Adel E. Clarke Janet KS Jennifer Ruth Fost, an Jenifer R. Fishman 1/ Biomedicalization be growth of medicalization ~defined as the pro- cesses through which aspects of ie previously out- irectional processes of medicalization that today ate being both extended and reconstituted through the emergent socal forms and practices ofa highly an ily technoscientitic biome the transformations made possible by scientifically enmeshed ways. Insttutionally, biomedicine is being reorganized not only from the top down or the bottom up but from the48 CLARKE, SHIM, Man inside out. This is occurring largely through the re informational, organizational, and hence the in of the life sciences and biomedicine via the incorpor and information technologies (Bowker and Star 1999; Cartwright 2000b; Lewis 2000; National Research Council 2000). vations are reconstituting the many i edge production, distribution, and information management information technologies informatics, networked or integrated systems of hospitals, clinics, group practices, insurance organizations, the bioscien tific and medical technology and supplies industries, the state, etc.) uch innovations are, of cours Extensive transformations are produced through new diagnos ments and proc s from bioengineering, genomi ugh improved access to knowledge, wish, iPhelp and biomedical goods and services. Standards of em bodiment, lng influenced by fashion and celebrity are now transformed ough the applications sare also pro ough technoscience (eg, “high-risk” statuses, DNA profs, Syn the incorporation of technoscientfic innovations is at ance so persed (from loca to global to local), heterogeneous (affecting man cHwoscien 1Ons 49 sly), and consequential for the very org broadly conceived that they manifest a tecorporation—a reconstitution —of this historically situated sector, We term this new social form the “Biomedical TechnoService Complex Inc” clear. The U.S. health sector has more than tiled in size over the las fifty years fom 4 percent toy percent of cbr, and itis anticipated to exceed 20 percent by 2040 the same time, Western biomedicine has become a ously webbed throughout mass cl- ), Health has been th site of multiple al, 2001) Biomedicine has (Leonhardt 200 Lupton 1994) medical TechnoService Complex Inc. particularly captures some politico- economic dimensions of biomedicalzat a regime of tru , the concept of biomedicine as 1980, 33), particularly cap- jurisdictional axes of change and their sitwatedness within a politico- sociocultural sector-—however vast~the ways in which somedicalation i reiproctly constituted and manifest the politcal economic con- tedicine; (4) transformations of biomedical knowledge production, in- and (5) transfor. production of new hese processes oper icalization and are alson. We then elaborate the five key historical processes through jomedicalization occurs. We conclude by reflecting on the implica- tions ofthe shift to biomedicalization. Historically, the rise in the United cine as we know it was accomplished cl and Gordon 1988; and Swan 1990)."Th (Abbott i988; Beckeret al rmedicalization was sen to take place when particular social problems deemed morally problematic and often affecting the body (e.g, sexuality, abortion, and drug abuse) were moved from isdiction of the law to that of medicine. Drawing on theory Conrad and od this “badness to sickness.” Si some cit as promot chwoscie RMATIONS 31 ich 1978; McKinlay and Stoeckle 1988; Navarro 1986; Waitekin 1989, 2001). “Through the theoretical framework of medicalzation, medicine came to be understood asa socal and cultural enterprise as well as a medico- scientiie one, and illaes and disease came to be understood not as neces- jons but a constructed through human (inter)action (Bury 1986; 1000). Parther, med caization theory as illuminated the importance of widespread individual and group acceptance of dominant sociocultural conceptualizations of ated macro-,mes0-, (Morgan 1998) ns, however uneven ( menopause, and contraception inthe 1970s to post-traumatic st rome (Ps), and attention defi +00; Conrad 1975, 2000; Conrad and Potter 2000; Conrad and Schneider 1o80a/1992; Figert 1996; Fox 1977, 2001; Halpern 1990; Litt 2000; Lock 193; Riessman 983; Ruzek 978; Schneider and Conrad 1980; Timmer mans 1999). Social and cul farther and, ae we argue next, largely ‘conditions understood at nagh te nomena that heretofore were deemed within the range of “nor and Bergen 1984) Hedgecoe 2001). “Then, beginning about 98s, we suggest that the nature of medi began to change as technoscientific innovations and as socal forms began to transform biomedicine fro tually, biomedic progress from the problems of moder postmodern. swe became accustomed & ion is predicated on what we the problems of late moder: he framework ofthe industrial re ig science” and “big technology” ~project52 CLARKE, Shin, MAMO, FOSKET, F such as the Tennessee Valley Authority, the atom bomb, and electrification and transportation grids. In the current technoscientific revolution, “big inside your body. That zed control over external nature ( nessing and transformation of internal nature (Le, biolog! can be argued that medical ty, while biomedicalizstion is also co- constitutive of postmoderity (Clarke 19), Important to the shift ate the ways in which hist (Clarke 1988). Biomedicalization is characterized by its grater organia- possible by computer and information sciences and scientific sed research and secord keeping. The scope ding comput of biomedicalization processes is thus much broader and includes concep- tual and clinical expansion the commodification of health the elaboration of sk and surveillance, and innovative clinical applications of sped larough new "as of spaces, persons, and technigues for caregiving, Innovations and iter- ed only by medical professionals but area ed experience of health and ness, creating new biomedicalized subjectvities, ident sms constructed around and through such new id ‘The table offers an overview of the shi ‘medicalization cobbled and webbed together through the imereasing =p- ine overarching analytic shift is THE SHIFT FROM MEDICALIZATION TO BIOMEDICALIZATION BIOMEDICALIZATION ough echnoscientiic cgi ons infastructures, knowledges Alu inzeasing provatization of resenrch including thvongh aves ind Lhborations wat increased privatization and commoifcaton of research resls as Managed-are-sstem dominated cnganzations Indvidalcate based (usualy oe based) contol ovr us of decision suppor technologies infomation snd computezed paint data banksin managed: care systemsTHE SHIFT FROM MEDICALIZATION To BIOMEDICALIZATION (CONTINUED) MEDICALIZATION, SIOMEDICALIZATION CONTROL TRANSFORMATION cloning “Medical peies based on body and processes and disease processes ited to mediclpoessonals down medica professions sociales from medicine exerting clinical and socal control over particular conditions to an increasingly technoscientifically constituted biomedicine also capable ‘of effecting the transformation of bodies and lives (Clarke 1995). Such tran formations range from life after complete heart failure, to walking in the ab- sence ofleg bones, to giving birth a decade or more after menopause, tothe capacity to genetically desiga if itself— vegetable, animal, and human. OF course, many biomedically induced bodily transformations are much less such as Botox and laser eye surgery, but these are no less techno- scientifically engineered. ‘The rest ofthe table describes shifts from medicalization to biomedical- sory emphasizes organizational/institutional mes and these are highlighted here in order to describe the processes and mechanisms of jon and change in concrete—if widespread ~ practices. firough the transformation of the orga zation of biomedicine as aknowledge- and technology-producing domain Biomedical aswelas one of clinical aplication. Computer and information technolo. ses andthe new social forms co-produced throug thet design animal w the key infastuctural devices jonalization (Bowker and Star 1999). The mations of one era become the (often invite next (Clarke 198,191) ‘The following points are at the core of our argument about the shit the new genres of meso- as powerful, we do not see them as de ‘ence, technology, and medieine studies scholars, 1s and technologies are made by people and {our 1987; Clare 1987). Human action and technoscience w, thereby refuting technoscientific determinisms (Smith banges wrought by biomedicalization are tion that 1988; Tesh 1990), the new social /cultural/economic/organizatiorAy produced as part and parcel of technoscientiic ms are usually analytically ignored (Vaughan 1996, 1999). That is, echnological, and heart of our the tasks of revealing these new social forms and ening up spaces to allow greater democratic participation in shaping human futures with technosciences “Therefore, central to our argument is the point that in dai biomedicalization processes are not pred Freidson 2001; Olesen 2002; Olesen and Bone 1998). la schools, homes, and hos as providers/health today, workers and people as 1 workers are responding to and scientific innovations and organi Schateman, et al. 1964; Wiener 2000) as varying levels of personnel respond to their constrain cown pragmatic negotiations within the institutions and in the situations in ly based bio. ble somewhere, while emergent, often based approaches also tend over time to articular event or moment or phenomenon, era cumulative momentum of increasingly ventions throughout biome tess of biomed storically and geographic ‘We turn next to an elucidation of of biomediealization. ye concrete practices and processes Key Processes of Biomedicalizat Biomedicalization is co-cor ted through ive central (and overlapping) processes: major political economic sifs; a new focusing on heath and and surveillance biomedicines; the technoscientization of biomedi- cine; transformations of the prod jstribution, and consumption of biomedical knowledges; an transformations of bodies and identi ‘We emphasize historical developments in the transitional and current bio- medica ECONOMICS: THE U.S. BIOMEDICAL TECHNOSERVICE COMPLEX INC tool for understanding the shift from medicalization to biomedicalization isthe concept of the “medi 1 medicalization er industrial complex” put Changes i forward in the 1970s in the medicine in that era were «7 economic development ofa imedical industrial complex” (taking of fom President Eisenhower's naming in the igs0s of “the military industrial com- plex” consolidated through World War Il) This concept was coined by a progressive health activist group, HealthPAC (Elenseich and Ehrenreich e mainstream medicine by Rel offer a parallel concept: the Bio Inc. This concept emphasizes the corpraized and privatized (ater than ical TechnoService Complex seatefanded) research, product, and services made possible by techno ra thatfrtherbiomedicalzation. The corpor fons that constitute this complex are increasingly mul idly globalizing both the Western biomedical model and biomedicalization processes per se, ‘The size and influence of the Biomedical Te )Service Complex Inc. ae significant and growing, ‘The healthcare industry is now 13 percent of ion annual US. economy. In the economic downturn of late lncare sector was even viewed by some as the main engine of the US. economy, offering a steadying growth. Pharmace -rcent per year (Leonhardt 2. cans spent mn on drags in 2000, double the amount spentin 990 (Wayne and Petersen 2001). The emergence ofa global econ38 CLARKE, SWIM, MAMO, FOSKET, FISHMAN ‘omy dominated by lexi corporations (Harvey 1989), strean management technologies (Smith 1997), and increased specialization en- ables many ofthe biomedicalization processes discussed here? ‘Through itssheer economic power, the Biomedical TechnoService Com- plex Ine. shapes how we think about soc id problems in ways that “Constitute biomedicalizaion, The most aotable socioeconomic changes dicative of and faci jon are, as indicated in the tabl (:) corporatization and commodif centralization, ratio ) stratified biomedicalization, 1g biomedical 6) tion, and devolution of services; and Trends in corporatization and commodification are embodied ate corporate entities to appropriate increasing areas ofthe hhealthcare sector under private management and ownership. In biomedi- are the juris “Satori expanding and being reconfigured, but se too are the frontiers of ‘whats legitimately defined as private versus public medicine, and corpora- tized versus nonprofit medicine. For example in’ the United States, federal in expanding the private surance coverage through in 1965, most recipients have been nics, hospital, and emergency roms competitive pressures for personnel and revenues ny of these facilites closed or were bought out and cxcalated, ho consolidated by ‘under way to move such patients into private HMtos, effectively privatizing social healtheare programs (eg, Estes, Harrington, and Pellow 2000). Second, under pressure from powerful biomedical cong] state is increasingly socializing the costs of medical research by underwrit- sch and development yet allowing commodi able products and proces .d—thatis patented, distributed, and profited from by private interests (Gaulle and Lowy 1996; Swan 1990)"The Human Genome Project is one high-profile example ‘What began asa federally based and funded research effort culminated inthe shared success of sequencing the genome between Celers Geno- corporations. By the late 1990s, efforts were ing startup expenses of res hat emerge tobe pr sue samples collected fo ties have become patented commodities of corporate entities that offered or community reimbursement Rabinow 1996). Another striking example is the patenting of the HRCA1 genes (breast cancer markers) by Myriad Genetis.The company not only receives royalties each time a also holds sole-proprietor rights (Zones 2000), though ownership of such rights is being challenged inthe company's own country (Canada) andin France (Bagnall oo) industry academy etic test for breast cancer is given but ics, and research units) inded for thirty years. The Us. Balanced Budget Act of gy7 cut an estimated $237 bilion, wth lage indirect medical education pay- 1997). Strapped academic medical centers are filling this gap in part by conducting extensive clinical il compaits requisite to binging new products to acts units, a new social form, have been established at try and research, trials for pharmace ‘major medical centers, often withi development,’ to negotiate Blanket contract overhe centical compas Trends toward increased pharmaceutical company search have become highly problematic, however. The cun editors of thirteen major medical oural stated in an ed rial in Journal of xy study that doss found that industry sponsored research is .6 times more eto the sponsoring company, implicating both universities 05 2003). CENTRALIZATION, RATIONALIZATION, AND DEVOLUTION OF SERVICES , healthcare services, and cor Centralization of fa coverage has been on the sse through the merger and acquisition of bos ‘pial facies, insures, physician groups, and pharmaceutical companies,00 CLARKE, SHIM, MAMO, FOSKET, FISHMAN ‘This has result oss of many community, public, and not-for-profit facil either could not compete or were acquired expressly for clo sure. The underiying objectives are to boost the efficiency and uniformity of services to centralize and rationalize decision making about service pro- vision, to capture more markets and arenas of health for profit and to exert greater economic control within these arenas. In practice, Foucauldian tion with adi “These patterns are greatly facilitated by meso level compater and information science practices and panoptical patterns of physical decentr tral jon are common (Foucault 1973, 1991 programs that automatically monitor highly dispersed developments for jagement operations. raolidaions bring some efficiency, they corporate concentration. Such dangers include, for example, inflationary tendencies from the concen- tration of pricing power, new administrative burdens, andthe enhanced power of conglomerate erage over poll also pose numel {ations now exert signifi- and regulatory processes, as well as decis making that affects provider groups, patent care, and sevice options in highly stratified ways (Waitekin 2001; Waitrkin and Fishman 1997). For ern California secently, Blue Cross ( fovider network) ly deny services to many Blue accepting Blue Cross insurance, eventuelly compel to higher sates. Devolution of healthcare services also demer rationalization, That is, there are health services while also shifting increasing proportions ofthe expensive hands-on care to families and individuals (Timmermans and Berg, tient surgery home healthcare, and elaborating subacute care 4s, nursing homes) are a few examples tothe fragmentation of (of devolution. Devolu hhealtheare and its geographic dispersal, making rationalizing more dificult. STRATIFIED BIOMEDICALIZATION Morgan (1998) recently reasserted the unevenness and instabilities of reminding us that medicalization was not mono- ¢ TRANSFORMAT! TECHNOS hic and ni problems of exclusion inclusion, pa gguments were itll elaborated in critical elucidation of the dual tendencies of medical dency, c-plative medialzaton, refers othe jurisdictional expansion of modern medicine —extending into areas of life previously not deemed sedical The second tendency, exclusionary di he smal oncous exclusionary actions of medicine that erect barsiers to 2ece55 10 medial insiations and resources that target and affect particular ind viduals and segments of populations. Historically, these dual strategies J market by race, class, ender, and other fave long predominated exclu onal bat heterogeneous and fraught with paradoxical pation, and resistances. Such ar- ich’ ( ton, The first ten- ly wornen, wt ization (such sof co-optative medi ation) have prevailed ,; Ruzek 1980; Ruzek, Ole- sionaty tendencies or part asprovision or imposition ofitt control and snd the poor (Riessman 19 alization. ‘We erm the reformulation and reconstitution of such proessesin the biomedicalization era stratified biomedicalizati !© The co-op! sd become increasingly om: roduced, Even as techno- completely bypass some protest excessive biomedical interes tase care Such innovation arf from the goal of nies acesile ‘ble healthcare promoted by some biocthicists and others (et, Callahan 1998) ‘Even rationalization islfs stratified, producing fragmentation. For xx ample, the availabilty of routine preventive car, screening services, phar- we services such as bone-marrow trans ble depending on ‘macentical coverage, fertility treatments are differentially avs cor lack thereof. There a sand dlfere of coverage, and thus, as a whole, the system Is hi and uncertain —the very things that, in theory, Ti 3001 the share ofthe population wholly uninsured for the entire year