Medicalization and resocialization: the future of social medicine


Social medicine, an approach that centres the social conditions of life as the cause of health and illness, can be thought of as an effort to ‘resocialize’ medicine. It is an attempt to reverse the narrowing of the medical gaze on the minutiae of material biology within individual bodies as the sole explanation for disease, and instead widen the frame to incorporate the situation of those bodies within society. In this sense, social medicine is the antidote to medicalization, that is, biomedicine’s tendency to appropriate aspects of human life that were erstwhile non-medical and thereby strip them of their social context (Conrad, 1992). 

I have highlighted the antipathy between social medicine and medicalization for a reason. If the task of this essay is to consider the future of social medicine, I contend that it is not possible to do so without first considering the past, and in particular, without considering how it is that we have arrived at a medicine in need of resocializing at all. This essay uses medicalization as a window into some of the tensions at the heart of social medicine – between individual and social, imperial and humanitarian – with which the discipline must contend if it is to reach its full potential. I have highlighted salient moments in which medicalization has been instrumental to the development of global health, a field closely tied to, though often at odds with, the development of social medicine. Lastly, I will consider the question of whether social medicine is itself an exercise in medicalization and the implications of this for the future of social medicine.

When medicalization is taken at face value, as simply ‘making something medical’, it should hold true regardless of whether or not that something has been historically considered the domain of the physician. Certain human experiences do not exist a priori with the label of ‘medical’ attached, and therefore the decision to categorize something as medical or otherwise is a conventional one. This characteristic of medicalization, the co-opting of particular aspects of human experience, has likely been present for as long as certain individuals have been recognized as healers among their peers (Lock & Nguyen, 2010, 67; see also Zola, 1972, 488).

Medicalization conceptualized in this way is an agnostic practice. When a social scientist points out that something has been medicalized, however, it is rarely a value-neutral observation. Instead, ‘medicalization’ functions most frequently as shorthand for the occurrence in the modern age of erroneous medicalization by practitioners of Western biomedicine (Conrad, 1992). Early critiques of medicalization hone in on its use as an instrument of disciplinary power. Irving Zola (1972), who coined the term, argued that medicine had supplanted other more traditional institutions of social control such as religion and law. He advised his reader to think of health and illness as C. S. Lewis thought of nature: ‘Man’s power over Nature is really the power of some men over other men, with Nature as their instrument’ (Zola, 1972, 500).

It is along these lines that strong critiques are levied by social science scholars against traditional biomedicine, and particularly against its guise of global health, in whose nascence as a specialized field medical imperialism and Western colonial imperialism worked hand in hand to medicalize and thereby domesticate the lives of colonial subjects (see, e.g., Anderson 2014; Chakrabarti 2013). European campaigns to eradicate outbreaks of infectious diseases in their colonies are a paradigmatic example of applying a biomedical lens to a problem that had previously been viewed through an environmental one.

In 1926, the French colony of Cameroon was afflicted by an epidemic of sleeping sickness, a disease caused by infection with trypanosoma brucei, a parasite inoculated into the human host by the bite of the tsetse fly. Enter the military physician and Pasteurian disciple Eugène Jamot, whose novel scientific approach underpinned by germ theory revolutionized the way epidemics were dealt with from there on out. Jamot instructed teams of men to screen, treat, and quarantine entire populations where the disease was present (Lock & Nguyen, 2010, 152).

Though the physical manifestations of infection have for centuries garnered responses from healers of one form or another (see, e.g., Ludwick Fleck’s [1979] history of syphilis), infectious diseases occupy a contentious node in debates about appropriate versus inappropriate biomedicalization following the widespread adoption of bacteriological approaches to their management. It is almost undoubtable that germ theory and the resultant discovery of effective vaccines and curative antimicrobial agents have saved millions of lives and billions, if not trillions, of dollars (Vanderslott, Dadonaite & Roser, 2019). That being said, the application of a limited and purely medical gaze obfuscates key social, political, and economic structures that place some people at much greater risk of infection than others.

The 1926 campaign against sleeping sickness was remarkably effective. Its success confirmed the Pasteurian faith in the power of medicine, and appeared to reify Pasteur’s oft-quoted though now recognizably unfortunate statement that ‘whatever the poverty, never will it breed disease’ (quoted in Packard, 2016, 49). Historical research, however, has since focused on the effect that colonial wars, mass displacements, and destruction of local ecosystems had in driving sleeping sickness epidemics, as they brought humans and parasites into contact in ways never before seen (e.g. Farmer, 2020, especially 237–279; Lock and Nguyen, 2010, 151–153). Furthermore, it is likely that the success of Jamot’s campaign was dependent not on the efficacy of medication – indeed the treatments applied were often ineffective and even dangerous, causing visual disturbances, permanent eye damage, and, at times, death – but on the ability of colonial masters to impose draconian quarantine measures on their subjects (Ibid.). A similar management strategy, which physician-anthropologist Paul Farmer (2020) calls the ‘control-over-care paradigm,’ occurred across other African nations and has remained relevant to the twenty-first century management of infectious disease outbreaks like that of Ebola in Liberia, Sierra Leone, and Guinea.

Ignorance of the wider environment in which bodies exist led Alan Young (1982) to refer to the creation of biomedical knowledge as a ‘desocializing’ concept, one that situates the root of suffering and the target of biomedical intervention within individual bodies. Almost one hundred years after the sleeping sickness outbreak described above, scientific attention has once again turned to trypanosomiasis infection with the discovery of an association between chronic kidney disease and the Apolipoprotein L1 gene. This gene appears to be expressed preferentially in people of West African descent due to an ability to confer immunity to sleeping sickness (Beckerman & Suzstak, 2018). Though beyond the scope of this essay, the critique of medicalization as desocialization is calling to be written.

Tracing the thread of colonial sleeping sickness epidemics through the interceding decades to modern-day concern with non-communicable disease underlines the transformative effect that biomedical approaches to epidemics (among other biomedical advances) have had on the ways in which health and illness are conceptualized across a range of levels. Margaret Lock and Vinh Kim Nguyen (2010, 147) have for this reason framed colonial epidemic control using Veena Das’s concept of a ‘critical event’: a moment when both the individual and social order were at stake, and which profoundly reoriented ‘global and local realities, crystallized new forms of knowledge and action, and realigned social relations in historically significant ways.’

The success of biomedical disease-eradication campaigns demonstrated that if one focused their efforts on the individual then the group would surely follow. In doing so, such efforts were constitutive of a new way of thinking about people and populations as biologically commensurate entities and as collectives of those entities. Whereas prior theories of medicine emphasized human difference, brought about by environmental variation or racial prejudice, biomedical control of infectious diseases reified the idea of the human body as a standard medium though which microbes circulated. While this was clearly evident when the microbes in question could be observed under the microscope, the idea of universally equivalent human bodies – of biomedicalized subjects – has spread alongside the globalization of Western science and medicine so that it too appears at times universal (Lock & Nguyen 2010; see also Anderson 2014). 

The issue at hand is more than this, though. With the universal body came the possibility of its manipulation by universal laws, and so it was not just bodies but the whole fabric of societies which were (and continue to be) transformed through medicalization. This was achieved in part through the tying of medicine to humanitarian endeavours that permitted its entry into political, social, and economic institutions from which it might ordinarily be excluded. The legacy of colonial disease-eradication campaigns in this respect – which were justified as a sort of ‘hygienic enlightenment’ of indigenous populations (Lock & Nguyen, 2010, 154; Farmer, 2020) – continued in the efforts of transitional and postcolonial regimes. Filipino doctors under Spanish and then American rule in the late nineteenth and early twentieth centuries, for example, took up the ‘civilizing’ medicine of colonial powers and channelled it instead towards the production of a new nationalist consciousness (Anderson & Pols, 2012). Though their aims were revolutionary, their means were colonial. They imagined the laboratory of public health as a place in which the body politic could be diagnosed and treated as much as the individual body: ‘the exemplary space of control, purity and precision, the model disciplinary site, a place of surveillance and transformation’ (Anderson, 2014, 322).

More recently, doyens of the medical humanitarian industry such as John D. Rockefeller and Bill Gates, along with their respective philanthropic foundations, have been criticized for donning a medical cloak in order to disguise otherwise highly political manoeuvres in the international health arena (Birn, 2014): that is, of adopting the desocializing logic of medicalization on a grand scale. In the early twentieth century, the Rockefeller Foundation turned to the morally unquestionable philanthropic outlet of health to counter growing public and political unrest towards exploitative capitalist business practices. The idea of medicine as humanitarianism managed to generate enough goodwill so that, behind the scenes, the foundation could continue unencumbered in its efforts towards ‘encouraging the transfer and internationalization of scientific, bureaucratic, and cultural values, stimulating economic development and growth, expanding consumer markets, and preparing vast regions for foreign investment, increased productivity, and incorporation into the expanding system of global capitalism’ (Ibid., 4). Certainly not everything on this list calls for automatic criticism. The point is to emphasize that by carrying out such missions, the Rockefeller Foundation (among other global organizations) acted as a ‘transplanting mechanism’ through which particular political economic ideologies, now inextricably tied to biomedicine, were promulgated from one continent to another; in so doing, they radically altered the underlying structure of people’s lives and their means of negotiating their place in the world.[1]

Fifty years ago, Zola (1972, 502) wrote that ‘the medical area is the arena or the example par excellence of today’s identity crisis – what is or will become of man?’ In a process that started with colonial disease-eradication campaigns and continues in the activities of biomedicine today, man has emerged on the other side of Zola’s estimation, crystalized in his medical form. As Nikolas Rose (2007) has argued, medicine has succeeded in making us what we are to the extent that we now exist in a time beyond medicalization. And if we live in a world that is medicalized to its core, where and how does one begin the resocializing project of social medicine? Indeed, against this backdrop, the line between the medicalization of society and the resocialization of medicine is very thin, perhaps only a matter of perspective, perhaps even non-existent.

By way of conclusion, I turn more fully to the question of whether social medicine is in fact a project to medicalize society and the implications of this for the future of social medicine. For some the answer is a matter of definition. ‘When social or behavioral activities are deemed medical risks for well-established biomedical conditions, as is becoming common, we cannot say that it is a case of medicalization,’ wrote Peter Conrad (1992, 223). Social medicine, however, is more than the recognition that environmental factors – social determinants – can influence individual health and illness. Rather, social medicine from its inception has been concerned with sickness inherent in the structure of the environment itself.

The pathologist and anthropologist Rudolf Virchow is considered by many as the father of social medicine for his role in the revolutionary health movement in Germany in 1848 (Fee, 1989; Waitzkin, 2006). It was during that year that Virchow published his report on the Silesian typhus epidemic, arguing that it was the destitute conditions of people’s lives that drove the severity of the outbreak. Thus, if diseases were socially created then the solution must involve social change. He is famously known to have written, ‘Medicine is a social science, and politics is nothing more than medicine in larger scale’ (quoted in Waitzkin, 2006, 7). This same thought can be traced through subsequent iterations of social medicine. Farmer, perhaps its most well-known contemporary advocate, has employed the term ‘structural violence’ to describe how large scale political-economic forces circumscribe the actual and possible conditions of people’s lives so that some have no option but to be at greater risk of disease and death than others (Farmer, 1996). When the task is to address structural violence, when it is society itself that is sick, then I would argue that social medicine is indeed the medicalization of society.

Acknowledging that social medicine shares the same logic of medicalization as mainstream biomedicine means taking stock of the fact that social medicine is on one level as much a continuation of as a reaction to medical imperialism; so too with ideas of ‘hygienic enlightenment’ and ‘philanthrocapitalism’ in regard to using the moral status of health as a humanitarian good to advance its agenda. This reliance on the same tools of change as traditional biomedicine goes some way in explaining the uphill battle for recognition and influence in which social medicine scholars seem to be perpetually engaged (Adams et al., 2019). As a physician myself, and therefore ultimately a pragmatist, I recognize the potential and necessity in this current moment of using health to generate support for social justice where other interventions have failed. My worry is that this is a circular argument that can only inadvertently reinforce medicalization, funnelling responsibility for change disproportionately towards medical personnel who, on account of their clinical practice, are poorly positioned to tackle the political and economic forces at work.[2] If the goal is to radically challenge the social structures that are the root cause of illness, then health as the sole rallying cry is not enough. Social medicine must align in coalition with other forms of social and political activism. To that end, the future of social medicine may actually be about being brave enough to say, ‘This is not medicine’.


[1] The idea of a transplanting mechanism is taken from Salmaan Keshavjee’s (2017) account of international non-governmental organizations as super-spreaders of neoliberal ideology to former Soviet countries in the years following the collapse of the Soviet Union.

[2] A salient example is the United Kingdom government’s suggestion that general practitioners ‘write prescriptions for money off energy bills’ in response to the recent energy crisis (BMA, 2022).

References

Adams, V., D. Behague, C. Caduff, I Lowy & F. Ortega. (2019). Re-Imagining global health through social medicine. Global Public Health, 14 (10), pp. 1383-1400. https://doi.org/10.1080/17441692.2019.1587639.

Anderson, W. (2014). Making Global Health History: The Postcolonial Worldliness of Biomedicine. Social History of Medicine, 27 (2), pp. 372-384. https://doi.org/10.1093/shm/hkt126.

Anderson, W. & H. Pols. (2012). Scientific Patriotism: Medical Science and National Self-Fashioning in Southeast Asia.Comparative Studies in Society and History, 54 (1), pp. 93-111.

Beckerman, P. & K. Suzstak. (2018). APOL1: The Balance Imposed by Infection, Selection and Kidney Disease. Trends in Molecular Medicine, 24, pp. 682-695.

Birn, A. (2014). Philanthrocapitalism, Past and Present: The Rockefeller Foundation, the Gates Foundation, and the Setting(s) of the International/Global Health Agenda. Hypothesis, 12, e8. https://doi:10.5779/hypothesis. v12i1.229.

BMA. (2022, August 21). Reported Plans for GPs to prescribe heating bill discounts ‘beggars belief,’ says BMA. https://www.bma.org.uk/bma-media-centre/reported-plan-for-gps-to-prescribe-heating-bill-discounts-beggars-belief-says-bma.

Chakrabarti, P. (2013). Medicine and Empire: 1600-1960. Basingstoke: Palgrave Macmillan.

Conrad, P. (1992). Medicalisation and Social Control. Annual Review of Sociology, 18, pp. 209-232.

Farmer, P. (1996). On Suffering and Structural Violence: A View from Below. Daedalus, 125, pp. 261-283.

Farmer, P. (2020). Fever, Feuds, and Diamonds: Ebola and the Ravages of History. New York: Farrar, Straus and Giroux.

Fee, E. (1989). From the Social Production of Disease to Medical Management and Scientific Socialism. The Milbank Quarterly, 67, pp.127-50.

Fleck, L. (1979). Genesis and Development of a Scientific Fact. (T. J. Trenn, & R. K. Merton, Eds. F. Bradley & T. J. Trenn, Trans.). Chicago: Chicago University Press. (Originally published in 1935).

Keshavjee, S. (2017). Blind Spot: How Neoliberalism Infiltrated Global Health. Oakland: University of California Press.

Lock, M. & V. Nguyen. (2010). An Anthropology of Biomedicine. Chichester: Blackwell Publishing.

Packard, R. M. (2016). A History of Global Health: Interventions into the Lives of Other People. Baltimore: John Hopkins University Press.

Rose, N. (2007). Beyond Medicalisation. The Lancet, 369, pp. 700-702.

Vanderslott, S., Dadonaite, B. & M. Roser. (2019). Vaccinations. Our World in Data. https://ourworldindata.org/vaccination.

Waitzkin, H. (2006). One and a Half Centuries of Forgetting and Rediscovering: Virchow’s Lasting Contributions to Social Medicine. Social Medicine, 1, pp. 5-10.

Young, A. (1982). The Anthropology of Illness and Sickness. Annual Review of Anthropology, 11, pp. 257-85.

Zola, I. (1972). Medicine as an Institution of Social Control. The Sociological Review, 20, pp. 487-504.

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