1. MATERIALIST APPROACHES: HEALTH AND SOCIETY

2. “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)

3. 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

4. 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

6. SOCIAL STRUCTURE, MOBILITY, HEALTH Social mobility affected by health Does not protect against class-based health backgrounds (ascribed status & health) “individual lifestyle factors” & the social basis of behavior Materialist explanations: link social inequality with biological Stress & class/ethnicity/gender inequality – Stress & diabetes Environment & health Occupation & health Food/nutrition & social inequality Housing & health

7. Social class? How to define? – Occupation, income & wealth, prestige, education, residence, ethnicity, gender, age, ? The adjective “Class” – descriptive (many historically anchored) – collectively organized actors (from kinship to caste to class) – 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

8. 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”

9. Capitalism, class, health care Profit & safety; accident & industrial organization – Not psychological characteristics of the individual Disease explanations & superstructure (culture & ideology) – Legitimates status quo as agent of social control – equates hospital care & consumption of drugs as health care – reproduces capitalist class social structure Political economy & medicine – Capitalist societies & medicines (profession, technology, medications) – A class project (struggle) – realization of collective interests – Links economy & politics – Class based monopoloy & profit Medical profession central to the control of labor

10. “health defined” Disease – abnormalities Illness – experience of Suffering – sickness episodes Health? – Ability to function – Independence – Both are crucial features of labor in capitalist society Medicine works to restore & remedy labor disruptions

11. Liberalism, Neoliberalism, Health in Capitalist Society Liberalism & welfare state capitalism – Liberalism emphasizes individual rights and equality of opportunity – Different forms of liberalism may propose very different policies – Liberalism rejected many foundational assumptions that dominated most earlier theories of government, such as the Divine Right of Kings, hereditary status, and established religion Liberalism: two major streams of thought which compete over the use of the term "liberal" – Classical liberals: only real freedom is freedom from coercion state intervention in the economy as a coercive power that restricts the economic freedom of individuals and favor a laissez-faire economic policy oppose the welfare state – Social liberals: governments must take an active role in promoting the freedom of citizens real freedom can exist only when citizens are healthy, educated, and free from dire poverty Government ensures the right to an education, the right to health care, and the right to a minimum wage.

12. Liberalism, Neoliberalism, Health in Capitalist Society Structuralist basis of welfare state capitalism undermined by decline of industrial sector & globalization of capitalist investment strategies State policy now directed at control over costs (rather than provisions) & quantity of health care Medicine caught between state & market From production to consumption as foundation of class formation in capitalist society

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