Janet K. Shim

Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine

The first social transformation of American medicine institutionally established medicine by the end of World War II. In the next decades, medicalization-the expansion of medical jurisdiction, authority, and practices into new realms-became widespread. Since about 1985, dramatic changes in both the organization and practices of contemporary biomedicine, implemented largely through the integration of technoscientific innovations, have been coalescing into what the authors call biomedicalization, a second transformation of American medicine. Biomedicalization describes the increasingly complex, multisited, multidirectional processes of medicalization, both extended and reconstituted through the new social forms of highly technoscientific biomedicine. The historical shift from medicalization to biomedicalization is one from control over biomedical phenomena to transformations of them. Five key interactive processes both engender biomedicalization and are produced through it: (1) the political economic reconstitution of the vast sector of biomedicine; (2) the focus on health itself and the elaboration of risk and surveillance biomedicines; (3) the increasingly technological and scientific nature of biomedicine; (4) transformations in how biomedical knowledges are produced, distributed, and consumed, and in medical information management; and (5) transformations of bodies to include new properties and the production of new individual and collective technoscientific identities.

Cultural Health Capital: A Theoretical Approach to Understanding Health Care Interactions and the Dynamics of Unequal Treatment

In this article, I propose and define the new concept of cultural health capital, based on cultural capital theories, to help account for how patient-provider interactions unfold in ways that may generate disparities in health care. I define cultural health capital as the repertoire of cultural skills, verbal and nonverbal competencies, attitudes and behaviors, and interactional styles, cultivated by patients and clinicians alike, that, when deployed, may result in more optimal health care relationships. I consider cultural health capital alongside existing frameworks for understanding clinical interactions, and I argue that the concept of cultural health capital offers theoretical traction to help account for several dynamics of unequal treatment. These dynamics include the often nonpurposeful, habitual nature of culturally-mediated interactional styles; their growing importance amidst sociocultural changes in U.S. health care; their direct and indirect effects as instrumental as well as symbolic forms of capital; and their ability to account for the systematic yet variable relationship between social status and health care interactions.

Understanding the routinised inclusion of race, socioeconomic status and sex in epidemiology: the utility of concepts from technoscience studies

Abstract The multifactorial model of disease causation constitutes the dominant conceptual framework underwriting the epidemiology of chronic illness. Under this rubric, factors correlated with disease are analysed at the individual level; accordingly, race, social class and gender are routinely conceptualised and incorporated into epidemiological research as individualised measures of racial category, socioeconomic status and sex. This paper employs three concepts from the field of technoscience studies to elucidate how epidemiological constructions about bodily ‘differences’ are infused with authority and legitimacy. The multifactorial model and accompanying representations of race, class and gender can be usefully conceptualised as a black box (Latour 1987, Latour and Woolgar 1986), in which individualised inputs to epidemiological studies are routinised while the interior workings of the black box – how exactly ‘differences’ come to affect health – are taken for granted. Second, processes of triangulation (Star 1985, 1986) are evident, as results from multiple lines of research on an array of different diseases are used to enhance the stability of the multifactorial model and associated constructions of ‘difference’. A final illuminating technoscience concept is that of the boundary object (Star and Griesemer 1989), whose dual properties of conceptual flexibility and integrity help in understanding the proliferation and institutionalisation of epidemiological methods of studying race, class and sex/gender in chronic disease.

Constructing ‘Race’ Across the Science-Lay Divide Racial Formation in the Epidemiology and Experience of Cardiovascular Disease

Social disparities in cardiovascular disease (CVD) have increasingly engaged the concern of the biomedical, epidemiological, and public health communities. In this context, cardiovascular epidemiology has emerged as an essential tool for understanding the determinants, risk factors, and distribution of CVD across populations. Race, ethnicity, culture, and related differences are studied for their effects on cardiovascular risk and are being constructed in heterogeneous ways as scientifically legitimate contributors to CVD risk. This paper presents findings from a qualitative, sociological study that compares epidemiological and lay conceptions of the meanings of ‘race’ and their accounts of the mechanisms through which racial differences in cardiovascular disease are produced. In particular, I analyze current conventions for classifying race in epidemiology, and identify multiple ways in which the lived experiences of race undermine the validity of scientific measurement. I describe a science-lay divide between the two accounts of cardiovascular risk, in which epidemiologists principally understand race as cultural difference, whereas lay people living with CVD tend to construct race in structural terms. I identify various aspects of these two kinds of constructions and offer reasons for their prominence. Finally, I discuss some of the implications of such disparate conceptions of the relationships between race and health, and important issues around lay knowledge and expertise that remain problematic for science studies scholarship.

“Is There Life on Dialysis?”: Time and Aging in a Clinically Sustained Existence

ABSTRACT Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of “normal” life outside the units to an exceptional state on the inside that some patients see as not-quite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article offers a phenomenology of the end of life as that end is drawn out, deferred by technological means, and effaced by the ethos and experiential course of dialysis treatment. ANN JULIENNE RUSS is a medical anthropologist and member of the research faculty at the University of California, San Francisco. Her research has focused on end-of-life care and communication among clinicians, patients, and their families in hospice and high-tech medical environments. Her publications have appeared in Cultural Anthropology and Culture, Medicine and Psychiatry. JANET K. SHIM is assistant adjunct professor at the University of California, San Francisco. Her research in medical sociology has focused on issues at the intersections of health inequalities, biomedical science and technologies, and race, gender, and aging. Her publications have appeared in Sociology of Health and Illness, American Sociological Review, and Social Studies of Science. SHARON R. KAUFMAN is professor of medical anthropology at the University of California, San Francisco. Her recent research explores life extension, technologies of dying, and subjectification in an aging society. She is the author, most recently, of … And a Time to Die: How American Hospitals Shape the End of Life (Scribner, 2005).

Medicalization and Biomedicalization Revisited: Technoscience and Transformations of Health, Illness and American Medicine

Medicalization theory has been at the heart of medical sociology or the sociology of health and illness for nearly 40 years (Zola 1972; Freidson 1970) and is also vital to medical anthropology (Hogle 2002; Lock 2001, 2004), the history of medicine (Nye 2003; Sinding 2004), medicine itself (Chervenak and McCullough 2005), bioethics (Bergeron 2007), and beyond. The still robust medicalization thesis is that the legitimate jurisdiction of Western or scientific medicine began expanding by including new domains of human life (such as alcoholism, drug addiction, and obesity) by redefining or reconstructing them as falling properly within medical (rather than legal, religious, etc.) domains (e.g., Ballard and Elston 2005; Conrad 1992, 2005, 2007; Conrad and Schneider 1980a, b).

CHWs Get Credit: A 10-Year History of the First College-Credit Certificate for Community Health Workers in the United States

Community health workers have become increasingly important in the U.S. health care system, playing a significant role in basic health promotion and care coordination; however, their status and visibility have not kept pace with their wider use. A major impediment has been the absence of systematic preparation—the field needs standardized education in programs that emphasize the actual skills and knowledge used by community health workers, programs that attract and retain nontraditional students from underserved communities and that foster professional advancement. This article chronicles the 10-year history of the first college credit-bearing community health worker certificate program in the country to address this need. Systematic research resulted in a program centered on the core competencies universally practiced by community health workers regardless of their topical focus. The certificate program combines performance-based methods with popular education into an innovative pedagogical approach that teaches skills, while solidifying, contextualizing, and enhancing crucial experiential knowledge. Program outcomes validate the approach.

Late-Life Cardiac Interventions and the Treatment Imperative

The treatment imperative, say the authors, refers to the almost inexorable momentum towards intervention that is experienced by physicians, patients, and family members alike.

Negotiating substance use stigma: the role of cultural health capital in provider-patient interactions.

Diverse aspects of life and lifestyles, including stigmatised attributes and behaviors are revealed as providers and patients discuss health. In this article, we examine how the stigma associated with substance use issues shapes clinical interactions. We use the theoretical framework of cultural health capital (CHC) to explain how substance use stigma is created, reinforced and sometimes negotiated as providers and patients engage in health interactions. We present two main findings using examples. First, two theoretical concepts--habitus and field--set the social position and expectations of providers and patients in ways that facilitate the stigmatisation of substance use. Second, we found both providers and patients actively exchanged CHC as a key strategy to reduce the negative effects of stigma. In some clinical encounters, patients possessed and activated CHC, providers acknowledged patients CHC and CHC was successfully exchanged. These interactions were productive and mutually satisfying, even when patients were actively using substances. However, when CHC was not activated, acknowledged and exchanged, stigma was unchallenged and dominated the interaction. The CHC theoretical framework allows us to examine how the stigma process is operationalized and potentially even counteracted in clinical interactions.

Race and Ancestry in the Age of Inclusion Technique and Meaning in Post-Genomic Science

This article examines how race and ancestry are taken up in gene-environment interaction (GEI) research on complex diseases such as heart disease, diabetes, and cancer. Using 54 in-depth interviews of 33 scientists and over 200 hours of observation at scientific conferences, we explore how GEI researchers use and interpret race, ethnicity, and ancestry in their work. We find that the use of self-identified race and ethnicity (SIRE) exists alongside ancestry informative markers (AIMs) to ascertain genetic ancestry. Our participants assess the utility of these two techniques in relative terms, downplaying the accuracy and value of SIRE compared to the precision and necessity of AIMs. In doing so, we argue that post-genomic scientists seeking to understand the interactions of genetic and environmental disease determinants actually undermine their ability to do so by valorizing precise characterizations of individuals’ genetic ancestry over measurement of the social processes and relations that differentiate social groups.