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One of the abiding interests of social scientists concerned with modernization and its eﬀects, particularly those who took up the legacy of Emile Durkheim and Talcott Parsons, has been to show how social order is produced and sustained in contemporary society. In this vein the sociologist Irving Zola argued in the early 1970s that medicine was becoming a major institution of social control, replacing the more ‘traditional’ institutions of religion and law, resulting in the ‘medicalizing’ of much of daily life in the name of health. Zola’s publication, by no means totally opposed to the process he highlights, gave birth to a genre of research in which the cumbersome word medicalization— ‘to make medical’— was adopted as a key concept (Zola 1972).
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It can be argued that medicalization commenced many hundreds of years before Zola’s observation, from the time that healing specialists were ﬁrst recognized among human groups. With the consolidation between approximately 250 BC and 600 AD of the several literate medical traditions of Europe and Asia that remain powerful today, healers were sought out to purge the stresses of everyday life in addition to dealing with physical malfunction. Common to these literate medical traditions is an emphasis on self-discipline, vigilance, and virtue as essential for sustained good health, and the function of healers is to restore order to the bodies of those patients no longer in balance with the social and environmental milieu.
1. Modernization and Medicalization
With modernity several fundamental shifts can be detected in the form taken by medicalization, most notably the involvement of the state in the systematic monitoring of the health of populations. Beginning in the seventeenth century, European and North America modernization fostered an ‘engineering mentality’ one manifestation of which was a concerted eﬀort to establish increased control over the vagaries of the natural world through the application of science. As a result, by the eighteenth century, health came to be understood by numerous physicians and by the emerging middle classes alike as a commodity, and the physical body as something that could be improved upon. At the same time, legitimized through state support, the consolidation of medicine as a profession was taking place, together with the formation of medical specialties and the systematic accumulation, compilation, and distribution of new medical knowledge. Systematization of the medical domain, in turn, was part of a more general process of modernization to which industrial capitalism and technological production was central, both intimately associated with the bureaucratization and rationalization of everyday life.
Medicalization expanded in several directions during the eighteenth and nineteenth centuries. First, there was an increased involvement on the part of medical professionals in the management not only of individual pathology, but of life-cycle events. Birth had been entirely the provenance of women, but from the early eighteenth century, in both Europe and North America, male midwives trained and worked at the lying-in hospitals located in major urban centers to deliver the babies of well-oﬀ women. These accoucheurs later consolidated themselves as the profession of obstetrics. By the mid-nineteenth century other lifecycle transitions, including adolescence, menopause, aging, and death had been medicalized, followed by infancy in the ﬁrst years of the twentieth century. In practice, however, large segments of the population remained unaﬀected by these changes until the mid-twentieth century.
Another aspect of medicalization can be glossed in the idiom of ‘governmentality’ proposed by Michel Foucault. With the pervasive moves throughout the nineteenth century by the state, the law, and professional associations to increase standardization through the rational application of science to everyday life, medicine was integrated into an extensive network whose function was to regulate the health and moral behavior of entire populations. These disciplines of surveillance, the ‘bio-politics of the population,’ as Foucault described it, function in two ways. First, everyday behaviors are normalized so that, for example, emotions and sexuality become targets of medical technology, with the result that reproduction of populations and even of the species are medicalized. Other activities, including breastfeeding, hygiene, exercise, deportment, and numerous other aspects of daily life, are medicalized—largely by means of public health initiatives and with the assistance of the popular media.
Medical and public health management of everyday life is evident not only in Europe and North America, but also in nineteenth-century Japan and to a lesser extent in China. In India, Africa, South East Asia, and parts of the Americas, medicalization is intimately associated with colonization. Activities of military doctors and medical missionaries, the development of tropical medicine and of public health initiatives, designed more to protect the colonizers and to ‘civilize’ the colonized than to ameliorate their health, are integral to colonizing regimes. As with medicalization elsewhere, large segments of the population remained untouched by these activities (Arnold 1993).
From the late eighteenth century, another arm of medicalization became evident. Those populations labeled as mentally ill, individuals designated as morally unsound, together with targeted individuals living in poverty were for the ﬁrst time incarcerated in asylums and penitentiaries where they were subjected to what Foucault termed ‘panopticism.’ Inspired by Jeremy Bentham’s plans for the perfect prison in which prisoners are in constant view of the guards, the Panopticon was, for Foucault, a mechanism of power reduced to its ideal form—an institution devoted to surveillance.
These changes could not have taken place without several innovations in medical knowledge, technologies, and practice, among which four are prominent. First, the consolidation of the anatomical and pathological sciences whereby the older humoral pathology is all but eclipsed so that belief in individualized pathologies is essentially abandoned in favor of a universal representation of the normal body from which sick bodies deviate. Second, the introduction of the autopsy enabling systematization of pathological science. Third, routinization of the physical examination and of the collection of case studies. Fourth, the application of the concept of ‘population’ as a means to monitor and control the health of society, central to which is the idea of a norm about which variation, which can be measured statistically, is distributed. The belief that disease can be understood both as individual pathology and as a statistical deviation from a norm of health becomes engrained in medical thinking as a result of these changes. Treatment of pathology remains, as was formerly the case, the core activity of clinical medicine, but the new epistemology of disease causation based on numeration gradually gained ground. Public health and preventive medicine, always closely allied with the state, made the health of populations its domain.
Other related characteristics of medicalization, well established by the late nineteenth century, and still evident today, can be summarized following Nikolas Rose (1994), into ‘dividing practices,’ whereby sickness is distinguished from health, illness from crime, madness from sanity, and so on. Following this type of reasoning certain persons and populations are made into objects of medical attention and distinguished from others who are subjected to diﬀerent authorities including the law, religion, or education. At the same time various ‘assemblages’ are deployed—a combination of spaces, persons, and techniques, that constitute the domain of medicine. These assemblages include hospitals, dispensaries, and clinics, in addition to which are the home, schools, the army, communities, and so on. Recognized medical experts function in these spaces making use of instruments and technologies to assess and measure the condition of both body and mind. The stethoscope, invented in the early nineteenth century, was one such major innovation, the ﬁrst of many technologies that permit experts to assess the condition of the interior of the body directly, rendering the patient’s subjective account of malaise secondary to the ‘truth’ of science.
Several noted historians and social scientists argue that from the mid-nineteenth century, with the placement in hospitals for the ﬁrst time not only of wealthy individuals but of citizens of all classes, the medical profession was able to exert power over passive patients in a way never before possible. This transition, aided by the production of new technologies, has been described as medical ‘imperialism.’ Certain researchers limit use of the term medicalization to these particular changes whereas other scholars insist that the development of hospitalized patient populations is just one aspect of a more pervasive process of medicalization, to which both major institutional and conceptual changes contribute. Included are fundamentally transformed ideas about the body, health, and illness, not only among experts but also among the population at large.
2. The Medicalization Critique
In writing a review article of medicalization Conrad (1992) states that over the previous 20 years the term had been used most often as a critique of inappropriate medicalization rather than simply to convey the idea that something had been made medical. Sociological literature of this period argued uniformly that health professionals had become agents of social control. This position was inﬂuenced by the publications of Thomas Szasz and R. D. Laing in the 1960s in connection with psychiatry where they insisted that the social determinants of irrational behavior were being neglected in favor of an approach dominated by a biologically deterministic medical model. Zola, Conrad, and others argued in turn that alcoholism, homosexuality, hyperactivity, and other behaviors were increasingly being biologized and labeled as diseases. While in theory this move from ‘badness to sickness’ ensured that patients could no longer be thought of as morally culpable, it permitted medical professionals to make judgments that inevitably had profound moral repercussions.
Once it became clear that life-cycle transitions and everyday behaviors were increasingly being represented as diseases or disease-like, a reaction set in during the 1970s against medicalization, particularly among sociologists and feminists. It was Ivan Illich’s stinging critique of scientiﬁc medicine in Medical Nemesis that had the greatest eﬀect on health care professionals and the public at large. Illich argued that, through overmedication, biomedicine itself inadvertently produces iatrogenic side eﬀects (an argument that no one denies) and, further, that the autonomy of ordinary people in dealing with health and illnesses is compromised by medicalization.
In the 1970s a majority of feminist critics characterized medicine as a patriarchal institution because, in their estimation, the female body was increasingly being made into a site for technological intervention in connection with childbirth and the reproductive life cycle in general. On the other hand it has also been argued within the feminist movement that insuﬃcient attention is paid to women’s health, and that medical research and the development of medications have been directed primarily at the diseases most common to men. The white male body has been taken as the standard for all. This countercurrent in the feminist movement has, in the long run, proved to be the more robust and has contributed to the line of argument most common in current publications on medicalization in which the question of individual agency is central and a rapprochement with medicine is sought out.
In contemporary writing it is common to assert that members of the public are not usually made into victims of medical ascendancy and, in any case, that to cast women in a passive role is to perpetuate the very kinds of assumptions that feminists have been trying to challenge. Although active resistance to medicalization has contributed to the rise of the home-birth movement and to widespread use of alternative therapies and remedies of numerous kinds, empirical research makes it clear that the responses of individuals to the availability of biomedical interventions are pragmatic, and based upon what are perceived to be in the best interests, not only of women themselves, but often of their families and at times their communities (Lock and Kaufert 1998). This is particularly evident in connection with reproduction when, for example, women who believe themselves to be infertile make extensive use of new reproductive technologies, despite the high failure rate and the expense and emotional upheaval that is involved. In Europe and North America resort to these technologies may be primarily to fulﬁll individual desires, but in other locations more may be at stake. Women can be subjected to ostracism, divorced, or thrown into the street, if they do not produce a healthy child, in many situations preferably a male child. Even when these drastic measures are not applied, it is clear that the majority of women internalize the norm that their prime task in life is to reproduce a family of the ideal size and composition, and that failure to do so diminishes them in the eyes of others. Under these circumstances it is not surprising that a pragmatic approach to medical technology and medical services is much more common than is outright resistance to these products of modernization. At times, as in the case of the breast cancer movement, AIDS, or where toxic environments are at issue, people unite to ﬁght for more eﬀective medical surveillance. Under these circumstances, the knowledge and interests of users results in an expansion of medicalization.
3. Medicalized Identities
Social science critiques of medicalization, whether associated more closely with labeling theory and the social control of deviance, or with Foucaldian theory and the relationship of power to knowledge, have documented the way in which identities and subjectivity are shaped through this process. When individuals are publicly labeled as schizophrenic, anorexic, menopausal, a heart transplant, a trauma victim, and so on, transformations in their subjectivity are readily apparent. At times medicalization may function to exculpate individuals from responsibility for being sick and thus unable to function eﬀectively in society. Medicalization is not limited to sickness and ‘deviance’ however. Wellness—the avoidance of disease and illness, and the ‘improvement’ of health—is today a widespread ‘virtue,’ notably among the middle classes.
As part of modernity, practices designed to support individual health have been actively promoted for over a century, and are now widely followed among the population at large. The sight of jogging wives of ﬁshermen in Newfoundland’s most isolated communities is testimony to this. The individual body, separated from mind and society, is ‘managed’ according to criteria elaborated in the biomedical sciences, and this activity becomes one form of self-expression. Body aesthetics are clearly the prime goal of some individuals, but a worry about the ‘risk’ of becoming sick is at work for the majority. By taking personal responsibility for health, individuals display a desire for autonomy and in so doing they actively cooperate in the creation of ‘normal,’ healthy, citizens, thus validating the dominant moral order (Crawford 1984). Health is commoditized.
As evidence is amassed to demonstrate conclusively how social inequity and discrimination of various kinds contribute massively to disease, ranging from infections to cancer, the idea of health as virtue appears increasingly out of place. Due to poverty large segments of the population in most countries of the world have shorter life expectancies and a greater burden of ill-health than do their compatriots. The pervasive value of individual responsibility for health enables governments to narrow their interests to economic development, while ignoring redistribution of wealth and the associated cost for those individuals who, no matter how virtuous they may be, are unable to thrive.
4. Risk as Self-governance
Activities designed to assist with the avoidance of misfortune and danger are ubiquitous in the history of humankind, but the idea of being at ‘risk’ in its technical, epidemiological meaning is a construct of modernity. In theory morally neutral, risk provides a means whereby experts can distance themselves from direct intervention into people’s lives while employed the agency of subjects in their own self-regulation through ‘risk-management.’ Among the numerous examples of this process, the transformation of aging, in particular female aging, into a discourse of risk is illustrative. Given that women live longer than men it seems odd that female aging has been targeted for medicalization, but this move is in part driven by a fear of the enormous expense to health care budgets that very old inﬁrm people, the majority of them women, are believed to incur.
Medicalization of female middle age, and in particular the end of menstruation, commenced early in the nineteenth century but it was not until the 1930s, after the discovery of the endocrine system, that menopause was represented in North America and Europe as a disease-like state characterized by a deﬁciency of estrogen. In order to sustain this argument, the bodies of young premenopausal women must be set up as the standard by which all female bodies will be measured. Postmenopausal, postreproductive life can then be understood as deviant. This ‘expert knowledge’ is buttressed through comparisons between human populations and those of other mammals, where postmenopausal life is very unusual. The arguments of biological anthropologists that older women are essential to the survival of highly dependent human infants and their mothers in early hominid life are ignored. Moreover it is argued erroneously that women have lived past the age of 50 only since the turn of the twentieth century, and that postreproductive life is due entirely to improved medical care and living conditions.
Today older women are warned repeatedly about heart disease, osteoporosis, memory loss and Alzheimer’s disease, and numerous other conditions for which they are said to be at increased risk due to their estrogen-deﬁcient condition. Daily medication on a permanent basis with medical monitoring has been recommended by gynecological organizations in many countries for virtually all older women, although some reversals of these blanket suggestions are now taking place. Few commentators deny that drug company interests have contributed to this situation. Misleading interpretations of often poorly executed epidemiological research create confusion about estimates of risk for major disease in women who are past menopause.
Furthermore, cross-cultural research indicates that the common bodily experiences of populations of middle-class North Americans at menopause is signiﬁcantly diﬀerent from that of women in other parts of the world, a situation to which local biologies and culture both contribute, making medicalization of this part of the life cycle exceedingly problematic (Lock 1993). Nevertheless, many thousands of women willingly medicate themselves daily in the ﬁrm belief that aging is pathology. Among them a few, but we cannot predict who exactly, may avert or postpone the onset of debilitating and life-threatening diseases, while others may hasten their death.
The combination of the emerging technologies of the new molecular genetics with those of population genetics is currently opening the door to an exponential growth in medicalization in the form of what has been termed ‘geneticization.’ As genetic testing and screening of fetuses, newborns, and adults becomes increasingly institutionalized, the possibilities for surveillance are boundless, particularly so because proponents of genetic determinism promote the idea that genes are destiny. Our genes are increasingly thought of as ‘quasi-pathogens’ that place us at increased risk for a spectrum of diseases. We are all deviants from the normative standards set by the mapping of the human genome, itself an abstraction that corresponds to the individual genome of no one.
This biomedicalization of life itself comes with extravagant promises about our ability in the near future to harness nature as we wish, the enhancement of human potential, and access to the knowledge that makes it possible to know what it is that makes us uniquely human. Based on the results of genetic testing, a laissez-faire eugenics, grounded in individual choice and the inalienable right to ‘health’ for our oﬀspring, is already taking place. Of course, suﬀering may be reduced if, for example, some families choose to abort fetuses with Tay Sach’s disease. On the other hand, how can discrimination of the basis of genetics, already evident in some workplaces, insurance companies, and the police force be controlled? Should entrepreneurial enterprises have a monopoly over the development and testing for multifactorial diseases such as breast and prostate cancer as is currently the case? How should the ﬁndings of these tests be interpreted by clinicians and the public when all that can be surmised if the results are positive is the possibility of elevated risk for disease in the future? Negative results do not indicate that individuals will not contract the disease. Who will store and have access to genetic information, and under what conditions? And who, if anyone, may patent and commodify genetic materials and for what purpose? The new genetics requires urgent answers to such questions.
It has been proposed that we are currently witnessing a new ‘biomedicalization’ associated with late modernity or postmodernity (Clarke et al. in press). A technoscientiﬁc revolution is taking place involving increased molecularization, geneticization, digitization, computerization, and globalization, and these changes are in turn associated with a complete transformation of the organization (including the privatization of a great deal of research), expertise, and practices associated with the medical enterprise. In this milieu the potential exists to make the body increasingly a site of control and modiﬁcation carried out in the name of individual rights or desire.
Such modiﬁcations are often highly proﬁtable to involved companies and frequently correspond to the utilitarian interests of society, one prime objective is to save on health care expenditure. Risk estimates permit the escalation of anxiety among targeted populations as when, for example, the public is repeatedly informed that one in eight women will contract breast cancer, and one in 25 will die of this disease. The one in eight estimate is incorrect because it is based on the cumulative probability of sustaining the disease over an entire lifetime, that is, somewhere between birth and 110 years of age; even for elderly women the probability is never as high as one in eight. Nevertheless this ﬁgure induces women to submit to breast cancer testing that then raises a new round of anxieties and uncertainties.
A danger exists of overestimating the consequences of technological innovation and associated biomedicalization. A large proportion of the world’s population eﬀectively remains outside the reach of biomedicine. That medication for HIV AIDS is not universally available is a gross injustice, as is the increasing incidence of antibiotic-resistant tuberculosis that could be controlled eﬃciently if biomedicine was competently practiced. At the other extreme, despite an enormous promotion of hormonereplacement therapy, research shows that less than a quarter of the targeted female population takes this medication, and even then not consistently. It is also clear that many women do not make use of selective abortion should a fetal ‘ﬂaw’ be found through genetic testing.
Medicalization understood as enforced surveillance is misleading. So too is an argument that emphasizes the social construction of disease at the expense of recognizing the very real, debilitating condition of individuals who seek out medical help. Rather, an investigation of the values embedded in biomedical discourse and practice and in popular knowledge about the body, health, and illness that situate or resist various states and conditions as residing within the purview of medicine better indicates the complexity at work.
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