well-being. Similarly, many of the major determinants of health inequalities lie outside the health sector and therefore require non-health sector policies to tackle them (Townsend and Davidson, 1992; Acheson, 1998; Whitehead et al., 2000). Recent acknowledgements of the importance of the social determinants of health are welcome but fail to seriously address the underlying political determinants of health and health inequity. Citizenship Citizenship is ‘a status bestowed on those who are full members of a community. All who possess the status are equal with respect to the rights and duties with which the status is endowed’ (Marshall, 1963). There are three types of citizenship rights: civil, political and social. Health, or the ‘right to a standard of living adequate for health and well-being’ (United Nations, 1948; International Forum for the Defense of the Health of People, 2002), is an important social citizenship right. These citizenship rights were only gained as a result of extensive political and social struggle during Western industrialization and the development of capitalism (Marshall, 1963). However, despite their parallel development (see Figure 1), the relationship between capitalism and citizenship is not an easy or ‘natural’ one (Marshall, 1963). Health is a strong example of this tense relationship as under a capitalist economic system health is, like everything else, commodified. Commodification is ‘the process whereby everything becomes identifiable and valued according to its relative desirability within the economic market (of production and consumption)’ (de Viggiani, 1997). Health became extensively commodified during the industrial revolution as workers became entirely dependent upon the market for their survival (Esping-Andersen, 1990). In the 20th century, the introduction of social citizenship, which entailed an entitlement to health and social welfare, brought about a ‘loosening’ of the pure commodity status of health. The welfare state decommodified health because certain health services and a certain standard of living became a right of citizenship. In short, capitalism and citizenship represent very different values: the former, inequality and the latter, equality. This tension means that the implementation of the right to health, despite its position in social citizenship and in the UN Universal Declaration of Human Rights, will for the foreseeable future require continuing political struggle.MiscAntiblacknessHealth Care Link – ColorblindnessAff’s colorblind focus on healthcare fails – any intervention into health must begin with the political economy of antiblackness, since modern health-care is structured by antiblacknessPlaney 17 (Arrianna, Ph.D student in the Geography & GIS department at the University of Illinois at Urbana-Champaign, with research interests in disability, health and medical, and economic geography. Their dissertation work examines the ways in which health policy shapes healthcare service access, utilization, and outcomes among people with disabilities in the U.S., with an emphasis on hearing healthcare (audiologists). This includes, but is not limited to, a spatial and political economic analysis of the hearing healthcare system in the U.S. They also investigate the effects of psychosocial stress on mental health outcomes among African-American families as a research collaborator in an interdisciplinary lab at UIUC. “Black History: Why A Political Economy of Healthcare Cannot Ignore Race & Racism”, Feb 5, 2017, online wordpress)As a health geographer, it is a given that place matters. Where you are born, where you live, where you work… these all shape our health and well-being, as well as our healthcare access. However, my background as a history student compels me to emphasize the importance of the histories of these places. Segregation was (and is) an essentially spatial management of racialized bodies and communities. In the U.S. residential segregation remains a reality, even after de jure segregation was ostensibly made illegal. Discriminatory bank lending practices, informal agreements among suburban residents post-white flight, and federal and state policies aimed at helping homeowners that disproportionately benefit white homeowners… these all shape the opportunities available to racially “othered” groups. For example, deindustrialization, the movement of jobs to neighboring suburbs, and hospital closures (esp. after the desegregation of hospitals) all converged to leave Black residents in larger cities in neighborhoods with lower jobs-to-residents ratios, more poorly-funded public schools, and fewer healthcare facilities in proximity. The result is that unemployment is higher, education quality is lesser, and those who do work are typically commuting longer distances to work, which exacts a higher temporal cost on top of the wage disparities these workers may already face. “Political economy” is more defined broadly as social scientific inquiry into relationships between people and society. When I say “political economy,” I refer to Anthony Giddens’ Theory of Structuration, wherein the self/identity is situated within a broader (“macro”) social order and social reproduction. In other words, the “micro” cannot be understood without the “macro.” For example, how I understand myself as a cisgender Black woman who is disabled is also contingent upon the ways in which I am racialized, gendered, and medicalized, as well as my class status and relative access to healthcare which confirms my status as “disabled.” My embodiment at the intersections of race, class, disability, and gender are all contingent upon the ways in which social categories (enforced to the end of social reproduction). In the case of healthcare, we have to begin by understanding healthcare providers as actors whose knowledge production is shaped by medical and scientific discourses and practices that include racial science, eugenics (reform eugenics includes the redefinition of race-as-biology via genomics**), and the history of medical researchers and institutions simultaneously excluding marginalized populations from care while exploiting them in their studies. In spatial terms, we can think of healthcare providers as actors whose location decisions are shaped by federal and state legislation pertaining to their scope of practice and insurance reimbursements for their services, as well as locations of clinical programs themselves. Also important is how these healthcare providers are racialized. Why? The American Medical Association prohibited Black physicians from joining their ranks, and this membership was important in determining physicians’ admitting privileges. This, in turn, meant that Black patients of Black physicians were doubly excluded from better-resourced hospitals that catered to white patients in the context of de jure segregation. The below linked article discusses the Simkins vs. Cone (1963) case that ended racial prohibitions on membership to medical professional organizations, which opened the door to desegregating hospitals. AAIHS | (4 Feb 2017) Civil Rights and Healthcare: Remembering Simkins v. Cone (1963) “In 1962, dentist George Simkins, Jr. unsuccessfully attempted to admit a patient to Moses H. Cone Memorial Hospital, one of two private white hospitals in the city supported by tax dollars. Combining his role as community dentist and President of the Greensboro chapter of the NAACP, Simkins initiated a class-action lawsuit against both Moses Cone and Wesley Long Community Hospitals. The NAACP’s Legal Defense Fund assisted in litigating the test case. Not only were African American patients barred from these institutions, Black physicians were barred from practicing there, even as both institutions received state and federal funds provided by the 1946 Hill-Burton Hospital Survey and Construction Act. Hill-Burton emerged from President Harry Truman’s failed healthcare reform and promised to rebuild and modernize the U.S. healthcare infrastructure. However, this program included a loophole where states that engaged in de jure racial segregation could use the money to build segregated facilities. Cone and Long Hospitals both benefited from this program and its segregation loophole. This is not to say that segregated hospitals did not exist before the Hill-Burton Program, however; historian Vanessa Gamble chronicles the movement to establish Black hospitals from 1920–1945. Initially, the district court of North Carolina sided with the defendant hospitals; however, the Fourth Circuit Court of Appeals (and later the United States Supreme Court, which refused to hear the case) deemed that the two hospitals’ policies of racial discrimination for both patient admissions and visiting physician staff privileges violated the fifth and fourteenth amendments of the Constitution.” and “Though the Simkins case is lauded for bringing about a swift end to segregation in healthcare, among other things, it led to the decline of Black community hospitals. While some, like Grady Memorial in Atlanta, successfully negotiated the new terrain of race relations, federal monies, power, and increased opportunities for Black medical students and doctors elsewhere, others like Homer G. Phillips Hospital of St. Louis and L. Richardson Hospital shuddered under the burden of increasing medical costs, lack of staff, and changing ideas around the importance of these institutions. In effect, Black hospitals were an anachronism in the post-Simkins era. Where some Black patients could, like my grandmother, walk to and from their community hospitals, such an action is almost inconceivable today given the large, distant campuses of many contemporary urban hospitals and medical centers.” Relatedly, we can link southern states’ refusal to expand Medicaid under the Affordable Care Act (ACA) with their antebellum tax regimes. Currently, Alabama, Georgia, Florida, Kansas, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee and Virginia have not expanded Medicaid. In the case of Alabama, its tax base was destroyed by Emancipation in 1865, because they taxed by the number of slaves owned, rather than taxing land values (oh, because enslaved Africans were PROPERTY/CHATTEL). During and after Reconstruction, attempts to tax land and other forms of property were resisted, such that the state could not generate tax revenue to cover its service provision. Why does this matter for Medicaid? Medicaid, administered at the state level, is about 50-50 federal and state funded- that is, the federal government matches state contributions of Medicaid programs.* Medicaid’s costs are higher when unemployment is highest and tax revenues are lowest, so even the federal contribution is not sufficient incentive. Unfortunately, these states are largely in the Black Belt, where poverty is concentrated and health disparities by race and class are notable. South Union Street | (4 Feb 2017) A Permanent Wound: How the Slave Tax Warped Alabama Finances “Like slavery, the slave tax would leave a permanent wound on the state. When slavery died, so did the tax. Reconstruction-era efforts to replace the lost revenue with increased property taxes — the only major source left — sparked an angry reaction. Legislators rushed to introduce tax restrictions after Reconstruction without making serious efforts to find other sources of revenue. “That set in place decades-long policies that, to this day, make it difficult and sometimes impossible for Alabama to generate enough revenue to pay for its state services.The $1.8 billion General Fund, which pays for most noneducation services in the state, should grow no more than $25 million in 2018; the state’s Medicaid agency alone has requested a $44 million increase for the year.”Health Care Link – GenericAntiblackness in healthcare is libidinal and structural, not something that can be solved with more coverage or more deliberative educationHolloway 16 (Kali, senior writer and the associate editor of media and culture at AlterNet, “Medical Racism and the Ignoring of Black Pain”, Alternet online, April 26, 2016)Education is often considered the cure for racism; a way to erase bigoted, erroneous and myth-based beliefs with colorblind facts. But biases are stubborn, deeply held things, more impervious to truth than we might like to consider. Researchers from the University of Virginia discovered this when they queried a group of 222 white medical students and residents and found that half believed in phony biological differences between black and white people, including “that blacks age more slowly than whites; their nerve endings are less sensitive than whites’; their blood coagulates more quickly than whites’; [and] their skin is thicker than whites.” Among those who cosigned at least one of those madeup racial differences, false beliefs correlated directly with the potential to screw up medical treatments. Future doctors who demonstrated racially biased thinking were also more likely to underrate the pain levels of hypothetical black patients. The end result was that those med school students were “less accurate”—a nice way of saying “more wrong”—than their less biased peers in recommendations for mitigating pain experienced by African American versus white patients. These findings may be troubling, but they’re not particularly surprising. Prior studies have not only shown the existence of racism in medicine—as in every American institution—but proved it to be a malignant condition with potentially life-threatening consequences for African Americans. In 2012, researchers at Johns Hopkins University School of Medicine found doctors with “unconscious racial biases tend to dominate conversations with African-American patients,” ignoring patient needs and engendering mistrust, discomfort and a decreased likelihood to return for necessary followups. Black children suffering from stomach pain are less likely than white children to be given pain medication by emergency room personnel, and Hispanic and African-American kids experience longer ER waits than their white cohorts. Daily Beast contributor Keith Wailoo cites two 1990s studies finding “white patients... treated for long bone fractures were dosed [with pain meds] more liberally than Latino patients in Los Angeles, and more liberally than black ones in Atlanta.” The Institute of Medicine noted in 2002 that “racial and ethnic minorities receive lower quality health care than whites, even when they are insured to the same degree and when other healthcare access-related factors, such as the ability to pay for care, are the same.” Like the UVA study, numerous others have found white doctors, as well as white laypeople and even white children think black people can endure more pain than whites. This idea of black immunity to pain is purely magical thinking, rooted in longstanding, widely circulated and scientifically baseless beliefs that essentially cast black people as something other than human. (Researchers behind one 2001 study concluded that “white Americans superhumanize black people relative to white people.”) Racist misconceptions about black people’s extraordinary tolerance for pain and suffering—what I would label a sort of “animalizing othering”—has helped rationalize centuries of cruelty and brutality against African Americans, assuaging white consciences around harsh mistreatment and reifying the fable of white humanity’s superiority. Keith Wailoo notes that backward ideas about “blood differences were once used [as the reasoning for] segregating the blood supply and to argue against racial integration.” Kelly Hoffman, the UVA psychology Ph.D. candidate who led the survey of medical students says, “These beliefs have been around for a long time in our history. They were once used to justify slavery and the inhumane treatment of black people in medicine.” Thoroughly modern systemic racism continues to be fueled by this sort of misinformation about African-American subhumanity, detrimentally affecting black life, and in plenty of cases, leading to black death. In addition to fallacious ideas about African Americans and pain, unfounded racial stereotypes about black and Hispanic tendencies toward drug addiction also make doctors less likely to prescribe needed pain medications to people of color. The University of Dayton Law School’s Race, Racism and the Law site notes that fears based in racial stereotypes are related to pharmacies in minority communities understocking opiate medications, with concerns varying from not wanting to “attract opioid-using clients” to “fear of drug theft from the pharmacy.” A population seen as unable to experience pain encounters resistance to treating that pain on nearly every front. If AfricanAmericans are innately more resistant to pain than other groups—and by that same supposition, more dangerous, threatening, beastial and just plain old scary—negative reactions ranging from medical neglect to police violence can be regarded as warranted. Fantastical ideas about inhuman black strength bolster shoot-to-kill policies and one-directional justification of stand-your-ground laws, while also negating anti-chokehold and other excessive force prohibitions. Under this skewed logic, unarmed black teenagers murdered by armed assailants who physically outweigh and pursued them are somehow transformed into aggressors who merited precisely what they got. African-American girls are seen as deserving physical assault and vicious manhandling by male officers. African Americans suffering from illnesses such as renal failure, cardiac disease and cancer are, studies show, less likely to be recommend curative care by their physicians than whites, even when insurance coverage is the same.Health Care Link – Mental HealthMental health cardHolloway 16 (Kali, senior writer and the associate editor of media and culture at AlterNet, “Medical Racism and the Ignoring of Black Pain”, Alternet online, April 26, 2016)Certainly, mental health issues are often undiagnosed and undertreated in every segment of the American populace. The inaccessibility of mental health services for many Americans is a source of national shame. But while there have been strides made, depression, mental anguish and sadness are presumed to be more profoundly, and legitimately felt by white Americans, so much so that they’re often considered the reason for negative resulting behaviors. This plays out time and again when, for example, white perpetrators carry out mass shootings, and their feelings—their hurt, their isolation, their mental anguish—become a central theme of the ensuing media coverage. The New York Times reflected on the “dark thoughts and...paranoid delusions of major depression" that may have plagued James Eagan Holmes in the weeks before he went on a shooting spree in a packed Aurora, Colorado movie theater, killing 12 and injuring 70. An op-ed from Fox News headlined “Why didn't anyone help Dylann Roof?”—the man who killed nine African-American parishioners in a South Carolina church—acknowledged that while the shooter “expressed hateful white supremacist” views, he may also have suffered from the kind of depression that can cause “bizarre beliefs that sometimes lead to the destruction of others.” (The article goes on to suggest that “those beliefs can look just like intense hatred of a particular person or a whole race of people,” as if being a hardcore racist should be reclassified as a mental condition.) In the wake of the Sandy Hook shootings, an investigation by the Connecticut Office of the Child Advocate resulted in a lengthy report detailing the “predisposing factors and compounding stresses” that contributed to Adam Lanza’s “commission of mass murder”: Authors conclude that there was not one thing that was necessarily the tipping point driving AL to commit the Sandy Hook shooting. Rather there was a cascade of events, many self-imposed, that included: loss of school; absence of work; disruption of the relationship with his one friend; virtually no personal contact with family; virtually total and increasing isolation; fear of losing his home and of a change in his relationship with Mrs. Lanza, his only caretaker and connection; worsening OCD; depression and anxiety; profound and possibly worsening anorexia; and an increasing obsession with mass murder occurring in the total absence of any engagement with the outside world. AL increasingly lived in an alternate universe in which ruminations about mass shootings were his central preoccupation. Though researchers are careful to point out that the report is not meant to serve as a statement of exoneration (“[He, and he alone, bears responsibility for this monstrous act,” they write), it suggests that Lanza’s pain, due to his parents divorce, his feelings of alienation and loneliness, played a role in his anger in isolation, and was among the motivating factors in his crime. In whole or in part, we are meant to understand that Lanza’s depression, anxiety and sadness played a role in his murderous acting out. Researchers write that numerous “interventions and services...could have and should have been delivered over the course of his life.” Compassionate statements like these, as well as the undertaking of the report, indicate a willingness to separate Adam Lanza from his crime, to see him as fully human, to investigate the underlying pain he endured that might make a person behave so abominably. This kind of empathy is never extended to African-American victims, much less those accused of horrific crimes. Compare the Lanza report with the New York Times description of Michael Brown, the unarmed 18-year-old killed by Ferguson police officer Darren Wilson. As cultural critic LaSha notes at Salon, the Times implicates Brown as “no angel,” notes that he “dabbled in drugs and alcohol,” wrote raps that “were by turns contemplative and vulgar” and would sometimes “talk back” to his mother. The article even digs into Brown’s infancy, dubbing him “a handful” presumably because “when his parents put up a security gate, he would try to climb it” (as if this is a rarity among toddlers). The author mentions that Brown “lived in a community that had rough patches,” but declines to suggest this may have been a source of pain and site of struggle. In fact, there has been no serious investigation of Brown’s mental state, of the anguish and inner turmoil he may have experienced or coped with through self-medication. African-American writer Trina Young perfectly sums up the frustration of witnessing this empathy gulf, and wonders about the dehumanizing effect of ignoring black pain. “Why shouldn’t we get this privilege that whites do?” Young writes in a Blavity post. “Why can they shoot up schools and the media highlights their mental health struggles, saying they were ‘just in pain’ and ‘no one saw it until it was too late?’ Instead of going along with the stigma of mental illness, we should be saying, ‘Hey, we go through this too. We are humans just like everyone else.’” The idea of black people’s extraordinary strength is likely rooted in the fact that suffering has been central to black American experience and overcoming that suffering is in many ways a source of black communal pride. But African-Americans’ internalized notions about black super-strength have also bred resistance to psychiatric interventions and other therapeutic responses to trauma and pain. Multiple studies find that African Americans are “significantly more likely to report major depression” than other groups, with one group of researchers concluding that black Americans are “20 percent more likely to report having serious psychological distress than” whites. In addition to the everyday difficulties that impact white lives, blacks must deal with “race-based trauma,” the result of both personal confrontations with racism and secondhand experiences, such as those that arise from viewing repeated coverage of racist violence, which has been linked with post-traumatic stress disorder. The trauma incurred from issues that disproportionately affect African Americans, from poverty to unemployment, can also take a deadly toll. A 2015 study found that over the last two decades, the suicide rate for black boys aged 5 to 11 nearly doubled even as it declined among white children of the same age. Despite all this, a 2011 CDC study found less than 8 percent of African Americans engaged with mental health services that year. Black notions of resilience contribute to these figures, as do the myriad other factors that make mental health care so difficult to access, such as expense. But Janet Taylor, a New York City psychiatrist, notes practitioner biases can also have a detrimental impact. “There are some health care providers who assume that…strife in black people or having a difficult time are what’s to be expected,” Taylor said in an interview with Ebony magazine. “In some cases they may normalize what may be a traumatic reaction.”A/T: Permutation – White ShameAff’s atonement and attempt to solve for the harms of antiblack policies merely legitimizes the new, legitimate forms of whiteness which find their apex in liberal notions of self-mastery and ethicality, reproducing colonial dominationHunter 10 (Shona, Lecturer in Sociology and Social Policy Governance at the University of Leeds, and Research Associate at the Research Centre into Visual Identities in Architecture and Design at the University of Johannesburg. “What a White Shame: Race, Gender, and White Shame in the Relational Economy of Primary Health Care Organizations in England”, 25 October 2010, Social Politics, Volume 17, Issue 4, Winter 2010)What does all of this tell us about (dis)continuities between colonial pasts and postcolonial presents? And what does it tell us about shifts in whiteness in contemporary multicultural contexts and in particular about the possibility for more reparative forms of whiteness? In the first section of this paper, I demonstrated associations between class, whiteness, and masculinity to be constituent components of imperial pride and, symbolized in medicine as the pinnacle of white, male imperial prowess and civilization. I went onto suggest that one consequence of postcolonial shifts toward the differential inclusion of minoritized subjects has been that these same sources of imperial pride now constitute sources of shame. However, on the basis of my interpretation of the empirical material presented in the second half of the paper, I argue that a “turning away” from the more overt racist cruelties and violences of Empire does not represent a wholesale rejection of colonial civilizing missions; rather, these civilizing missions are changing in nature. Characterized by differential inclusion, the current postcolonial moment is constituted through less clear-cut divisions between “victim” and “oppressor,” and these ambivalences are evident in the empirical material I presented around shame. From these data, I want to claim that one of the key shifts reflected in moves from imperial pride to individual expressions of shame at the racist consequences of imperialisms is the shift from whiteness as constituted through saving the colonized other to whiteness as constituted through saving the white racist self. My argument in this paper points to developing distinctions between legitimate and illegitimate whitenesses, but suggests that it is the expression of shame, rather than pride which can serve to sanitize whiteness. Whereas legitimate and idealized whiteness in the past was based on heroism and civilizing missions in far-off places, legitimate whiteness is now based on the ability to explicitly atone for past wrongs, the ability to civilize the self at home. Legitimate whitenesses are constructed not through the displacement and annihilation of blackness, but through the displacement of illegitimate whiteness. Expressions of shame then become the marker of legitimate forms of whiteness. This construction of whiteness as control and mastery of the self is not in itself new. Richard Dyer's (1997) work highlighted colonial whiteness as achieved through “superhuman” self control as well as mastery of the Other. However, the original element to contemporaneous markers of white self control is shame, and in my account above, an explicit role accorded to white women in public shaming.DisabilityA/T: IntersectionalityThe oppression of disabled peoples is theoretically and materially distinct from other oppressionsLang 01 (Dr. Raymond Lang, Senior Research Associate Overseas Development Group University of East Anglia, “THE DEVELOPMENT AND CRITIQUE OF THE SOCIAL MODEL OF DISABILITY”, January 2001, pg. 5-6, Rawle)Paul Abberley (1987) has also analysed the concept of social oppression as it applies to disabled people. He argued that other groups within society, such as women and ethnic minorities, encounter oppression, but that is not possible to construct a monolithic theory that provides an adequate explanatory framework to comprehensively analyse the phenomenon for all marginalised groups. Social oppression is specific in the manner in which it operates in relation to form, content and location, “so to analyse the oppression of disabled people in part involves pointing to the essential difference between their lives and other sections of society, including those who are, in other ways, oppressed”. (Abberley, P. 1977:163). Abberley delineates four supplementary defining characteristics of social oppression as it relates to disabled people. He stated:- “To claim that disabled people are oppressed involves, however, arguing a number of other points. At an empirical level, it is to argue that on significant dimensions disabled people can be regarded as a group whose members are in an inferior position to other members of society because they are disabled people. It is also to argue that these disadvantages are dialectically related to an ideology or group of ideologies which justify and perpetuate the situation. Beyond this it is to make the claim that such disadvantages and their supporting ideologies are neither natural nor inevitable. Finally, it involves the identification of some beneficiary for this state of affairs”. (Abberley, P. 1987:163) Social oppression in turn gives rise to institutional discrimination, analogous to that experienced with sexual and racial discrimination. Barton (1993) on commenting upon the meaning of institutionalised discrimination within the British context stated:- “An extensive range of research findings has demonstrated the extent of the institutional discrimination which disabled people experience in our society. This involves access and opportunities in relation to work, housing, education, transport, leisure and support services. Thus, the issues go far beyond the notion that the problem is one of individual disabilist attitudes. These are not free floating but are both set within and structured by specific, historical, material conditions and social relations. Goodwill, charity and social services are insufficient to address the profundity and stubbornness of the factors involved”. (Barton, L. 1993:242). Disabled people have been subjected to a multiplicity of oppressive social attitudes throughout history, which have included “horror, fear, anxiety, hostility, distrust, pity, over-protection and patronizing behavior” (Barton, L. 1996:8). Such pejorative attitudes, coupled with an inhospitable physical environment such, as inaccessible buildings and unusable transport systems, are considered to be the real concerns of disability. (Barnes, C. 1991). It is therefore maintained that “disabled people live within a disabling world”.A/T: MarxismTheories of disability can be expressed in materialist ontologiesLang 01 (Dr. Raymond Lang, Senior Research Associate Overseas Development Group University of East Anglia, “THE DEVELOPMENT AND CRITIQUE OF THE SOCIAL MODEL OF DISABILITY”, January 2001, pg. 9, Rawle)Vic Finklestein (1980) was one of the pioneers in developing a materialist explanation. He postulated that history can be divided into three “distinct and sequential phases”, and that within each phase, the manner in which disabled people are socially included or excluded within contemporary society will differ. Firstly, the period before the European industrial revolution was characterised by agrarian feudalism and some cottage industries. During this period, there was scant social mobility, and this mode of production did not preclude disabled people from active participation in their local communities. During the second phase, spanning the industrial revolution and its immediate aftermath, disabled people were effectively excluded from being in paid employment, due to the fact that they were not able to maintain the pace set by the factory system. As a consequence, disabled people were separated and thereby socially excluded from mainstream social and economic activity. Finkelstein maintained that during the third phase, which was just commencing, disabled people will witness and experience their liberation from social oppression. This will be achieved through disabled people and their allies working collaboratively to achieve commonly agreed goals, through the aegis of the disability movement. ................
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