Medical Sciences and Technology Research Paper

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Introduction

Science and technology hold a special significance in biomedicine and in public health. Arguably, the intensity of technologization of biomedicine is now its most characteristic feature. Both doctors and patients envision clinical care as the application of scientific knowledge. Public health is seen as a means of efficiently managing the health of populations through a judicious application of evidence. There is no doubt that the invention of the first diagnostic tools, and the bacteriological discoveries of the nineteenth century, set in motion massive changes in the ways that the health and illness of bodies are understood and managed. The twentieth century has been a period of extraordinary medical transformations. With this, however, came new uncertainties about the meaning of these changes for our societies.

The empiricist model of science views these changes as solely the logical result of scientific progress toward a truer account of nature. Scientific knowledge can be applied well or poorly, but what is actually done with that knowledge involves social and political issues that are separate from the conduct of science. Social analysts, in contrast, argue that the making of science and the making of society are intertwined. New knowledge and new tools emerge out of distinctive social practices and, in turn, alter the social and natural milieus in which we live. This view implies that science is social and political in ways that have previously gone unrecognized, and that cannot adequately be described as simple bias.

Positioning The Social Analysis Of Science And Technology

The social study of science and technology (also called science studies) is an emerging interdisciplinary field of research and theory. Anthropologists, historians, and sociologists use a variety of concepts and methods to clarify our understanding of the ways developments in science and technology intersect with social relations. The term technoscience is used to capture the increasing interdependence of science and technology.

Social research contributes to public health efforts in many important ways described elsewhere in this volume. But the social study of science research discussed here is distinctive: It begins from the premise that science is a sociocultural endeavor, and must be analyzed as such. Unlike approaches that simply accept the biomedical account of problems and look solely at the application of medical scientific knowledge, this research examines the ways in which the actual objects, categories, classifications, protocols, and evidentiary claims of science come into being, and are made to matter in the world.

The social study of science research poses the following questions: What is the relation between science and technology, on the one hand, and social relations, cultural values, and regimes of power, on the other? Is technoscience simply an inherently neutral way of accomplishing ends, in accordance with underlying laws of nature? Or is it a socially organized activity through and through, one that produces facts and inventions that carry traces of values and social relations? Do the very processes through which technoscientific innovations emerge reflect and reproduce particular social ends, or sustain certain kinds of social arrangements, and if so, how? Are the meanings and consequences of technoscience in medicine the same everywhere, or for everyone? How, exactly, does work in science and technology alter our worlds?

These types of questions can be applied to the analysis of such issues as pharmaceutical development, distribution and use; disease surveillance and control strategies; vaccine development, promotion, and acceptance; diagnostic technologies and their use in prevention and screening; genetic mapping, testing, and screening; contraceptive and reproductive technologies; the integration of biomedical and other medical traditions; the uses of and global trade in body parts and tissues; the negotiation of international standards of disease classification; and the creation of population-wide databases and information systems. The insights from this work shed light on crosscutting issues of ethics, politics, access, policy formation, and public attitudes as these intersect with technoscientific innovation.

Public policy discussions of innovations in the life sciences and new biotechnologies use an instrumentalist way of speaking of social impact or social consequences. The instrumentalist approach suggests an image of one billiard ball hitting another, an image of the self-contained sphere of science propelling the sphere of the social in a given direction: Cause and effect. The social study of science sets itself apart from this approach by arguing that sociality does not, as this common view suggests, follow after the fact of technoscientific innovation. Instead, social science researchers hold that the production of scientific knowledge itself is a social endeavor.

This position does not assume that scientific objectivity is mere illusion (because it is cultural). Rather, it asks how objectivity is understood and what is involved in achieving it. By looking at what Bruno Latour (1987) has famously called science-in-the-making rather than readymade science, it becomes possible to take into account the interplay of doubts and certainties, and of public controversy and acceptance, which characterize the role of the life sciences in our world. Science studies thus argue that in order to fully understand the implications of the pathways taken in science and technology, it is necessary to develop a more robust picture of how those pathways are built and where they lead. In other words, their investigations of science in society focus on what science ‘does.’

The social study of science can be jarring because it asks us to rethink the conventional ways that we think about facts. It can easily be misunderstood as an attack on science, or even as an attack on reason all together, because it seems to pull the rug out from under claims to objectivity in science. In contrast, researchers in this field argue that to see medical science and technology as inherently cultural requires, first and foremost, that we clear a conceptual space where it is possible to consider what is social in a set of practices that claim to transcend context all together. Thus, rather than accept the truth claims of science and medicine a priori, social researchers are concerned with the relationship between science and society and they inquire into how scientific assumptions are made and are then made persuasive.

This honed, process-oriented focus on the production and use of evidence bears a clear relation to public health’s core concern with improving health at the population level. It sheds new light, for instance, on the complex of factors in a given place and time that make some directions in health related science appear exciting and others uninteresting or infeasible. Given the enduring 10/90 gap (that 10% of research resources go to investigating the health problems afflicting 90% of the world’s population), concerned advocates can benefit from nuanced analyses of how research agendas are built up, backed, pursued, and put to use.

Science studies research is also concerned with examining the dynamics of controversies. For instance, case studies have looked at how the tobacco industry strategically mobilized doubt in the face of evidence of the harmful health effects of smoking (Proctor, 1998); how people living with AIDS in the United States were able to mobilize as an effective patient-advocacy group influencing unfolding scientific research (Epstein, 1996); and how survivors of the 1984 Bhopal chemical disaster are enabled and constrained in their claims for restitution amidst legal debates over evidence of harm (Fortun, 2001). For many researchers in science studies, the purpose of developing theories about the nature of truth claims is, ultimately, to address pressing questions of social justice and democracy.

Methods And Goals In The Social Analysis Of Science And Technology

Social scientists distinguish between the narrative of science – the abstract ideal, or myth, of science as completely objective, solely rational, and innately progressive – and the instantiation of particular applications of technoscience: Moments that one can describe and analyze what really comes to pass in particular settings. Their research emphasizes the mediating role of various social processes in bringing to fruition actual existing ways of conducting medicine and public health.

The social study of science involves empirical research in laboratories, clinics, and industries and among experts (scientists, engineers, clinicians, medical technicians) and lay people (patients, health activists, and communities at large). Researchers look at how scientists develop and pursue research problems; they analyze the everyday laboratory practices through which data are produced and interpreted; they note how novel or ambiguous test results are interpreted, and how standardized clinical protocols are used in the messiness of real situations; they track the ways that disease categories and classifications are proposed, used, and challenged; and they look at the organizational and interactional aspects of health-care delivery and the implementation of public health programs.

Because medical science and technology are part of the ordinary structure of people’s lives, social researchers prefer to explore larger theoretical questions by documenting case-specific factors and effects. They listen to what people say, think, and believe about medical technologies. They pay attention to how people actually use technoscience, and how their access to technological possibilities is structured. Public health practitioners can benefit from critical social research on medical science and technology. By adopting a wider temporal scope, and a more comprehensive contextual view, these studies bring into view the ways in which immediate medical and policy issues fit into more fundamental processes.

The Biomedical Model And Technology

In relation to clinical medicine and medical science, the dominant framework that guides actions is the biomedical model. It is important to understand that the biomedical model guides action by making some pathways seem logical and others difficult to formulate.

The biomedical model represents an extreme concentration on the component parts of the material, organic body. The view of a machine-like body, whose workings depend on the functioning of its component parts, owes much to the anatomical tradition of Western renaissance medicine. With an emphasis on body parts rather than physiological wholes, doctors in the early stages of medicine secretly dissected cadavers in order to see the site-specific lesions that illnesses left in organs and tissues. In the nineteenth century, as stethoscopes and other newly invented diagnostic technologies first entered into common use, physicians began to see the body as an interior space that they could observe objectively. Freed from their dependency on patients’ reported symptoms and sensations, the body could now be imagined as purely material space, separable from embodied consciousness and lived circumstance. Significantly, early technologies such as the thermometer (which, it should be noted, took many decades to perfect and to gain acceptance as a useful tool) were among the first to objectify the body by replacing an observer’s perceptions with a standardized numerical scale against which an individual’s biophysiological pathology could be gauged (Reiser, 1978).

Measurement tools, once calibrated and standardized, made it possible to chart the course of a disease, and compare data from numerous patients. These new ways of objectifying and collating medical findings eventually became the means to build a scientific medicine, something for which reformers of the early twentieth century pushed. The first half of the century also saw the increasing molecularization of medicine. Together, the increasingly minute view of molecular interactions, and the vast scale of statistical management of data on disease and therapies, furthered a view of the body as an objective and objectifiable bundle of material components, fully knowable without reference to its social or environmental context.

Although biomedicine does not entirely disavow social factors or the subjective experience of illness, it acknowledges social influences only as a malleable, fuzzy context or interpretations – as second-order factors surrounding the hard, immutable inner kernel of biological reality. This conceptual dichotomy makes it difficult to develop incisive models that can account for the ways in which sociopolitical processes and molecular–physiological process are in fact imbricated and coconstitute each other.

Medicine And Technology In Sociocultural Perspective

If we regard the biomedical model as merely one among many – thus refusing to accept its claim to a privileged power to explain illness – then how, practically speaking, are we to regard the knowledge of disease, physiology, and molecules produced by biomedicine? How do we open up space to inquire into the social and political processes woven into these patterns of explanation? What factors contribute to the development of certain explanations? How are patterns of explanation used? What are the consequences of particular patterns of explanation? These questions invite analyses of the myriad effects – not merely the efficacy – of biomedical and public health science.

Malaria eradication is a case in point. From the midtwentieth century, technological solutions to public health problems have been promoted in various health development initiatives and launched through international cooperation. In an era of technological optimism, and abiding confidence in the superiority of Western know-how, authorities invested in disease eradication and control campaigns. Faith in vector control strategies was buoyed by Fred Soper’s influential analysis (for the Rockefeller Foundation) of the Anopheles gambiae mosquito’s spread to northeastern Brazil. Soper’s interpretation of regional specific evidence regarding endemic forms of malaria, climate, human movements, and the economic conditions that drove them became the evidence upon which the success of vector control was based. But historians Randall Parkard and Paulo Gadelha (1997) have shown that Soper’s evaluations were flawed; and even at the time of the research, others had contested its accuracy. Nevertheless, Soper’s analysis of the reasons for successful vector control in this particular malaria outbreak provided the model and paved the way for a worldwide eradication program.

The targeted, narrowly technical interventions involved in vector control effaced complex webs of causality, in particular, the links between socioeconomic inequalities, living conditions, ecological changes, and ill health. The technological focus on attacking microbes and other pathogens implicitly offered a straightforwardly linear and biomedical solution to disease, rather than more nuanced bio-social-ecological conceptions of disease causation. This explanatory framework fortified the belief that health conditions could be improved through judicious deployments of medical expertise, which did not require complex examinations of socioeconomic conditions or sustained interactions with local populations.

Internationally coordinated efforts to deal with malaria have swung from goals of eradication (i.e., WHO’s Malaria Eradication Campaign, 1955–1972) to goals of control (i.e., the current Roll Back Malaria Initiative). But at stake is not merely the efficacy of vector elimination versus protection with bednets – that is, a difference in which technology a campaign focuses on and what that technology does. Rather, at stake are different policy visions of how a given technology works with and through various kinds of social relations. In the heyday of the WHO malaria eradication campaigns – one of the most top-down and administratively centralized international public health efforts of the twentieth century – specially hired teams conducted sweeps to spray houses with DDT. Widespread in rural areas around the world, these everyday actions of eradication became one of the most visible ways that poor, marginalized rural residents came in contact with the institutions of the state. In contrast, the emphasis of bednet campaigns is on achieving local sustainability through community involvement. This technique operates through more dispersed networks of relations among various institutional agents for change and local communalities.

The differences in these two initiatives do not reduce in any simple way to the technologies themselves, nor to the relative merits of their explanatory approaches to public health. Rather, the technologies, and their varying philosophies, are both complexly intertwined with donor–state relations, and administrative infrastructures, such that the relative success of either strategy cannot be reduced to the merits of the technology itself.

Patterns of explanation can produce logics within biological research that implicitly legitimate particular social orders. Melbourne Tapper’s (1995) analysis of mid-twentieth century clinical research on sickle cell anemia in the United States demonstrates how the definition of sickle cell as a so-called Negro disease drove research agendas. Researchers responded to cases of sickle cell in apparently white patients by aggressively pursuing investigations into their ancestry to uncover hidden black ancestors they were convinced must be there. The research was shaped within the binary racial logic of U.S. society; and its application enforced the absolute separation of Blacks and Whites by policing the racial classification of individuals. On a population level, anemias such as sickle cell were used to classify races.

Comparative research on fetal ultrasound further demonstrates how medical technologies function in cultural, political, and moral contexts, with both meaningful and instrumental dimensions. As a technology, ultrasound is meant to search for anomalies. But as an obstetrical practice in North America it also reconceptualizes pregnancy by focusing on the fetus as a patient, by treating pregnancy as a potential risk and pathology, and by guiding women to disregard their own embodied perceptions, in favor of expert monitoring of their condition.

Research in North America shows that sonographers function as both diagnostic technicians and tour guides to the womb. Interacting with expectant parents, gazing at the screen, their words and actions straddle these dual roles. Sessions are typically divided between measuring and showing the baby. Sonographers guide parents in translating blurry images into reassuring in utero signs of fetal personhood. Researchers Lisa Mitchell (2001) and Janelle Taylor (2002) have both found that ultrasound alters the lived experience of pregnancy for women, as well as building up, in society at large, new ways of imagining and relating to fetuses.

Parents and sonographers enthusiastically join forces in this cultural project of personifying the fetus. Parents routinely display printed ultrasound images as their baby’s first picture, with little thought for the ways in which this diagnostic procedure configures new social realities. Yet so powerful is ultrasound’s contribution to a cultural discourse of fetal personhood, that feminists have argued its augmentation of the social status of the fetus has diminished women’s rights, a logic that in the United States even makes it possible to arrest women for endangering their fetus.

However, ultrasound sessions are conducted differently outside North America where both the test and the images have varied meanings. The monitor may be oriented toward the physician; women may not watch the screen; and there may be no inclination on the part of medical personnel, or expectant parents, to speak of the fetus as a little person. In rural Rajasthan, Maya Unnithan-Kumar (2004: 66) notes that women use ultrasound scans mainly as a way to prove fertility and confirm, for the extended family, the reality of the pregnancy long before it is evident to the eye. Rather than promoting maternal–fetal bonds as in North America, the scan ‘‘serves to strengthen the connection between pregnant women and their affinal families.’’ Cross-cultural research alerts us to the fact that the ways people use technology emerges from the desires, paradoxes, possibilities, and needs specific to a particular context.

The practices of science are themselves enmeshed in cultural assumptions. Anthropologist Vincanne Adams (Adams, 2002; Adams et al., 2005) has studied efforts to carry out randomized clinical trials in Tibet. Routine aspects of biomedical research protocols such as randomization, blinding, and informed consent do not translate readily into this context. To doctors, researchers, and patients in Tibet, they are neither obviously sound ways to empirically assess the efficacy of a medicine, nor obviously ethical ways to handle research. The interpretation of evidence is similarly open to competing claims rooted in different ways of comprehending the physiological processes involved. What indicator will count as evidence that a disorder has been cured? The presence of bacteria may be detectable but the gastric symptoms might be completely eliminated, with no recurrence. A uterine growth might be visible through ultrasound, leading Western researchers to assume the condition persists, while the diagnostic indicators from Tibetan medicine may indicate that the underlying problem that is causing the growths has been solved. Adams’s research underscores the importance of translation and negotiation. These

are not simply about scientific ways of knowing, but about how what gets defined as legitimately scientific in these settings is about power in a discursive sense: what gets defined as legitimate can be key to financial rewards, political power, the health of populations, and in some ways, the very survival of cultures

(Adams et al., 2005: 286).

Producing Social Relations

Increasingly complex and nuanced studies of science and technology remain mindful of medicine’s capacity to reproduce power relations, but focus attention on the ways that changing knowledge and medical technology can actually alter social relations. Such alterations have far-reaching implications for how people relate to each other, through both differentiation and collective action. As ways of knowing and manipulating bodies change, the sociopolitical potentials and dangers also shift, demanding greater attention to the multiple stakes that different actors (producers and users, experts and the public) have in science and technology. This approach foregrounds the notion of agency: people’s efforts to shape the world to the ends they seek, and the complex, open-ended, and unfinished character of those efforts. Such studies suggest that medical technoscience becomes an experiential vehicle through which people live particular social formations. When people deal with medical knowledge and medical technologies, they interact not merely with immediate instrumental possibilities, but with a network of infrastructures, loosely assembled constraints, and institutional forms.

Gender and race have long been entwined with the medical science as concepts that link bodily form to categories of social personhood. Since the nineteenth century, this link has been articulated in the idiom of biological essences and the quest to discern distinct, often dichotomous biological types. Biological essentialism – the authoritative attribution of all kinds of differences to a generative, immutable biological nature – was the target of a first wave of critical studies of science. Inspired by insights into the ideological uses of biological claims, science studies researchers show that taken-for-granted gender and race arrangements may enter into medical science in more diffuse and contingent ways.

Oudshoorn (1994), for example, argues that the agenda of sex hormone researchers, in the early twentieth century, was shaped by the existence of a clinical specialty geared to women’s reproductive diseases; no comparable specialty existed for men. Clinical work on reproductive disease made available a supply of research materials – specifically dissected ovaries – that provided the conditions of possibility for pursing basic research questions about ‘all’ hormones; but this situation clearly skewed research toward women’s bodies. As a result, the sex hormone industry, and the technologies it produces (such as contraceptives), has been directed almost exclusively toward women. Thus, women around the world have complicated stakes in the benefits and dangers of these products. Population control programs have focused mainly on women. Modern hormonal contraceptives can give women control over their fertility, often in convenient forms, but they also make them dependent on the systems that deliver these products and evaluate their safety.

Historian Meaghan Vaughan (1991) shows that in early twentieth-century colonial Africa, biomedical knowledge helped build knowledge of ‘the African.’ Concepts of ‘the’ African body not only relied on a naturalized sense of difference, they also portrayed that difference as inherently pathological:

As the notion of biological ‘race’ came under attack, white liberals (amongst whom were many doctors), became uneasy with medical theories which relied on the embodiment of difference, and elaborated other theories to account for perceived variations in … the manifestation of a disease amongst different social groups. In these theories, medical science demonstrated its ability to draw on ‘social science’ as well as on natural science for its authority … It drew primarily on anthropology and substituted culture for biology in many of its accounts

(1991: 13).

By the 1930s, the erosion of appropriate differences was itself seen as a factor predisposing some to disease. Poor health and living conditions of urban industrial workers in South Africa was by then commonly attributed to their maladjustment to civilization, which, in turn, became a justification for restrictions on black mobility and the maintenance of reserves. The widespread (white) idealization of a supposedly healthy rural lifestyle enabled medical authorities to ignore evidence about actual factors impoverishing rural areas (Packard, 1989).

In the 1990s, when AIDS became known in Africa, a version of this explanation resurfaced when so-called African AIDS was attributed to the breakdown of traditional culture due to the modern lure of cash and commodities that led (it was suggested) to sexual promiscuity and prostitution. Again, ostensibly social explanations contain a masked logic of biological difference. The science studies perspective does more than attribute these explanations to racial prejudice. It provides tools for better understanding how, why, and when such explanations come to seem reasonable, sound true, and even how consensus is reached around what terms and categories constitute legitimate explanation. This approach enables us to ask not only what is the best evidence? but also what determines what evidence counts as true?

At the population level of public health, even the most basic core assumptions and categories can contribute to the production of social inequality. One of these is the normalized ideal of the healthy person – with its concomitant stigmatization of deviance – recognition of which has proven fruitful for science studies. Sociologists have argued that health-promotion activities in Western industrialized nations proffer a model of right living with an essentially moral character that ultimately distinguishes proper from improper conduct. The emphasis on self-control, prudence, and rational management of the body not only values a certain kind of self, it also makes health appear as an achievement to be secured by the individual through autonomous actions. Such a formulation inevitably places blame on those who do not, or cannot, conform to medically sanctioned normality (Lupton, 1995).

Critical analysts argue that these seemingly innocuous frameworks, which favor a rhetoric of personal choice, help legitimate socioeconomic inequalities by obscuring the factors that constrain options in everyday life. Some, following Foucault’s theory of biopower, draw attention to the unobtrusive and dispersed mechanisms through which people are molded into the very sort of self-regulating person the discourse of health promotion imagines. In this theoretical formulation, people do not experience the power effects of health promotion activities as coercive. Instead they internalize the subject positions created for them through the multiplicity of small everyday actions; they experience the power of authoritative knowledge as a common sense acceptance of what they should desire and aspire to.

Researchers looking at colonial public health note similar patterns. In the colonial polities of the 1920s and 1930s, the emerging technocratic management of hygiene, sanitation, and maternal practices among ‘the natives’ tied efforts of health promotion very specifically to wider projects of ‘civilizing’ and ‘modernizing’ colonized peoples. From soap to latrines, from hospital births to childrearing practices, the reform of ‘native’ practices in the name of health was carried out through a racial idiom that insistently marked the difference between civilized and native bodies. Thus programs of hygiene, sanitary reform, and disease eradication were important arenas through which colonized peoples experienced rule in their everyday lives.

Around the world, the symbolic association of biomedicine with modernity carries meanings weighted with colonial moralism. The status connotations of being someone who is ‘developed,’ or someone who is ‘backward,’ play out in the smallest interactions. In a small town in the Peruvian Amazon, young women who are selected to become peer educators begin dressing in the shoes, skirts, and hairstyles that convey their more cosmopolitan modern status. In rural Nepal, villagers hide their use of ritual healers from government health post officials to avoid being chastised for their continued superstition. In his disturbing analysis of the handling of a cholera outbreak in Venezuela in the 1990s, Charles Briggs (2003) develops the concepts of sanitary citizenship and medical profiling in order to highlight the tight relation between representations and practical consequences. Sanitary citizenship describes an eligibility for societal benefits and civil rights that was based on a ‘proper’ relationship to public health. ‘‘Public health officials, physicians, politicians, and the press,’’ he writes (Briggs and Montini-Briggs, 2003: 10), ‘‘depict some individuals and communities as possessing modern medical understandings of the body, health, and illness, practicing hygiene, and depending on doctors and nurses when they are sick.’’ Those who would not, or could not, adhere to these standards – often for reasons related to their class, race, or gender – were deemed unsanitary citizens and were denied equal assess to medical services and treatment by health professionals. Briggs terms this process of differentiation medical profiling.

Forms Of Biosocial Collective Life

Biosociality is the term Paul Rabinow (1996) proposes to talk about how new biotechnological possibilities (such as genetic mapping) rearrange our actions in relation to nature, identity, and collective life. Techniques that manipulate cell functionality, for instance, or that create mice that have been genetically designed for testing cancer treatments, highlight the fact that biological nature no longer exists a priori, but is a malleable product of organized human action. Biotechnologies generate new categories for conceptualizing the vulnerabilities of bodies and somatic suffering through the manipulation of, or promise to improve, biology. Through these processes, biotechnologies generate a proliferating awareness of genetic risk and susceptibility. A number of researchers note that in Western industrialized contexts widespread promotion of technologies that identify hidden or potential disease (as in the case of mammograms, genetic screening for Huntington’s disease, or screening for heterozygote carriers of genes for Tays-Sachs disease or cystic fibrosis) encourage people, in general, to think of themselves not as well or unwell, but as always already potentially ill. As Nicolas Rose and Carlos Novas put it, ‘‘one has long been responsible for the health and illness of the body, but now one must know and manage the implications of one’s genome’’ (Rose and Novas, 2005: 441).

An important implication of this shift is the emergence of new biosocial identities, a sense of collective belonging based solely on our consciousness of shared biological traits that are knowable through technological renderings. Given this, researchers ask: What are the wider arrangements that make people demand or need these identities? How is their understanding of themselves formed, precisely, through their interactions with experts (medical specialists, laboratory scientists, and medical ethicists), and with institutionalized experiences (the accessibility to patented tests, treatments, and bioproducts), or through such factors as entitlements, embedded in systems of health-care payment? To what extent do certain categories of people seek out these biosocial identities and to what extent are the labels placed upon them by powerful others?

Often, biosocial identities form under situations of marked scientific uncertainty, and in situations and institutions that are far removed from the realms we think of as science. In the U.S. context, for instance, Joseph Dumit (2000) has researched the varied uses to which the ostensibly objective evidence from brain imaging (PET scans) has been put, in relation to such ambiguous disorders as multiple chemical sensitivity, chronic fatigue syndrome, and bipolar disorder. The etiology of these disorders is not well understood, and they have been alternatively framed as mental, psychiatric, and biological. But the framing of these disorders not only results in radically different treatment recommendations, it produces identities whose status is fraught with legal and medical questions related to disability and insurance purposes. In this way, nonscientific locations (insurance agencies or courts) become the places that – legally and institutionally, temporarily and situation ally – establish what information counts as facts, based on the presentation and interpretation of brain scans.

But scientific research is neither the starting, nor end point in the establishment of truths. As Dumit (2000: 227) comments,

scientific and medical statements come to be central and yet nondecisive in many settings. Brain imaging – arguably the most ambiguously promising diagnostic technology – has and will continue to play a key role in resisting the easy assignment of blame, stigma and causation to the individual. But it appears it will not do so by settling the matter once and for all in biology.

To be a sufferer of one of these conditions is also to be an activist involved in negotiating what sorts of evidence count in different contexts. Prenatal diagnostic tests for genetic disorders expose other uncertainties fundamental to the formation of new forms of biosocial being-in-the world. Rapp (1999) observes that in New York City, prior to administering amniocentesis, genetic counselors present patients with ostensibly objective and neutral information regarding the possibility of Down syndrome so that informed decisions can be made. Yet women who are experiencing pregnancy within particular moral, cultural, or economic constraints must make complex reproductive decisions whose parameters are underdetermined by probabilistic facts about genetic events. Potential parents do not confront knowledge of the fetal body in a vacuum, but do so in relation to highly complex configurations of knowledge, intentions, beliefs, and desires related to their own bodies; their sense of responsibility to future children; their obligations to kin, culture, and society; and to the choices provided by biomedicine. Rapp refers to parents, placed in this position, as moral pioneers, to emphasize the ways that people in diverse circumstances must navigate the prospects of aborting genetically disabled fetuses, or forging lives with disabilities, through complicated landscapes of uneven scientific knowledge and therapeutic promise.

Such observations expose the limitations of trying to understand the social aspects of the biotechnological revolution simplistically on the micro level of individual experiences, in relation to the macro level of public policy decisions about the common good, as if both occurred against a backdrop of stable and consolidated scientific expertise. Certainly the questions raised in these studies highlight the inadequacy of linear models that assume that science simply supplies evidence to decision makers who, in turn, set policies for the institutional structures within which, in their turn, people seek diagnosis, care, and recovery. Rather, biosocial modes of social engagement involve far more convoluted and multidirectional pathways connecting experiences to institutional structures and expert knowledge.

Perspectives And Prospects

The approaches described here have roots in the sociology of knowledge but reflect a shift toward the analysis of practice. While earlier efforts to make science an object for sociological inquiry looked at knowledge claims, models, and even at whole epistemologies, they erred in treating science solely as a mental activity and knowledge as a set of linguistically expressed claims. They promoted what are now seen as an overly monolithic, systematic, even frozen portraits of knowledge claims. Researchers soon became far more concerned with understanding how knowledge is produced and reproduced; how it is used and contested. In the study of biomedicine as a cultural system, this entailed a shift from a critique of ‘the’ biomedical model to more nuanced descriptions of diverse biomedicines. This emphasis on heterogeneity has been accompanied by attention to the orchestration of practices involved in doing science and delivering medicine.

One criticism of the study of knowledge claims per se is that it misleadingly portrays science as a linguistic or representational activity, rather than a hands-on form of tinkering with tools, instruments, materials, and organisms. Practice-focused approaches are now preferred because they enable researchers to talk more convincingly about how scientific and medical activities intermingle representations with materiality.

The concept of cultural or social construction has been important to the social study of science and medicine since the 1970s. This concept stresses the reality of features of the social world; these realities come to exist because of people’s actions and attitudes and because people know them to exist they act accordingly. Constructionist analysis draws attention to the interrelationships among scientific knowledge production and such varied domains as law and government; the economic organization of industry, labor, and consumption; popular media; and domestic arrangements. The concept of social construction helps frame the complex and usually uneven ways that events in these domains work together with science to produce what we call socially constructed ways of engaging somatic distress.

One limitation of the current body of work on medical science and technology is that it is heavily weighted toward cutting-edge science and high-tech interventions. This means that most empirical research is conducted in industrialized countries with the economic resources and health-care infrastructures to support this type of science and medicine on a broad scale. Far too little research looks at medical sciences and technologies in a full range of contexts. Many questions remain about precisely how locations in the world become connected through the various circuits of science, including the circuits of research materials, experts, and populations. More research is needed on the fragmented and partial presence of biomedicine for people in most of the world. Concerns about the stark inequalities in access to even the most basic and reliable forms of biomedical care can easily overshadow another disturbing feature of these contexts, i.e., how they can be simultaneously tightly integrated with particular elements of biomedical technoscience while largely cut off from others. These are important political questions.

Sociologist Deborah Lupton cautions that public health professionals would benefit from being more attuned to the way their actions both reproduce and express social contradictions. She challenges them to ‘‘critically interrogate their use of knowledge and to become aware of the interests they serve and reproduce as part of their working lives’’ (Lupton, 1995: 13). Nicolas Rose, for his part, states that it is important to document and track not only how the present has been shaped by the past and how our current assumptions might bolster existing social arrangements, but also how new forms may be emerging. ‘‘No single future is written in our present,’’ he writes (Rose, 2007: 259), making the case for the analysis of medical sciences, technologies, and the forms of governance, infrastructure, management, industry, and profit associated with them.

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