1. The Social Lives of Health and Medicine

2. A new global agenda for health equity Our children have dramatically different life chances depending on where they were born. – Japan or Sweden 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. In countries at all levels of income, health and illness follow a social gradient – the lower the socioeconomic position, the worse the health. WHO (2009)

3. Inequities and Inequalities It does not have to be this way and it is not right that it should be like this Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. WHO (2009)

4. “It’s Not the Germs!” Etiology – disease causation – Germs, nature, society, individual factors, super- nature Ethnoetiology – local knowledge & practices related to theories of disease causation – Agents (personalistic) – Contextual (naturalistic) – Internalizing (physiological/internal mechanisms) – Externalizing (events outside the body/external pathogenic agencies)

5. The Blane Report (1977) 4 explanations for patterns of inequality in health – Statistical Artefacts: modes of measurement – Outcome of natural or social selection (?) Health experience upward mobility & unhealthy downward – Behavioral or cultural practices – Class and health are linked by structural factors

6. WHO on Social Determinants of Health health inequities are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries. WHO (2009)

7. MATERIALIST/STRUCTURALIST Emphasizes social, political, economic factors which adversely affect health Forms of social/econ./pol. org., environment, health services, transport, economic conditions, work practices We are born into society with a ‘material structure’ (ascribed status?) – ‘shapes us’ Social org. rather than individual biology Foundation for health inequalities/ disparities/population health approaches

8. Three principles of action Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health. WHO (2009)

9. Social class? How to define? What variables do we use? – Occupation, income & wealth, prestige, education, residence, ethnicity, gender, age, ? The adjective “Class” – descriptive – collectively organized actors – people become identified independently of kinship as a constituent of class – for example, biological differences or functions as defined in the culture rather than social identities become increasingly important Class formation – the formation of collectively organized actors Class consciousness – the understanding of actors of their class interests Class struggle – the practices of actors for the realization of their class interests – In contest Interrelationships of all these

10. How do we know social classes exist? Social stratification the unequal distribution of goods and services, rights and obligations, power and prestige all attributes of positions in society, not attributes of individuals there are significant breaks in the distribution of goods services, rights, obligations, power prestige as a result of which are formed collectivities or groups we call strata or “class”

11. Neoliberalism, Class, and Health Neoliberalism – move from a bureaucratic welfare-based society toward a meritocracy – in the interests of business – based on individual and economic liberty Health & health care consequences – Individual centric – Achieved health Class analysis?

12. Accounting for the Social Social Constructivism Social capital In contrast to: – the ‘variable approach’

13. Social Constructionism how social phenomena develop in particular social contexts a concept or practice which may appear to be natural and obvious to those who accept it, but in reality is an invention or artifact of a particular culture or society -- SOCIAL CONSTRUCT Social constructs -- by-products of countless human choices rather than laws resulting from divine will, nature, OR ANY OTHER EXPLANATION THAT PURPORTS OTHERWISE

14. Deconstructing Social Constructs uncover the ways in which individuals and groups participate in the creation of their perceived social reality looking at the ways social phenomena are created, institutionalized, and made into tradition by humans Socially constructed reality is seen as an ongoing, dynamic process reality is reproduced by people acting on their interpretations and their knowledge of it.

15. Deconstruction: Derrida A strategy of critical analysis understanding language as writing and how this leads to the impossibility of a straightforward theory of intentional meaning concepts in terms of their structure and genesis Individual language users operate within a system of meaning that is given to them from outside Meaning is therefore not fully under the control of the individual language user

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

17. Disease as a natural fact ? recognizable by natural scientific methodology Statistical concepts of normality Diseases change independently of their biology – TB steadily declined prior to discovery of tubercule bacillus & vaccine Diseases produced in social environments – Repetitive strain injury (RSI) – Chronic fatigue syndrome – PMS

18. Pierre Bourdieu: 3 types of capital Economic capital: command over economic resources (cash, assets). Economic capital Social capital: resources based on group membership, relationships, networks of influence and support. Social capital Cultural capital: forms of knowledge; skill; education; any advantages a person has which give them a higher status in society, including high expectations. – E.g. Parents provide children with cultural capital, the attitudes and knowledge that makes the educational system a comfortable familiar place in which they can succeed easily.

19. With regard to social capital, studies increasingly show that communities supported by a substantial stock of social capital have better economic and social performance (Putnam, 2000). Better health, health conditions, and health care. Social Capital & Health in Canada