Op-ed in STAT: “Authoritarian love in the time of TB”

Patients are seen in their room at the National Tuberculosis Reference Laboratory in Pyongyang, North Korea.
ERIC TALMADGE/AP

Excited to share my recent op-ed piece in STAT news: “Donald Trump and Kim Jong Un: authoritarian love in the time of TB“. It begins:

“President Donald Trump, North Korean Leader Kim Jong Un, and Mycobacterium tuberculosis — the airborne bacterium responsible for causing tuberculosis, the deadliest infectious disease on the planet — are embroiled in a potentially awkward three-way love triangle.

I wish this was the setup to a late-night talk show host’s punchline, but it isn’t.”

Check it out!

Review of “Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS” (2014)

Sanyu Mojola’s “Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS” (2014) presents a compelling, multilayered, processual account of the ways that changing ideas of modernity and the expansion of a gendered market economy combines with the physiological and ecological structure of HIV transmission risk to produce the outrageous inequity in HIV burden borne by women in Africa. She says, “Specifically, I illustrate how consuming young women have been cultivated and produced, in three contexts—communities, schools, and labor markets” (p. 8). For her, the dramatically gendered disparities in HIV burden and experiences can only be adequately explored by tracing the interwoven threads of the structuring market, its shaping force on cultural norms and dispositions, and the implications for young womens’ search for love and desire amidst the specter of HIV. As Mojola describes, women are caught between the culturally and institutionally cultivated demand to consume—products, beauty goods, daily signs of status and modernity—while also being structurally excluded from the vast majority of the formal labor market and consistent income potential. The demand for stable income leads to emergence of various forms of “transactional sexual relationships” that take on different forms in different settings, but all help to satisfy consumptive needs and norms.

Mojola was born in Tanzania but attended college in the UK and graduate school at the University of Chicago. As she as a result her writing has an emotional and intellectual proximity that is unusual. It makes the evidence—qualitative and quantitative—all the more compelling. As she says, “I was Robert Park’s ‘marginal (wo)man”, belonging, yet not quite belonging, understanding yet not quite understanding…Far from an impersonal and purely academic account, then, this book is a study about the young women whose dangerous transitions I might have had to traverse except for the strange turns my life has taken” (p. 27-28). Using a life-course framework to study young people’s transition to adulthood in the context of the HIV epidemic, she mobilized interviews with 185 people (young people, middle-aged adults, and older adults) from the Nyanza province of Kenya; population-based survey data from Kenya; and, ethnographic field work.

Mojola’s central puzzle is: what social forces lead women to be so extremely vulnerable to HIV infection in sub-Saharan Africa, specifically the eastern part of the continent? Research on the issue tends to focus on three broad sets of interrelated causal factors—biophysiological, proximate explanations, and social structural causes. Biophysiological factors include the relationship of female anatomy/physiology and its relationship to HIV transmission potential. Proximate explanations tend to focus on the age at first sex, the number of sexual partners, condom use, the structure of sexual networks, and migration patterns. Mojola identifies one key social-structural cause, which is the central analytic lens of the book: consumption. She explores the how socially produced consumption desires shape behavior and consequent risk for contracting HIV; how consumption operates within networks and institutions (such as schools and labor markets) to shape HIV risk; and, how the structuring dynamics of consumption patterns are similar across high-prevalence settings across Africa.

Mojola begins her substantive argument by tracing the phenomenology of “modernity” as experienced by young women, transitioning to adulthood, in sub-Saharan Africa. Globalized notions of taste, marketing and media enable brands and consumption patters to be extended to even places “remote” from the metropole/former colonial centers. In places marked by significant poverty, “consumption is available used and at a deep discount—through secondhand North Face clothing that has made its way from Western charities, for example, or through cheap pay-as-you-go Nokia mobile phones” (p. 34). This modern (post-modern?) form of consumption has a markedly gendered dimension: “the dominant signifier of modernity for young women is the purchase, consumption, and display of modern goods. Indeed, there is a sense in reading these accounts that transactional relationships as a means for enhanced consumption are an indelible part of the landscape of young African women’s relationships” (p. 36). As has most notably been discussed by Viviana Zelizer and others, money, transactions, gifts, sex, and intimacy are often interwoven within relationships. Women and men engage in “relational work” to maintain culturally appropriate and sanctioned matches between money, media, and morals within intimate relationships. This is no less true in the relationship forms of young African women, and these structures have significant implications for the observed disparities in HIV rates. “In Kisumu, Nyanza, for example, three-quarters of men surveyed reported giving an average of 10% of their monthly income to their nonmarital, noncommercial sexual partners… transaction in intimate relationships was the norm rather than the exception in this setting” (p. 37).

As has been demonstrated in research on “sugar daddies” and other forms of explicit and non-explicit forms of transactional intimate relationships (in the U.S. and elsewhere), “when access to money and resources is structurally constrained, transactional sex emerges as a way of ‘redistribution and reciprocity in an unequal and uncertain world,’ where men’s dominant access to wealth and resources ‘compels them’ to have concurrent sexual partnerships involving transactional sex” (p. 42). Market demands for consumption are therefore intimately tied to the gendered risk of contracting the all consuming illness of HIV/AIDS (“Ayaki [Luo word for AIDS] came from the root word yako, which means to consume very fast, in such a way that displays greed” (p. 51)). An interesting aside is the parallelism in the discussion of consumption in HIV and the history of tuberculosis as a consumptive disease. The entanglement of aesthetic, ethical, cultural, and market demands for consumption are structuring for the experience of infectious disease transmission risk. The pursuit fo the raha—the good life of enjoyment and consumption—shaped the HIV epidemic which was “not just consuming anyone; it was consuming young women” (p. 59).

Mojola describes the “great transformation” of colonial/post-colonial settings in a Polanyian way: relationships, particularly intimate ones, are embedded within a complex, historically rooted matrix of moral, ethical, and social meanings and commitments. “It was not money that alienated or ‘ushered in moral confusion’ or that created alienated social exchange. Rather… ‘it is important to understand the cultural matrix into which it is incorporated” (p. 75). Money and the consumptive market economic logic imbricated with existing historical norms of kinship, marriage, relationship, and sexual norms. Mojola indicates two primary forms of transactional relationships that have emerged: relationships for education and relationships for sex. The former, however, often evolved into the later. “For many young men, the only fair exchange or reward for the gift of money was having sex in return. Boy did not necessarily need to be wealthy, but needed to have the ability to get or earn money to help their girlfriends” (p. 83). In Zelizerian terms, gifts of cash and consumptive products (beauty and other types) [the media] were matched with evolving transactional relationships which were not poisoned, or “tainted” by such cash and “economic” transactions, but were actually imbued with additional meaning and moral significance as a result. “Both sex and money expressed love. In other words, love = sex + provision” (p. 87).

These dispositions were actively cultivated in young women, as explored by Mojola, in two primary institutions: the school and the labor market. Puzzlingly, women with more education are observed to have higher rates of risk for contracting HIV. “The thinking goes, if education has such dramatic effects on one sexually transmitted condition—fertility—why not on HIV/AIDS?” (p. 114). Her explanation hinges on the ways that structural processes and norms, refracted through gendered practices, shaped the notion of a “modern schoolgirl” as “Consuming young women [that] had desires that could only be satisfied by consumption, desires that were considered necessities and integral to schoolgirls’ transformation” (p. 132). This culturally disciplining nature of the demand for becoming a modern, consuming, young woman combined with the norms of engaging in transactional relationships with working-class men to get money to pay for those needs, is Mojola’s main explanation for the linkage between increased education and increased HIV risk.

Finally, the gendered nature of the economy and the structure of the labor market was another way that the embedded forms of economic and meaning making became entangled in and produced the risks of contracting HIV. As she states, “In particular, the predominantly one-way transfer of money and gifts—from men to women—in transactional relationships reflect the fact that in most settings, men have relatively greater access to money and resources due to the gendered structure of local economies” (p. 151). This gender-structured labor market exacerbated the sociocultural/economic structures that produced unequal HIV transmission risk. The structural disconnect between the cultivation of young, modern, consumptive young women in the emerging mass education system and the exclusion of women from the labor market and formal income-generating mechanisms that would be necessary to finance this consumptive demand, produced the need for transactional sexual relationships with men. “They had to be continual consumers and thus continual transactors” (p. 169).

Mojola ends this book with a call to action: “The large number of young women currently beginning their sexual lives in high HIV-prevalence environments suggest that policy actions (or nonactions) undertaken in the next five to ten years may very well determine the course of the HIV pandemic in Africa” (p. 183). She calls for continued individual-level interventions such education and awareness raising, but also claims that this will be insufficient. As is the topic of this book, change will only occur with changes in the socio-structural determinants of HIV transmission: changing the school environment, cracking down on sexual relationships between teachers and students, legislating and making paying jobs more available to young women. Most promising is her brief summary of the potential of conditional (and unconditional) cash transfers to schoolgirls for HIV prevention. By reducing the structural/economic pull that young women feel in their pursuit of accomplishing the role of being successful young, consuming, modern women, perhaps the trajectory of the HIV pandemic can be altered.

Some key questions that come up for me:

Mojola seems to base her theoretical contribution building off of a combination of Zelizer and Granovetter: networks and institutions structurally shape the networks of relationships (the circuits) through which HIV is transmitted, but also reinforce the cultural feel, aesthetic view, and moral meanings associated with these transactions, interactions, and at times loving/intimate relationships. While this does seem like a powerful case example of embeddedness and relational work in an understudied setting/population—with important policy implications—what does it add to sociological theory?
While she clearly engaged with young women who were in difficult straights, her respondents / sample does seem to be relatively well off, urban, school-bound women. She explicitly says on several occasions that these were not transactional relationships of necessity (in order to eat, have shelter), but rather the needs expressed by the young women were structured by the demand to consume along the lines dictated by the cultural pursuit of modernity. I wonder if this presents a limitation or simply a purposeful focus for the structure of her research design?
A question that rises for me after having read this study is how the formal healthcare system shapes / impacts these cultural norms any of these socio-cultural structural determinants? If the school system (which arguably has a much more powerful shaping function) shapes and transmits norms, how could the healthcare system be present in schools, or more available in contexts where their prevention activities could be improved?
How does this research intersect with James Ferguson’s (and others) work on cash transfers? Would love to talk about this in the context of “Give a Man a Fish.”

Review of “Unprepared: Global Health in a Time of Emergency” (2017)

Andrew Lakoff’s “Unprepared: Global Health in a Time of Emergency” (2017) explores the assemblage of practices, knowledge forms, and politics that underlie the production of preparedness for the unquantifiable risk of catastrophic pandemic disease under the current global health security regime. It tells the story of how “the machinery of global health security was cobbled together over a two-decade period, beginning in the 1990s… it is a story of the assemblage of disparate elements—adapted from fields such as civil defense, emergency management, and international public health— by well-meaning experts and officials and of response failures that have typically led, in turn, to reforms that seek to strengthen or refocus the apparatus.” (p. 7).

Lakoff takes the approach of “historical ontology.” In the spirit of Ian Hacking and Michel Foucault, Lakoff seeks to unmask how “taken-for-granted objects of existence—whether the economy, the psyche, or the population—are brought into being through contingent and often-overlooked historical processes.” (p. 7). This approach enables him to observe “two [current] regimes for governing global health problems: global health security and humanitarian biomedicine.” (p. 10). For him, global health security focuses on the logic of protection of powerful nation-states, particularly maintaining the smooth flow of global capital and trade that disproportionately benefits wealthy capital holders. Humanitarian biomedicine, on the other hand, takes on the “need to save all lives, regardless of political boundaries, from treatable maladies such as malaria, tuberculosis, and HIV/AIDS.” (p. 10). The distinction and relationality between these two approaches to governing global health is a central theme of this book.

How did the notion of “preparedness”—the never-ending process and series of practices of developing skills, knowledge, plans, etc. to governmentally approach managing perceived threats—come in to existence? Lakoff links the techniques of preparedness to a response to the political demand posed by the contemporary category of “emergency.” (p. 15). Different from notions of “risk” (under which probabilities of different outcomes are thought to be relatively well-known and stable, thus capable of being calculated and sufficiently technically managed) preparedness hinges on a state of emergency under which “a catastrophic occurrence… may not be avoidable and so generates knowledge about its potential consequences through imaginative practices like simulation and scenario planning. Such practices make it possible to gauge vulnerabilities in the present, which can then be the target of anticipatory intervention.” (p. 19). A strategy of government, preparedness encompasses a series of practices and techniques that are meant to support the preservation of life in a future time of emergency and includes activities such as “early warning systems, scenario-based exercises, stock-piling of essential supplies, and the capacity for crisis communication.” (p. 19).

Practices of preparedness have their historical roots in the Cold War-era national security strategies of the United States. Lakoff writes, “Given these concerns about American susceptibility to a sudden and devastating attack, Cold War national security strategists sought to ensure that the nation could rapidly put into motion an efficient military production apparatus in the midst of a future emergency.” (p. 22). Although this as a national-level civic defense strategy, Lakoff makes the argument that the normative rationality underlying these scenario-planning and preparedness exercise techniques were eventually taken up as the basis for a more general approach to health and security threats, within the United States and globally. This shift, a part of Lakoff’s historical ontology approach, is distinguished from other past regimes of governmental sovereign power. He makes the distinction between sovereign state security, population security, and vital systems security: sovereign state security being the 17^th century efforts of monarchs and rulers to deploy military force to combat opposing extra-territorial forces; population security as the nineteenth century modern state’s deployment of population-level statistics to distribute risk and promote particular forms of life; and finally, vital systems security targeting the distinctive type of threat of the event “whose probability cannot be calculated but whose consequences are potentially catastrophic.” (p. 38).

The practices of stockpiling vaccine serum in preparation for potential “Swine Flu” pandemic influenza is a case example explored in in-depth by Lakoff. Under the specter of the catastrophic 1918 influenza pandemic which killed more than half a million people in the United States, President Ford made the decision to stockpile and subsequently immunize the entirety of the population of the U.S. The strategy “defied actuaries”, as no policy like this had ever been deployed and the risk of serious side-effects of the immunization were not known. Despite these various setbacks, by December 1976, forty million people had been immunized. But, because of a handful of cases of serious Guillain-Barre syndrome and no evidence of an impending pandemic, the New York Times editorialized this as the “Swine Flu Fiasco.” Rather than leading governmental leaders to question the logics ongoing preparedness in the face of unknown risks, they chose to double down instead. Failure was attributed to “administrators’ lack of foresight. The Federal health officials did not have contingency plans in place and so reacted in an ad hoc manner as unexpected events occurred. Going forward, public health authorities coalesced around the changed notion of what type of knowledge ought to be ascendant in times of emergency: “rather than statistical calculation of risk based on historical patterns of disease incidence, the emphasis of experts [should] be on knowledge of system-vulnerabilities gathered through the imaginative enactment of singular events.” (p. 65).

These logics moved to the global sphere amidst the next global pandemic threat: the so-called H5N1 influenza virus, also dubbed “avian flu.” Specifically, this situation brought to the fore the geopolitical tensions inherent in sharing biological data about viral strains, accurate epidemiological data, and other forms of knowledge necessary to assess the risk of a deadly global pandemic. Specifically, Indonesia refused to share samples of influenza virus with the Global Influenza Surveillance Network (GISN) under the—rather reasonable—assumption that this knowledge sharing (and the potential pandemic prevention it could enable) would benefit them less than the wealthy countries of the world. This example is a case study of the challenges and tensions inherent in the modern regime of “global health security” which focuses “on ‘emerging infectious diseases,’ whether naturally occurring or manmade, which are seen to threaten wealthy countries and which typically (although not always) emanate from Asia, sub-Saharan Africa, or Latin America. [Global health security] develops techniques of preparedness for potential events whose likelihood is incalculable but that threaten catastrophic political, economic, and health consequences. Its advocates seek to create a real-time, global disease surveillance system that can provide early warning of potential outbreaks, and to link such early warning to systems of rapid response designed to protect against their spread to the rest of the world.” (p. 71).

The global health security regime of global health governance is set against the regime of global health humanitarian biomedicine, which is meant to alleviate the suffering of individuals, independent of national and social identity. “Whereas global health security develops prophylaxis against potential threats to the populations of wealthy countries, humanitarian biomedicine invests resources to mitigate present suffering in other parts of the world.” (p. 72). Perhaps exemplified by Medecins sans Frontieres (MSF) and the Bill and Melinda Gates Foundation (I actually don’t completely agree with this typification, and would like to think about this more) and artfully described by Peter Redfield as having a “secular commitment to the value of human life,” it is a logic that is practiced through medical intervention. Also subsumed under this banner are the primary health care movements who have strived for a “right to health for all,” which has primarily been driven by philanthropic organizations and development aid. Lakoff links the emergence of humanitarian biomedicine to the efforts and social movements that surrounded the emerging infectious disease of HIV/AIDS.

Alongside the humanitarian biomedical response to HIV/AIDS though, was the nagging fear of the specter of continued viral and other novel infectious-agent emergence. With the advent of new tools like the internet-based reporting systems (ProMED and the Global Public Health Intelligence Network) and the outbreak of severe acute respiratory syndrome (SARS) in 2002, there was a need to govern and control the rapid circulation of information about infectious disease outbreaks across national borders: a new form of global disease surveillance was needed.

Enter the International Health Regulations. “According to legal scholar David Fidler, the 2005 IHR revision was ‘one of the most radical and far-reaching changes in international law on public health since the beginning of international health co-operation in the mid-nineteenth century.’” (p. 84). For Lakoff, these revised regulations created a new legal framework of obligations and duties—as well as obligation to accept global intervention—in a world viewed to be “under threat from ominous Emergency.” (p. 85). Central to the changes was the technical assemblage of knowledge and practices that formed the new instrument called the public health emergency of international concern (PHEIC). “This technique of classification is a way of bringing a singular event—the outbreak—into a more general category, which in turn puts into motion a machinery of action steps that guide institutional actors and limit the scope of interpretation and debate.” (p. 87). This is, purely, a mode of global governance and relocated sovereignty. “As Fidler put it, ‘the strategy of global health security is essentially a defensive, reactive strategy,’ given its narrow emphasis on detection and response to outbreaks of emerging disease. ‘The new IHR are rules for global triage rather than global disease prevention.’” (p. 94).

All told, Lakoff’s historical ontological study of changing notions and regimes of governance for managing threats of existential proportion amount to typifying the forms that biopolitics take at the world-level. As techniques of governance have moved from the relatively small-scale territories of 17^th century fiefdoms and monarchies, to the post-war modern welfare nation state, to the new post-modern landscape of decreasing state-level sovereignty and fragmented/decentralized reason and authority, how does governmental power sediment and crystalize into different forms, techniques, technologies, tools, policies, and procedures? I found this book quite useful to explore these concepts through the lens of assemblages: “a grouping of heterogeneous elements that have been brought together contingently to address what is, at least in principle, a common scientific and governmental problem” (p. 122).

My interests in the notion of Bourdieu’s (and other variants) field theory runs deep. A challenge, as I’ve learned and thought more a field theory, is its, at times, lack of “materiality.” I mean that sometimes it seems as if fields of practice are theorized as purely “social” in the sense that they are a “free market” of competition between different forms of field-specific capitals. I’m not sure Bourdieu well accounts for the types of power-sedimenting/crystalizing, field-distorting effects of things like material/technical assemblages developed and deployed by powerful actors attempting to govern in contingent and uncertain situations. So, some questions that emerge for me:

Assemblages are contingent and “sticky” techniques of government that bring together knowledge, tools, people, and procedures to manage emerging and uncertain situations. How do the conditions of their development linked to their functioning? For instance, while Lakoff does an amazing job describing the historically contingent nature of assemblages that mark our current regime of global health security governance, could fields be useful in thinking about the shaping forces of various assemblages?
Leadership: there is some creativity and agentic leadership involved in the creation of new governance assemblages. Could leadership (or McAdam/Fligstein’s ‘social skill’) be viewed as the field-positioned ability for an actor to assemble politically potent-assemblages?
Lastly, the typology of “two regimes of global health” seems overly simplistic and I’m not sure what it adds to the discussion. There seems to be more ways to view it: purely profit-driven market orientation to global health, a “developmentalist” orientation, citizen-driven popular politics, etc. Could a field-based perspective here lend nuance to his argument?

In Somatosphere: The De-socializing of Jim Kim?

I recently had a piece published on Somatosphere: The De-socializing of Jim Kim?

The 12^th president of the World Bank Group, Dr. Jim Yong Kim, is arguably the most powerful anthropologist in the world. As the co-founder of the groundbreaking NGO Partners In Health, the former president of Dartmouth College, the former head of the World Health Organization’s 3 by 5 Initiative, and longtime champion of “the science of global health delivery” (Kim, Farmer, & Porter 2013) and liberation theology’s exhortation to make a “preferential option for the poor,” Kim’s work has routinely used the “re-socializing” disciplines of anthropology and the social sciences to build arguments for greater investment in caregiving programs for poor people around the world. As a clinician and a scholar, Kim has coupled his work as a doctor for the poor to an ongoing process of “ethnographically embedding evidence within the historically given social and economic structures that shape life so dramatically on the edge of life and death” (Farmer, 2004). This is certainly a different approach from any past—or, likely near future—presidents of the World Bank, who have tended towards business titans or highly quantitative economists.

Historically, Kim has also been a fierce critic of the World Bank. Co-editing the tome, Dying for Growth, which takes aim at the market fundamentalist policies of powerful governments and neoliberal financial architecture built into the structure of World Bank loans and development assistance through the 1990’s, Kim has routinely advocated intellectually linking the widespread suffering of the global poor, to particular neocolonial policies and extractive financial procedures of the powerful people residing in places like Geneva, New York, and Washington, D.C.

Which is why Kim’s latest reform agenda as the head of the World Bank is so puzzling. It deserves special scrutiny by social scientists interested in global governance, international development, global health care delivery, and social justice.

Check out there rest, here!

Reflections on the struggle for the right to health

My journey to the fight for the right to health stems from a personal health experience: as a three-year-old, I almost lost my left kidney due to infection caused by a congenitally blocked ureter. But, because of the heroic advocacy of my parents, and the resources we had available to us, I was able to receive the reconstructive surgery necessary to repair the damage and save my kidney.

Because my story is the exception, not the norm, I’ve become veritably obsessed with political, social, and economic forces that systematically exclude the vast majority of humanity from access to the care they need to live. Why is it that effective surgical intervention is reserved to the top 1% of humanity? Why is it that I, a privileged white, wealthy, cis-gendered, straight man, am nearly guaranteed a life of comfort and freedom, despite a nearly life-ending congenital illness as a child? Why is it that if I had been born into another body, or in another place, I’d likely not be alive to write these words?

We know the answer: most humans on the planet are deeply constrained by intersectional forces of grinding poverty, racism, sexism, homophobia, and democratic exclusion. Paul Farmer and others have termed this ‘structural violence:’ the violence that seems to have no individual perpetrator–it appears to be all around us, yet not advanced by any of us in particular–that causes the systematic and unnecessary death of the poor, excluded, marginalized, different.

Today, though, we have a name to put to structural violence. It’s called the GOP-led efforts to repeal the ACA and dismantle the only safety-net healthcare program in the U.S. aimed at enabling the poor and disabled to gain access to healthcare: Medicaid.

And, we have a perpetrator. 51 one of them, in fact. Sen. Mitch McConnell’s efforts to destroy healthcare for the poor, and his craven band of greedy sycophants disguised as public servants, are guilty of structural violence. We know what will happen if they get their way: 31, 16, or 15 million people will lose health insurance depending on which of their undemocratic bills pass. Most of these people will be poor, elderly, disabled, or children with severe health problems. Tens of thousands of unnecessary deaths annually can be predicted as a result.

This is structural violence with a face. It’s happening in real time, in front of all of us. We watch in horror at our Twitter streams or our Facebook news feeds at the latest news from Washington. We applaud and click the “like” button for our friends who share progressive articles cheering distant protests with arrests, sobbing, and screaming. And we go about our day, even if a little shaken.

All of this brings up another question: what obligation do we have to ACT? As people claiming the mantle of health and human rights workers, what responsibility do we bear to stand up and actively fight back against the obvious perpetrators of structural violence?

I would argue that for those of us making strong claims about the right to health comes great obligation to fight to protect and realize those rights. Certainly, this fight must come in many forms. But, it also certainly involves more than the ongoing clicktivism that we so often see as our primary mode of action.

I’ve made the 10-hour bus ride to DC and back on three separate occasions in the last three weeks, doing all that I can with my body, my money, and my effort to stop this heinous and undemocratic attempt to destroy healthcare for the poor. I don’t say this to be self-congratulatory.

I say this because my efforts have paled in comparison to members of the disabled community. Members of ADAPT, mostly wheelchair users with significant disabilities camped outside in front of the Russell Senate Office Building for three-straight nights and days, in the pouring, thunderous rain, to be seen and heard. They chained their chairs together in defiance of the Capitol Police in the center of the Hart Senate Office Building, sending their own thunderous roar through the halls of Congress. They did this because they knew it was life or death for them.

I say this because my efforts have paled in comparison to members of the LGBTQ community. Gay, lesbian, and transgendered people are leading this fight, putting their bodies on the line, getting arrested in civil disobedience, and putting themselves through the real risk, cost, and humiliation of jail time. They did this because they know what is at stake, having lived, or at least heard tales, of the fights of the 80’s and 90’s in the AIDS treatment struggle. And, they are facing the realtime threats of this administration in the ongoing fight for LGBTQ civil rights. Their heroism, borne of self preservation, protects us all.

I say this because my efforts have paled in comparison to the efforts of people of color: A mother, her teenage daughter, and their aunt from Georgia made the trek to D.C. because of their need to access to mental health and diabetes medicines to survive. An elderly man from Kentucky who needs support for his blood pressure medicine. Each on Medicaid and limited income, they are desperate to see these repeal efforts fail. And so, they are the ones turning out, showing up, and laying it all on the line.

Our community needs to be doing more. When I say, “our community,” I know that it’s a fraught term. But, let’s say the “health and human rights community.” We have resources, some time, and a hell of a lot of privilege and power at our disposal. I know that there are a million challenges and problems that we are dealing with on a nearly daily basis–our solidarity efforts in clinics and offices here, or in Rwanda, Sierra Leone, and Haiti will be ever present–but when clear and readily apparent structural violence is being advanced in front of our eyes, are we not obligated to act?

The only cure for structural violence, as Paul Farmer would say, is pragmatic solidarity. It’s about making common cause with the suffering and doing what needs to be done, as it’s needed, to practically advance their needs and demands.

This is a moment for pragmatic solidarity in America. And pragmatically, this means standing together in direct, non-violent, political action against the named perpetrators of structural violence: the leaders of the GOP.

CEO pay and global health politics

Yesterday, Scott Weathers had a great piece calling out the short-sighted, faux-outrage of Ian Birrell, a British journalist whose main focus seems to be taking pot-shots at DFID and the UK’s investments in development assistance more broadly. To sum up, Birrell takes umbrage with the relatively high salary of Seth Berkley (more than $500k annually [update! turns out the salary is only approx £220k!]), the CEO of GAVI, the vaccine alliance which works to make childhood immunizations available to populations around the world. Birrell writes:

The astonishing pay arrangement is the latest outrage, exposed by The Mail on Sunday, of charity chiefs pocketing massive salaries and bonuses while taking British aid to fight world poverty.

Gavi is one of six new groups paying exorbitant amounts to senior executives. Two weeks ago, we revealed how seven major charities were doling out salary packages of up to £618,000 a year.

International Development Secretary Priti Patel demanded an end to ‘excessive profiteering’ when she was questioned over our revelations by the Commons’ International Development Select Committee two weeks ago.

But, as Weathers well points out:

Birrell’s criticism also reveals a common mistake when we talk about the “do-gooder” sector: misguided attention to inputs, rather than outputs. Instead of allowing organizations to determine how they can most effectively spend their money themselves and judging their performance based on results, critics like Birrell would rather focus on the narrowest examples of what they consider waste and fraud. This spending ― rarely put into financial proportion or given proper context ― often amounts to a small fraction of what we spend improving the lives of the poor. However, these examples are then often generalized to an entire sector in order to justify slashing donor funds that support life-saving aid.

While Birrell is playing an ideologically motivated, anti-aid game, it’s also true that relatively high pay for executives is the norm, especially for large development contractors. And, there are often large pay gaps within the pay structures for staff in capital cities / NGO headquarters versus site-based, country national staff. Weathers cites a blog post, but there is a lot of literature showing that CEO pay has very little to do with past performance and has small effects on motivating future performance: it’s mostly a function of the bargaining position of a given executive in relationship to their board of directors. NGOs, like for-profit corporations, are caught up in the same types of isomorphic pressures that cause them to look more and more like one another, often both in structure and in function, as norms, policies, and best practices diffuse through the field (Powell & DiMaggio, 1991).

So, while I agree with Weathers that CEO pay cannot be a wedge used to diminish support for vital development assistance programs, I worry about the political effects of NGOs succumbing to the market-based forces of the broader institutional field in which they are embedded. Throwing up our hands and saying that its just the “market at work” for exceptional talent at the very top seems not only an insufficient answer, but also tone-deaf politically. As Kristof Decoster quipped on twitter, relatively high CEO pay is an all too easily cherry-picked argument for aid critics:

Still – this was an accident waiting to happen in our "new" times #globalhealthvulnerability #inperceptionveryclosetoelites https://t.co/ZYDX4stZiY

— Kristof Decoster (@KristofDecoste1) January 3, 2017

For me, all of these issues are deeply political and not simply a matter of costs and benefits. We can make all of the “rational” arguments we want by demonstrating quantitatively the cost-effectiveness of relatively small investments in CEO pay compared to the enormous benefits of lives saved. But, I worry that this line of reasoning serves to depoliticize the whole issue of delivering effective health services to the poor. We need leaders and their organizations to embody an active resistance to market forces rather than reproduce inequalities that are at the root of health injustices in the first place.

Powell, W. W., & DiMaggio, P. (1991). The New institutionalism in organizational analysis. Chicago: University of Chicago Press.

The evolving structure of a scientific citation network and its political effects

1) Introduction

Existing literature describes academic citation networks and the structure of knowledge fields: their diverse patterns, clustering, fragmentation, structural cohesiveness, and the link between micro and macro level processes in emerging domains of scientific knowledge production (Small & Griffith, 1974; Hill & Carley, 1999; Gondal, 2011; Daipha, 2001). However, little has been written to describe the specific structural changes over time of citation networks. How do certain nodes emerge and become central or structurally important over time? How and why do other nodes, important early in the citation network’s evolution, become far less important as the network matures? What are the macro and micro level processes that describe and govern this behavior and what social, epistemological, and political lessons can we draw from these changes?

These questions are important for growing our theoretical understanding of evolving scientific domains of knowledge. Practically, these questions are also important to explore the biopolitical dimensions of evolving hegemonic scientific domains and the constraints they place on practitioners making use of domains of scientific knowledge. A central notion in the sociology of health and medicine is the social construction of illness. Sickness, disease, and health problems are simultaneously materially located biological phenomena and a socially created meaning making processes through which normalcy and deviance get defined and play out in socially relevant displays of power and inequality. Some illnesses are particularly embedded with cultural meaning, others are socially constructed at the individual level–based on how individuals come to understand and live with their illness. Others are especially shaped by technical medical and scientific knowledge and are not necessarily given by nature but are primarily constructed and developed by claims-makers and interested parties (Conrad & Barker, 2010).

Additionally, the process of medicalization—the tendency to inscribe more and more social problems to be within the professional domain of medicine—continues to be a dominant trend in society. By expanding the medical domain to ever more issues and social problems, the challenges and conflicts associated with naming and framing illness comes to the fore. Rather than a given biomedical fact, we have a set of understandings, relationships, and actions that are shaped by diverse kinds of knowledge, experience, and power relations, and that are constantly in flux. This social constructionist perspective looks at how the phenomenon was identified and acted upon. Diagnosis is a matter of the “politics of definitions” (Brown, 1995).

Though medical sociology has given great attention to the complexities and power-processes associated with naming, diagnosing, and building systems to care for diseases at the population level, less attention has been paid to the ways that the structure of academic literature, and the citation networks that represent them, contributes to the processes of naming, framing and governing of illness. This paper looks at the structural evolution of the academic literature that deals with the intersection of noncommunicable diseases and “global health.” Historically and currently, both the terms “global health” and “noncommunicable diseases” (hereafter, NCDs) have been hotly contested (Airhihenbuwa et al., 2014; Whyte, 2012; Fassin, 2012; Beaglehole & Bonita, 2010). Both the broad and diffuse concept of “global health” and seemingly technical and clinically delimited field of noncommunicable diseases demonstrate the ways in which medical and scientific knowledge is socially constructed in complex ways (Keane, 1998; Brown, 1995; Lantz & Booth, 1998). The framing of NCDs in the global policy literature, in particular, has been a battle ground of biopolitics (Bukhman et al., 2015; Binagwaho et al., 2014; Katz, 2013; Mamudu et al., 2011).

Building off the current literature, I visually examine the changing structure of the global health / NCD academic literature citation network as well as quantitatively explore the changes in some of the macro-level characteristics of the citation network and their changes between 1995 and 2016. Additionally, using ERGM techniques, I also find evidence in support of important changes in the density and the emergence of a small number of structurally important paper / nodes in the network.

To conclude this paper, I will explore how structural changes in this citation network correspond with the content of the papers that dramatically change their structural position within the network. By linking this to a historical understanding of the changing framing of NCDs in the global policy making domain, I hope to make the argument that structural changes in the NCD/global health citation network shaped the framing for and contributed to limiting the political opportunities available to activists seeking to mobilize new resources for the growing NCD burden amongst low income populations globally.

2) Research Question

More concretely, I hope to answer the following questions: 1) How do the global characteristics of the NCD/ global health citation network change, qualitatively and quantitatively, between 1995 and 2016? 2) What were the most important micro-level structures that caused macro-level changes in the network over that time period? What historical, social, and political effects could these structural changes in the network both represent and perhaps be causing in the broader field of global health governance?

3) Data and Methods

Research focused upon the structure of knowledge production frequently relies on network data (Gondal, 2011). As Gondal describes,

“The nodes in the network may be researchers, documents, concepts, or organizations. The edges connecting these nodes correspondingly are collaborative authorship (Babchuk et al., 1999; Moody, 2004; Goyal et al., 2006), social and intellectual contacts between scientists (Lievrouw et al., 1987), co-occurrence of references in the bibliographies of other documents or co-citation (Small and Griffith, 1974; Moody and Light, 2006), shared citations of the same other documents or authors also known as bibliographic coupling (Kessler, 1963), sharedmem- bership in organizations (Cappell and Guterbock, 1992; Daipha, 2001), or conceptual similarity between documents (Small, 1978; Lievrouw et al., 1987; Hill and Carley, 1999). The analysis of such networks constructed from citation indices, organizational memberships, and authorships is largely conducted at two levels. At the dyadic level, researchers have been concerned with the meaning attributed to the edges interlinking the nodes. At the ‘global’ or ‘macro’ level, researchers analyze the topological properties of the network as a whole providing a bird’s-eye description of the research field. There is yet another level – the ‘local’ or ‘micro’ level – involving more than one tie but significantly less than the complete network which remains relatively under-analyzed in the literature.”

In this paper I attempt to show not only the birds eye view of how this citation network grows and evolves over time, but also how the micro-level structures that cause ties change evolve over time as well. I accomplished this by building a plain .txt citation data set from Web of Science (webofknowledge.com) querying the database and downloading all relevant citation and paper data for the papers meeting the search criteria. My criteria for this search were a) any of the diseases listed by the Institute for Health Metrics and Evaluation as a “noncommunicable disease” (each with logical ‘or’), AND b) the term “global health”, c) between the dates of 1995 and 2016. I then used the CRAN “bibliometrics” package, downloaded to RStudio to transform this plain text data file into an adjacency matrix (see Appendix 1 for R code). From there, I was able to generate the annual graphs of the growing NCD / global health citation networks and their corresponding betweenness, closeness, and degree statistics. I additionally used the VOSViewer software for mac to further explore the structure and patterning qualitatively for the network. Finally, using the CRAN ERGM package in R, I ran ERGM models, testing for the log likelihood of the presence or absence of various important micro-level structures that may or may not be present in the given networks and may or may not change over time. Overall, this data set give me a useful view into both the micro and macro level structures and patterns within the global health / NCD citation network, but it also gives me good resolution as to how those network properties have changed over time.

4) Results

4.1 Global Properties of the Network

Figure 1 visually shows the evolving NCD / global health citation network over time, between 1995 and 2016. We see the network going from a mere handful of papers in 1995 to a seemingly very densely packed mess of papers, citations, and nodes in 2016. Nodes are slightly expanded based on their degree number (number of papers citing that paper) and so we see, starting in about 2001, the emergence of some “key nodes”—or papers that seem to be growing quickly in the number of citations that they are receiving from other papers in the network. Starting at about 2006, we see a significant density pattern towards the bottom of the network graph.These patterns are more easily visualized in the VOSViewer software. Using this visualization software, it is easy to see the breakdown of papers, the authors, their topics, and the conceptual/issue area/disciplinary clustering. Figure 3 shows the results of the visualization of the NCD / global health citation network in 2016 via the VOSViewer. Here we see that it has grouped the important nodes in the network into disciplines / areas of research based on the number of shared citations. The blue region represents papers concerned with global mental health issues. The green region represents pulmonary disease, heart disease, and epidemiological studies focused on lifestyle risk factors and population level public health intervention. The red region has to do with chronic pain issues, arthritis, and other rheumatic diseases. Finally, the yellow region represents papers that have to do with various forms of cancer. It is interesting to note that papers of similar topic and clinical area tend to group together.

Another interesting finding from this analysis was the see the rapid growth in importance of large scale epidemiological modeling and burden of disease measurement papers at the expense of more clinical/intervention focused papers. Specifically, the papers by Murray, Jemal, and Lozano are all large scale quantitative epidemiology papers aimed at measuring different components of the noncommunicable disease burden across the globe. This corresponds to some of the other the important findings in terms of changing structural importance within the network, which we I will discuss shortly.

4.2 The Changing Network Over Time

In addition to visually seeing the evolution of this citation network over time, I also wanted to explore some key network statistics—particularly different measures of centrality—of the papers in the network, and how those changed over the evolution and maturation of the citation network. Figures 3, 4, and 5 show all of the networks papers’ betweenness centrality, closeness centrality, and degree between 1995 and 2016. Betweenness centrality refers to the number of actors that must “pass through” a given node in order to reach other nodes. More technically, “if the geodesic between actors n2 and n3 is n2n1n4n3 — that is, the shortest path between these actors has to go “through” two other actors, n1 and n4 — then we could say that the two actors contained in the geodesic might have control over the interaction between n2 and n3” (Wasserman & Faust, 1994, p. 188). This “actor in the middle” has some degree of control over the graph, hence it is an important statistic to quantify. Closeness centrality focuses on how close an actor is to all the other actors in the set of actors. The idea is that an actor is central if it can quickly interact with all others (Wasserman & Faust, 1994, p. 183). Lastly, degree simply refers to the number of edges connected to a given node. In this case degree is equal to the number of papers citing a given paper in the network.

Viewing Figures 3, 4, and 5 together reveals an interesting and striking pattern. First, in Figure 3 we see betweenness centrality unfailingly, yet unequally increasing for all papers in the network. Figure 4 shows conversely that paper’s closeness centrality unfailingly decreases over the time period observed, but again at slightly different rates. Finally, Figure 4 shows that degree appears to go up for all papers in the network, again at dramatically different rates across this citation network.

These observations demonstrate an interesting conclusion for this network: that betweenness and closeness appear to be inversely related to one another over time as a citation network grows over time. Practically, what this means is that as papers continue to be added to the scientific network space of global health / NCD research, they are increasingly citing seminal papers and making connections with other, less cited papers in the network. This rapidly growing, but relatively sparsely connected network creates more and more betweenness for each paper—there are more steps through the networks through which to go and therefor each paper in those steps are between ever more papers. But, at the same time, papers are being added to the network at such a rapid rate (and papers can only cite so many other papers) that network is becoming increasingly less dense and therefor the closeness of the papers within the network shrinks dramatically, especially starting around 2000. Finally, it also makes sense that in general, the degree for papers in the network would grow consistently over the course of the evolution of this citation network. Papers, even those rarely cited, will only grow in their number of citations and won’t decrease.

Table 1 (to be discussed more below) shows the number of papers in the network for each year: there is an almost exponential addition of new papers to the network starting around 2002. Given this explosion of new nodes being continually added to the network, the relatively few citations any one paper can have, it makes sense that closeness centrality would plummet over the course of the evolution of this network and that betweenness within the network would increase as the sparsely—yet still completely connected—network continues to grow.

4.3 Differential Eigen Centrality Trends

So, over time, the NCD / global health citation network seems to both be growing in terms of its overall size, the number of citations, and therefor its average betweenness of the papers in the network. Conversely, the network is becoming far more sparsely connected because of the sheer rate of addition of new papers and the limited numbers of citations that each paper can make (see Figure 10). What about the importance of particular papers? Are there specific papers (or groups) that seem to be becoming more or less important in the network despite the rapid expansion of the network itself?

Eigenvector centrality is one such measure of importance or influence within a citation network. It assigns relative scores to all nodes in the network based on the number connections and quality of the scores of the connections a node has. The more important the node’s connections, the higher that node’s eigenvector centrality will be (Newman, 2014). We might hypothesize that similar to the betweenness measure, all papers would tend to become more important within the network over time. Or, conversely, perhaps, eigenvector centrality would tend to decrease rapidly with the rapid increase of the size of this citation network. Puzzlingly, neither seems to be the case: Figure 5 seems to show that some of the papers in this citation network are increasing in their eigenvector centrality score between 1995 and 2016, while other papers in the network decrease in terms of eigenvector centrality over this time period. How can we account for this?

It seems that there is some pattern—some papers increase in eigenvector centrality while other papers decrease in eigenvector centrality—over the time period observed. But, what is the relationship between the papers that tend to increase or decrease in relative importance / influence in this network over time? To explore this, using R (see code in Appendix 1) we separated out the papers that had increasing eigenvector centralities and those with decreasing eigenvector centralities. Figures 6 and 7 show the plots of the increasing eigenvector centrality papers in red and the decreasing eigenvector centrality papers in blue. What unites these papers?

To gain a better understanding of the overall network trend of eigenvector centrality for the papers in question, I decided to create a boxplot of all of the paper eigenvector centralities for each year, which is represented in Fiugure 8. Figure 8, once again, shows a striking outcome: while there certainly are some papers that become far more important, structurally, over time within the network, the vast majority of the papers are virtually inconsequential as far as eigenvector centrality goes. For instance, in 1995, the average eigenvector centrality score was close to .9 with a modest standard error; by 2001, it was less than .2. As time progresses from 2001 through 2016, the average eigenvector centrality score crashes to nearly zero, while a handful of outliers grow in their structural importance within the network. Who wrote these papers and what were they about? Why and how have they become so structurally important within this network?

4.4 ERGM and the Analysis of Micro-Level Structure

One hypothesis may be that local, or micro-level structures could have an important role to play in the structural evolution of this citation network over time, thus causing certain papers/nodes within the network to have a structural advantage over the others as the field of knowledge production expands. Here I attempted a modest ERGM analysis (exponential random graph modeling). ERGM are a class of stochastic models which use network local structures to model the formation of network ties for a network with a fixed number of nodes (Wang et al., 2009). They are a useful method that uses Markov Chain Maximum Likelihood Estimation to approximate estimates for the odds ratio of the presence of different micro-level structures within a network.

Table 1 shows the results of these modeling exercises on these NCD / global health citation networks as they evolve between 1995 and 2016. While running these models (which, it turns out, takes a ton of time and computing power) I learned that many of the network parameters that I had hoped to test within this network (such as k-star, 4 cycles, triangles, and triad census) would not produce MCMC models that would converge. So, I was not able to estimate those parameters.

However, I was able to estimate the ERGM parameters for the presence of edges, transitive triplets (ttriple), and density, and their values are found in Table 1. The column labled ERGM~EDGES can be interpreted as a log odds measure of the density of the network. As might have anticipated based on the analysis of betweenness and closeness, as well as the growth of the number of notes of the network, the log-odds of the probability of any tie (i.e. the density) crashes and starts to become negative starting in 2001. The column labeled ERGM~DENSITY demonstrate an analogues trend. The column labeled ERGM~TTRIPLE demonstrates a slightly different trend. It seems to start modestly low (I could not get the model to run for 1995 data, so it starts in 1996) and then seems to level out at approximate zero, not becoming more negative or positive as the network grows. This potentially represents the relative lack of importance of transitive triplets in the micro structure of this network.

Overall, I would be skeptical to make any grand claims about the utility of this ERGM analysis. Although my MCMLE models seemed to converge, I was not able to run goodness of fit analyses to test how well these estimates fit the model and my actual networks. Additionally, ideally, I would run these analyses on a faster computer or gain access to a university-based super computer since this is such a large data set and I am doing so many analyses with this time series panel data.

5) Discussion

One clear puzzle emerges from this analysis: while betweenness universally increases for this network and closeness universally decreases, eigenvector centrality climbs for some papers and crashes for others. What’s more, Figure 8’s boxplot overview of eigenvector centrality scores by year shows that, on average, the papers are inconsequential to the overall structure of the network and a handful of papers emerge to the top as by far the most dominant. What are these papers and what might it signify both for this as a domain of scientific knowledge and for the politics of global health priority setting?

Through analyzing the titles, abstracts, and authors of the papers that are most important in terms of eigenvector centrality and degree, ten papers emerge as centrally important:

The European Organization for Research and Treatment of Cancer QLQ-C30: A Quality-of-Life Instrument for Use in International Clinical Trials in Oncology
The MOS 36-Item Short Form Health Survey (SF-36) 1. Conceptual Framework and Item Selection
Diagnostic and Statistical Manual of Mental Disorders Source Information (1994)
Diagnostic and Statistical Manual of Mental Disorders Source Information (2000)
Measurement of patient outcome in arthritis
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
Statistical Power Analysis for the Behavioral Sciences
Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study
A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

There are several things that are remarkable about this list of the (by far) most important papers in this citation network. First, aside from the first most important paper—which is about the clinical process of diagnosing and treating cancer—none of these pieces are about a specific disease or even class of diseases. Instead, they are all meta-analyses or statistical overviews of epidemiological trends in noncommunicable diseases and their relative burdens globally. Second, the disease upon which they are focusing tends to be biased towards wealthy-world health issues: the DSM for mental health issues (which has a highly western-centric focus) and arthritis (has not been considered a ranking global health priority). Finally, all them have to do with capturing global measurements, standardized practices and protocols, and dominant paradigms—built from programs and practices rooted in the U.S. and Europe—that are to serve as models for health care systems in the global south. Considering that this network, examined from 1995 through 2016 was about “global health” and noncommunicable diseases, it seems surprising that these would be the overwhelmingly dominant papers in this sparsely connected network.

6) Conclusion

I began this paper with a commentary on the ways that scientific citation networks can enable and constrain the biopolitics of global health by reinforcing the legitimated framing of diseases and their interventions in certain ways, and not others. This paper points to the possibility that the structural evolution of the NCD / global health academic paper citation network has contributed significantly to this biopolitical conundrum. Specifically, important puzzle in the field of global health is: why have non-communicable and chronic diseases been so dramatically marginalized within the global health priority mix? First, comparing the burden of noncommunicable diseases (NCDs) and infectious diseases to their relative magnitude of investment via development assistance for health (DAH) demonstrates a remarkable disparity. Despite accounting for more than 30% of the overall disease burden globally (especially in low and middle income countries), less than 1% of all DAH is allocated specifically to care, treatment, and prevention of noncommunicable disease (Daniels, Donilon, & Bollyky, 2014).

Second, there has been a concerted effort by the noncommunicable disease community of practitioners and scholars to raise the profile of NCDs on the global stage (Geneau et al., 2010). Much of this political and scientific labor has culminated in rare and highly important United Nations General Assembly High Level Meeting focused on the global burden of NCDs in 2011. This meeting was the first UNGA High Level Meeting on a health topic since HIV/AIDS in 2000. Yet, despite the attention from global leaders on the world stage, nearly no new resources have been committed and invested in global NCD care and management. Finally, central to this debate has been a question about the nature of the social construction of NCDs globally, especially with regards to the burden, causal sources, and necessary systems-level interventions to meet the burden. Leading up to the 2011 UNGA High Level Meeting on NCDs, the World Health Organization (WHO) has doubled down on a focused framework of limited shared “lifestyle modifiable” risk factors as the dominant causal source of the NCDs globally. Dubbed the “4×4 Framework”, the WHO has sought to limit the terms of debate and focus to what they deem to be the four most “important” NCDs and the corresponding individual level lifestyle modifiable risks: cancer, diabetes, cardio-vascular disease, and chronic respiratory disease; tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol (WHO, 2013). Scholars and practitioners, especially those providing care in poor, remote regions of the world have taken aim at this framing, saying that it excludes much of the important burden of illness, especially amongst the very poor and rural populations around the world (Binagwaho, Muhimpundu, & Bukhman, 2014; Bukhman, Mocumbi, & Horton, 2015; Kwan et al., 2016; Bukhman et al., 2015).

These three interlocked challenges—the sheer disparity between NCDs / infectious diseases’ resources and burden, the negligible growth in resource commitments despite NCDs’ expanded profile on the international stage, and the dynamic scientific and political contest of NCDs’ social construction and framing—create an interesting empirical puzzle that has important implications for the politics and governance of global health. What is blocking the political progress in expanding resources and academic focus on a progressive strategy for NCD care and control?

One hypothesis—that is supported by the findings of this paper—is that the dominant NCD framing (especially from the WHO and the global scientific community) historically has been rooted in a North American / European-centric view: a narrow set of illnesses and their associated individual-level, modifiable, statistically determined risk factors as the root causes (4×4 Framework). This framing has blocked the political momentum of NCDs because 1) it situates the locus of cause in bad decisions/behaviors of individuals and 2) it appears to be an unhappy byproduct of economic development and income growth. This framing renders the true experience of the poorest and most marginalized invisible to global policy makers and makes it difficult for activists to demand new modes of financing to support ministries of health to build progressive NCD treatment and prevention programs.

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Structuring structures constructed through historically structured structures: A.K.A. where Bourdieu’s ideas came from

“The past of social science is always one of the main obstacles to social science.”

– Pierre Bourdieu, Sociology in Question (1993)

Introduction:

In this semester’s classical social theory course Prof. John Stone remarked: “if nothing else, I hope that this course has given you a healthy skepticism of placing too much faith in social theory.” After closely reading classical theorists from Montesquieu to Veblen, I can see why: these thinkers and their grand ideas were products of their time and circumstance. In Postcolonial Thought and Social Theory, Prof. Julian Go makes a compelling argument for the problematic ontology and epistemology set out by classical theoreticians. They were often (in hindsight) obviously shaped by their cultural and historical moments and were therefor subject to their own biases and blind spots. More sociologically, we could say that these ideas were social productions of interested actors, most of whom were of privileged classes that increasingly deployed concepts to make sense of and manage threats to social order from below their ranks. In much of their research, early sociologists also tended to “reproduce the imperial gaze” by which empires operated, reproducing and reifying stereotypes and systems of power relations within and between social groups (Go, 2016, Chapter 2).

Sociology’s foundation was developed during the Enlightenment and rested on three central concepts: humanism, that there is a universal human nature that can be improved based on Reason; universalism, that the world is made up of basic unalterable truths that can be understood independent of space and time; and positivism, the reliance on scientific method as the best approach for understanding the world in general. This ontological way of knowing and epistemological lineage has come to shape how the discipline of sociology has evolved, leading Go and others to call for new social theory agenda that brings a subaltern (postcolonial) and relational perspective to understanding the social world.

Emerging from the elite intellectual community of France in the 1960’s, Pierre Bourdieu is one such relational sociologist. A giant of 20^th century sociology, Bourdieu built a theory of social action based on field research ranging from kinship relationships in isolated villages in Algeria to the social processes of production, circulation, and consumption of art and literature in 19^th century France. His work sought to bring “reflexive” sociological methods into building a whole understanding of social action: to “uncover the most profoundly buried structures of the various social worlds which constitute the social universe, as well as the ‘mechanisms’ which tend to ensure their reproduction and their transformation” (Bourdieu & Wacquant, 1992). Bourdieu’s work seeks to develop a way to understand the “buried” mechanisms that undergird social life and tend to create and reproduce dominance and domination in society.

Although Bourdieu’s perspective is by no means a “southern” theory—Bourdieu was born in southern France and ascended to the pinnacle of elite intelligentsia in the French academe—his work does, at first glance, appear to be a way to obliterate the antimonies and dichotomies that ontologically and epistemologically reproduce power relations through what he would call symbolic violence. In this way, he attempts to challenge and subsume some of the most pressing theoretical problems of classical social theory: the dilemma of structure vs. agency, the objective vs. subjective divide in epistemology, and the ontological problem of the individual or structural locus of agency.

In seeking to make this course not simply a philological exercise, my goal in this paper is to explore the classical theoretic roots of Bourdieu’s work. In doing so, I hope to assess whether he is successful in breaking with the “imperial episteme” and dissolving the age-old antimonies that bedevil social theory. Do Bourdieu’s “structuring structures” get up and out of the historically constructed and epistemologically limited structures of classical social theory?

Specifically, I seek answers to four broad sets of questions: 1) Who were the principal classical theorists referenced by Bourdieu (implicitly and explicitly)? 2) What ideas were most important in the formation of his theory of practice and social life? 3) How do these foundational concepts relate to Bourdieu’s ontology of the social and to his epistemological approach to social science? 4) Finally, given the problematic roots of classical social theory, does Bourdieu’s repackaging of classical ideas into a reflexive and relational sociology give us a “way out” of the colonial-epistemological bind?

I will start with a very brief background on Bourdieu’s biographical, educational, and historical context, then proceed to an explanation of his core theoretical concepts (field, capital, and habitus) and their applications, break down their most important conceptual linkages with classical social theorists, and then I will comment on their implications for Bourdieu’s epistemological project. I will conclude with an assessment of Bourdieu’s field-theoretic approach to relational sociology and its ability to emancipate social theory from the shackles of symbolic and historic violence.

Bourdieu’s Roots

Bourdieu’s biography matters only insofar as it helps to explain his internalized dispositions and socialized perspectives—his habitus, as he would put it. He began his journey being born in 1930 to a lower-middle class family in Deguin, a small town in the south of France. His father was the town postal worker and it was a fairly inauspicious start. This is important only in juxtaposition to the fact that he would rise to the pinnacle of French intellectual life.

More important than his early biography was his identification as a brilliant student who was able to gain entrance into École Normale Supérieure (ENS), one of the most prestigious universities in all of France. While there, he was able to study under the great structural Marxist, Louis Althusser, he had Jacques Darrida and Emmanuel Le Roy Ladurie as classmates, and was enveloped in classical and contemporary social theory and philosophy. He quick rose through the ranks of French intellectuals.

For these reasons, he would always feel like something of an outsider in the upper reaches of French society. This history and how it shaped his internal dispositions and priorities (habitus, which I will describe below) is important because it trained his focus on the ways that people (especially academics) shaped and defined the terms of debate, doing symbolic violence through dominating the ways knowledge was created. Loic Wacquant has an interesting perspective on this: “Back in 1981, he [Bourdieu] had seriously envisaged turning down the Chair in Sociology to which he was eventually elected at the Collège de France, the country’s top research institution, because he could not resolve to go through the official pageantry of the inaugural lecture. He assumed the position only after he had figured out how to turn the event onto itself and make it over into a performative paradigm for reflexive sociology by delivering a ‘Lecture on the Lecture’ in which he would dissect the social springs and underscore the symbolic arbitrariness of the very ‘rite of consecration’ he was enacting.” (Wacquant, 2013). Perhaps, because of his insider/outsider experience and the ways it shaped his own habitus, Bourdieu was hyper vigilant in identifying and exposing imbalances in symbolic power.

During this time, ENS served as a breeding ground for “young Durkheimians.” Indeed, he was able to carefully read, write on, and even began to lead lectures on Marx, Weber, and Durkheim while there. Additionally, he began to work closely with and was mentored by the illustrious sociologist, philosopher, and political scientist Raymond Aron as he launched his European Center for Historical Sociology. It was in this remarkable intellectual milieu that he began to form his ideas about the social world that would begin to take more formal shape while doing ethnography in Algeria (Swartz, 1997, 16).

Central to his philosophical development was his engagement with the tension animated primarily between two important French intellectuals: Jean Paul Sartre and Claude Levi-Strauss. These two academics embodied a confrontation of ideas—two extremes on an intellectual spectrum. Sartre was an engaged humanist and Levi-Strauss represented more of a detached scientist. As we will see, for Bourdieu, this tension proved fruitful and extended beyond just their styles of intellectual and scientific engagement, it also represented antithetical poles of basic opposition between subjectivism and objectivism in philosophy and social science. This would be a central focus for the future of Bourdieu’s scholarship (Brubaker, 1985).

Another important early philosophical influence was Gaston Bachelard who theorized on the philosophy of science in the midst of the scientific revolutions of the development of relativity theory and quantum mechanics. For Bachelard, “scientific knowledge is ‘constructed’ and ‘dialectical’ knowledge, one that does not arrive at final truths but proceeds as an ongoing project of correction and rectification of past errors” (Swartz, 1997, 31). He argues that in the face of radical scientific advances, the positivist philosophy of the past will not suffice and instead scientists must adopt a “dialectical reason”—an early example of “reflexive epistemology,” and a notion that Bourdieu would lean on heavily in trying to confront the productive tension between Sartre’s existential subjectivism and Levi-Strauss’s structuralism / objectivism.

Finally, as mentioned before, Marx, Weber, and Durkheim all played extremely important roles in shaping the contours of most of Bourdieu’s concepts and theoretical strategies. I will discuss their important contributions once I have sketched the key components of Bourdieu’s approach. As an aside (I will not be exploring these thinkers in this paper) theorists and philosphers such as Ausin, Cassirer, Heidegger, Husserl, Merleau-Ponty, and Wiggenstein also played somewhat important roles in shaping Bourdieu’s thinking (Swartz, 1997, 30).

Bourdieu’s Theoretical Apparatus:

We will start with a brief overview of Bourdieu’s key concepts that he developed over many years of teaching, fieldwork, systematic scholarship and engaging with some of the leading intellectuals of his age.

The concept of field brings a spatial / geographic element to Bourdieu’s theory of social practice. The field of social action is produced and reproduced by individuals and organizations that do not exist in a vacuum—they exist in relationship with one another. Individuals and organizations also compete with one another as they work in pursuit of shared aims, develop shared taken-for-granteds, grow shared interpretations, and fight over scarce resources. Loïc Wacquant offers a succinct definition: “a field is a patterned system of objective forces (much in the manner of a magnetic field), a relational configuration endowed with a specific gravity which it imposes on all objects and agents which enter it… Simultaneously, [it is] a space of conflict and competition, the analogy here being with a battlefield, in which participants vie to establish monopoly over the species of capital effective in it” (Bourdieu & Wacquant, 1992, 17). This social jostling and competition between actors in the field set up the terrain of a social game that is played out by social actors vying for dominance.

The habitus can be understood as an individual’s patterns of thoughts, behaviors, tastes, and actions acquired by their experienced participation in the social field of action. Bourdieu describes it as: “embodied history, internalized as a second nature and so forgotten as history—the active presence of the whole past of which it is the product.” (Bourdieu, 1990, 56). Wacquant expands, “Cumulative exposure to certain social conditions instills in individuals an ensemble of durable and transposable dispositions that internalize the necessities of the extant social environment, inscribing inside the organism the patterned inertia and constraints of external reality… habitus is creative, inventive, but within the limits of its structures”. (Bourdieu & Wacquant, 1992, 13-19) The field of practice tends to produce individuals who have experienced and internalized the rules of the game as their habitus. Those individuals tend to then act in a way that reproduces the socially constructed field of practice, which, in turn, reinforces the internalized habitus of those in the field.

Finally, Bourdieu conceptualizes capital as multifaceted forms of field-specific power: economic, social, and symbolic. Economic capital is immediately transformable into money, but social capital (social relationships, friendships, partnerships), symbolic capital (prestige, clout), cultural capital (credentials, awards), and other forms of field-specific capital aren’t immediately transformable into financial resources. Non-economic forms of capital can be used to dominate fields of practice that organize society. Bourdieu compares each field to a market in which individuals and collective actors compete for the accumulation of the various forms of capital. In a field of practice, an agent with more capital will be successful over those actors with less capital (Ibid., 15). Again, Wacquant summarizes: “together, habitus and field designate bundles of relations. A field consists of a set of objective, historical relations between positions anchored in certain forms of power (or capital), while habitus consists of a set of historical relations ‘deposited’ within individual bodies in the form of mental and corporeal schemata of perception, appreciation, and action.” (Ibid., 16)

Bourdieu’s Classical Theory Roots

Bourdieu’s linked theoretical and empirical project has been one of the widest-ranging, diverse, and inventive since World War II. Publishing more than 25 books and 260 articles over a 40-year period, he did away with disciplinary boundaries and sought to tackle and reformulate some of the most challenging questions of the social sciences. Bourdieu stands out in his ability to draw from sociology, anthropology, history, linguistics, philosophy, political science, aesthetics, and literary studies and in his efforts to combine methodological approaches such as detailed ethnographic fieldwork, constructing statistical models, and abstract theoretical formulation. His work has been driven by a singular commitment to the idea that there could be a unified political economy of practice and that symbolic power could be understood in a way that could dissolve central social science puzzles: the challenge of analyzing micro and macro-level processes together, the difficulty of co-explaining social structure and the feeling of individual agency, and objective / subjective ways of interpreting meaning in the world (Bourdieu & Wacquant, 1992, 2-6). His goal is to build a truly “philosophical anthropology” in which social reality and ideas about human living would not just be built off of speculation and reflection on the universal attributes of humanity, but would be linked to a rigorous process of inquiry with the epistemic authority of scientific method (Peters, 2012).

Based on my readings of Bourdieu and a host of other books and articles dissecting his ideas and influences, I constructed the diagram below as a schematic of the ontological and epistemological roots of his core ideas. I have tried to demonstrate how various classical theorists’ ideas have served as building blocks and have been recombined to form Bourdieu’s central structuring structures. These theoretical constructs have given him the platform to systematically explore a wide variety of social phenomena empirically. My question then will be to assess whether he has truly constructed a theoretical base that can free social theory from the historical legacy of colonialism and symbolic domination.

Figure 1. Diagram of Bourdieu’s Influences and Theory

Synthetic Ontology

Bourdieu’s way of thinking about the nature of existence of the social world, his ontological vision, can best be described as synthetic, relational, and non-Cartesian. It “refuses to split subject and object, intention and cause, materiality and symbolic representation.” (Bourdieu & Wacquant, 1992, 5). Wacquant goes on:

“A total science of society must jettison both the mechanical structuralism which puts agents “on vacation” and the teleological individualism which recognizes people only in the truncated form of an “oversocialized ‘cultural dope’” or is in the guise of more or less sophisticated reincarnations of homo economicus. Objectivism and subjectivism, mechanicalism and finalism, structural necessity and individual agency are false antimonies. Each term of these paired opposites reinforces the other; all collude in obfuscating the anthropological truth in human practice.” (Bourdieu & Wacquant, 1992, 10).

One can see Bourdieu’s distain for artificial antimony throughout his work and his almost obsessive attempts to destroy these false divisions. Biographically and intellectually, it is possible to trace the roots of this obsession to his engagement with the intellectual battles between Jean-Paul Sartre and Claude Levi-Strauss and their followers who dominated much of the intellectual landscape in France in the wake of World War II. The tensions at the heart of this intellectual battle were philosophical/ontological, aesthetic/stylistic, and political.

Stylistically, Sartre represented the classic French “total intellectual”; he lived in such a way that he had complete alignment between his intellectual, scholarly, political, and practical engagements. As a public intellectual, he felt that he must “miss nothing of our time” (Swartz, 1997, 36). Conceptually, Sartre’s existentialism and subjectivism represented one distinct way of understanding social life: the carefree individual, creative and self-determining. Conversely, Levi-Strauss’ aesthetic was one of the professional academic, rather than the public-facing, politically active, celebrity-intellectual. His brand of causally-powerful social structures and formal view of the ways that social structures shape human thought could not be more in tension with Sartre’s (Swartz, 1997, 39-40).

This real-life, socially constructed rivalry and its effects in reifying an important antimony in the philosophy of human existence was an important shaping force for Bourdieu’s early thinking and his forming professional style and methodological commitments as well. It developed within him the motivation to try to build an understanding of the social world that was not simply about immutable social structures and sets of rules that govern the actions of social groups and could be measured in a statistically positivistic way. Nor was social life to be understood as the existentialists would have it: as a collection of individual agents freely floating through life with complete autonomy of spirit and freedom of will. As we will see, this tension filled relationship, and these polarized conceptual apparatuses, form a creative space which could very well be the roots of one of his most important conceptual tools: the habitus, as described previously.

In addition to Bourdieu’s formative encounter with the intellectual and stylistic dualisms of Sartre and Levi-Strauss, Bourdieu was also a close scholar of Marx, Weber, and Durkheim, and their formative ideas became very important, in different ways, to Bourdieu’s formulation of theory and method in understanding the social world. Sometimes scholars have viewed Bourdieu’s ideas as having been influenced by Weber, Durkheim, and Marx in equal proportion: a focus on the symbolic dimension from the first, a sociology of domination from the second, and an interest in class struggle from the third (Riley, 2015). However in my reading, Durkheim’s approach and work weighs most heavily in Bourdieu’s formulations of theory.

In particular, Durkheim’s understanding and description of the symbolic dimensions of social life and its power to effect social action was highly influential for Bourdieu. Although Bourdieu would distance himself from Durkheim’s highly positivistic method, statistically measuring patterns of variation in the social world (Durkheim, 1951), he would come to adopt and utilize the idea of “social facts as things.” Particularly key is Durkheim’s somewhat “neo-Kantian” epistemological approach, which we will come to soon (Robbins, 2003). Additionally, Durkheim’s view of understanding of the ways symbolic manipulation plays into social life is central in Bourdieu’s conceptions of less material forms of capital and the ways these forms of power can render symbolic domination within fields of struggle (Swartz, 1997, 46-48; Durkheim & Fields, 1995). He also came to identify with Durkheim’s style (as he tended to resonate stylistically with Levi-Strauss) and came to view sociology as a professional scientific discipline.

Max Weber’s thinking also loomed large in Bourdieu’s foundational ontology. Specifically, Weber’s tools to describe symbolic resources and practices were central to Bourdieu’s understanding of symbolic capital and domination (Swartz, 1997, 41). At the heart of understanding Bourdieu’s notion of field as a contested social space of material and symbolic domination is Weber’s “value spheres” (Bruun, 2008). For Weber, values spheres were linked to the philosophical triad of truth, morals, and culture: things we know, what we ought to do, and what we want to do. They were spaces or domains of social life governed by “inherent laws” pertaining to these fields or systems. These value spheres can be linked to Bourdieu’s fields as empirically identifiable spaces of social relations, historical periods, or geographical periods—not some settled systemic criterion (Ibid.). Although perhaps oversimplified, scholars have suggested that Bourdieu’s fields resemble quasi-Marxist Weberian value spheres. By “subjectivizing” Marxist thought with Durkheimian concerns with the forms and functions of symbols, and Weber’s work on symbols and their concrete power as well as a more formal structuralism, Bourdieu has attempted to unify some of the most frustrating divisions in social theoretical thought and advance a more fully-fledged ontological view on social life (Brubaker, 1985).

Reflexive Epistemology

Where things become particularly interesting in is how these base-level ontological influences become recombined into Bourdieu’s conception of how we can come to know things about the social world. One aspect that makes Bourdieu so unique in my view is his seemingly complete and parsimonious view of the philosophical nature of social life and his practical methodological process of generating knowledge about its formation and function. At the same time, Bourdieu was pragmatic and his views evolved and morphed over the course of his studies. Throughout his career, Bourdieu was prepared to use whatever sociological explanations were to hand and which seemed to fit plausibly the historical, ethnographic records with which he was working (Robbins, 2003). By seeking to obliterate the distinctions dividing the existentialists from the structuralists and bringing together a synthesis of key concepts uniting the classical theorists, Bourdieu needed not just new ideas, terminology, and ways of thinking about social life. He needed a new of way of doing social science work. This is accomplished through linking his synthetic ontology with a highly reflexive epistemology of science and knowledge.

The keys to Bourdieu’s epistemology of the social are also at the roots of Durkheim’s thinking. Although as previously discussed, Bourdieu rejected Durkheim’s highly positivist philosophical leanings and methods, he embraced his “neo-Kantian” approach which brought in a phenomenological way to understanding the mind and subjective experience of people in social life (Ibid.). For Bourdieu, all social analysis involves the analysis of a system of relations within which individuals operate and through which their individualities are defined. At the same time, those producing social analysis are themselves embedded within a system of relations, which have a shaping effect on the researchers own perspectives, dispositions, resources, and opportunities. The fundamentally relational nature of social life and the correspondingly relational nature of the productive work of social analysis, demands a completely relational nature of knowing. Producing knowledge requires turning back on oneself, reversing the “scholarly gaze” to explore the system of relations and dispositions that shape the researcher and their approach to research. From Robbins:

“We know from Bourdieu’s later articulation of a reflexive methodology, involving conscious ‘epistemological breaks’, that he was as dissatisfied with an ethnomethodological approach that might suppose that phenomena could absolutely speak for themselves as he was with the detachment of structuralist objectivity. As a method of enquiry, Bourdieu’s ‘post-structuralism’ sought to integrate both aspirations, but it was also always the case that he saw his texts as products generated within a system of communication where meaning is constructed reciprocally in the way in which he had outlined in ‘Champ intellectuel et projet créateur’” (Robbins, 2007)

One important intellectual resource for Bourdieu in this formidable task was the work of Gaston Bachelard, French philosopher of knowledge and science during the early 20^th century, who was referenced earlier. Bachelard’s non-positivist epistemological approach was starkly different from French sociologists at the time and it enabled Bourdieu to begin to imagine what a non-positivist, reflexive sociological epistemology could look like. For Bachelard, “scientific knowledge is ‘constructed’ and ‘dialectical’ knowledge, one that does not arrive at final truths but proceeds as an ongoing project of correction and rectification of past errors” (Swartz, 1997, 31). Sociolanalysis requires reflexivity, because knowledge must be communicated and legitimated in language and we are embedded in concrete social relations that produces that language.

Similar to Bachelard, Karl Mannheim presented Bourdieu with more theoretical resources for a non-positivist epistemology of science. For Mannheim, the sociology of knowledge (or Wissenssoziologie) attempts to analyze the relations between symbolic forms of knowledge and objective social structures. The idea of socially bounded knowledge implies a set of necessary assumptions: meaning/knowledge is organized according to certain structures, these structures take on “symbolic forms,” and that these symbolic forms are more often than not delineated by socio-economic or class membership (Kögler, 1997). Mannheim states: “Different social strata, then, do not ‘produce different systems of ideas’ {Weltanschauungen) in a crude, materialist sense—they ‘ produce ‘ them, rather, in a sense that social groups emerging within the social process are always in a position to project new directions of that ‘intentionality’, that vital tension, which accompanies all life” (Mannheim, 1921/1922).

Another resource for Bourdieu in developing notions of reflexive epistemology in the social sciences was the work of another anti-positivist, neo-Kantian: Georg Simmel. Simmel worked to develop a formal sociology defined by relations. For Simmel, all of social reality came from the form of social interactions, the content of these interactions, and the reciprocal influence that these interactions would have on individuals over time. For Simmel, one could not understand social phenomena without first beginning with small-scale interactions and the micro-level structural shape/form that they took (Simmel, 1895). Taken together, Bachelard, Mannheim, and Simmel describe neo-Kantian notions of the phenomenological alongside non-positivist, reflexive approaches to the sociological study of science. These thinkers paved the way and enabled Bourdieu to formulate a truly innovative way of generating situated knowledge about the social world that was thoroughly scientific while also relational with respect to the subjects and the researcher alike.

Unified Praxeology: Reflexivity of the Researcher + Relational Methodology

Bourdieu’s synthetic ontology—which collapsed old antimonies—set up the possibility of a truly reflexive epistemology: a way in which knowledge could be generated without resorting to positivistic, macro-level studies using statistical controls or falling back to philosophical hand-waving about the state of nature. Rigid theoreticism and methodologicism can now be done away with and a total science of the social can now be advanced. Agnostic to any one particular method, Bourdieu was freed to pursue modes of inquiry, data collection methods, and tools of analysis that fit the question at hand—both practically and philosophically.

This meant that a well-trained scientific habitus would need to be developed: social scientists need to think relationally, particularly while constructing their object of study (Bourdieu & Wacquant, 1992, 224-235). As would be assumed from a reflexive epistemology, there can be no separation between empirical “technical” choices and “theoretical” choices in the construction of the object of study. There must be unity between the hypotheses given by the existing literature, the theoretical presuppositions given by the existing evidence, and the theoretical-methodological choices made in trying to gather and interpret data / evidence about the given social phenomenon. What’s more, the positionality and relationship of the researcher to constructed object of interest must also be carefully taken in to account. Bourdieu explains:

“To construct a scientific object also demands that you take up an active and systematic posture vis-a-bis ‘facts.’ To break with empiricist passivity, which does little more than ratify the preconstructions of commons sense, without relapsing into the vacuous discourse of grand ‘theorizing,’ require not that you put forth grand and empty theoretical constructs but that you tackle a very concrete empirical case with the purpose of building a model (which need not take a mathematical or abstract form in order to be rigorous.)… Ordinary sociology, which bypasses the radical questioning of its own operations and of its own instruments of thinking, and which would no doubt consider such a reflexive intention the relic of a philosophic mentality, and thus a survival from a prescientific age, is thoroughly suffused with the object it claims to know, and which it cannot really know, because it does not know itself.” (Bourdieu & Wacquant, 1992, 236).

These epistemological breaks more often than not correspond to social breaks: with decorum, methodological purity, political norms, and group definitions. This is how Bourdieu has chosen to advance such a radically politically subversive social science agenda. Rather than serving as the total “public intellectual” a la Sartre or the completely politically dispassionate, positivistic social scientist such as Levi-Strauss, Bourdieu demonstrates the depth of symbolic power that the scholar can wield. By documenting the concrete relationships between actors in a field of practice, displaying the types and relative inequalities in ownership of different species of capital by those actors, and watching, over time, as those actors demonstrate dominance or submission in relationship to one another, a praxeological socio-analyst can uncover social realities previously obscured. Perhaps more importantly, by exposing these previously hidden social realities of dominance and submission, new modes of political action and activism are made thinkable and therefor possible.

Conclusion: Bourdieu as a way up and out?

I will conclude with an assessment of if and how Bourdieu’s work creates the opportunity for a truly liberating social theoretical approach. Does Bourdieu’s repackaging of classical ideas into a reflexive and relational sociology give us a “way out” of the colonial-epistemological bind?

As I discussed in the introduction, social theory is rooted in an ontology and has developed an epistemological approach that made imperialism understandable and justified. Auguste Comte first used the term “sociology” in 1839 to characterize “the social” distinct from political, economic, and religious realms. In practice though, it was a way of creating a new technical domain of elite social scientific researcher. Privileged classes have been able to use the technical understanding produced through sociology to manage threats to social order from below their ranks. As Julian Go describes, classical social theory could be looked at in juxtaposition to postcolonial thought, which is fundamentally anti-imperial and grew out of English and literature departments at the beginning of the 1980s. Writers such as Edward Said, Gayatri Spivak, and Homi Bhabha; historians including Ranajit Guha or Dipesh Chakrabarty; and anti-colonial theorists Frantz Fanon, Aimé Césaire, Amilcar Cabral, W. E. B. Du Bois, and C. L. R. James were central to these efforts. These writers, and others, sought to articulate a worldview and cultural analysis that rejected the humanist/positivist way of knowing the world. (Go, 2016).

Taking a Bourdieusian approach, we might ask: in what systems of relations were classical social theorists embedded? What types of risks and rewards—material and symbolic—were at stake in their lives and their work? Similarly, we might ask the same questions of the subaltern, southern-positioned, and post-colonial thinkers. What concrete sets of embedded relationships, forms of symbolic and material capital, and lived dispositions form the matrix of their decision-making and practice? Though I have not done this analysis, I can imagine the value. And, for me, this is why I would answer the fourth question I laid out in the introduction affirmatively. Using a relational, reflexive, Bourdieusian approach, we can actually approach these questions in systematic and rigorous way. Through constructing these questions as empirical objects of praxeological socioanalysis, we could imagine generating new knowledge about the situated nature of the production of knowledge, and to the power processes embedded within and reified by the network of actors responsible.

Bourdieu’s epistemological approach, alongside a pragmatic praxeological sociolanalysis, does in fact give us the theoretical leverage to overcome the colonial roots and symbolically violent forces of historically constructed classical social theory. Bourdieu’s work does not, however, give us answers. It does give us an alternative social scientific language necessary to ask different types of empirical questions. These empirical questions, when paired with a relational methodology and reflexive epistemology have the potential to split apart the deep structure of power and privilege to enable serious analysis. Whether or not this is a truly liberating approach will have to do with the courage and skill of the sociologists who attempt to deploy it. While it may be true that “the past of social science is always one of the main obstacles to social science,” Bourdieu’s work can help us to imagine a future social science that is at once more synthetic, unified, and critical.

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The evolution of a citation network

Building off my initial work to understand the academic citation network for noncommunicable diseases and global health, I started to wonder: how has this academic knowledge network changed structurally over time? Were the papers that were published earliest in the network the ones that remained dominant in terms of citations? What disciplines / areas of scholarship do the dominant papers tend to come from?

So, I decided to run the same analysis I did for the last post for for the cumulative citation network for each year from 1994 through 2016.

A couple of interesting observations:

As was clear in my previous post, there seems to be an important inflection point around 1997. The plot of number of average citations over time and the number of articles published each year shows that the number of articles published each year and the average number of citations per article lines cross each other around then. Also in the network plots, we see that the network, for the first time, expands beyond the initial core of about 5 or 6 papers to a new domain of papers previously outside of the network. A question: what are those papers? What causes the change in the average number of citations and causes the rapid increase in the number of papers published annually?
It appears (though I still need to test this statistically) that the core group of papers that originally made up the center of the network, remain centrally located and develop a primarily core-periphery structure to this citation network. Is this true? Are the papers that are most important early in the network still important later on in the late 2010’s?
I wonder what the “framing” of these papers are? Do they tend towards the dominant 4×4 framing that the WHO has stuck by, despite the fact that it probably misses much of the NCD experience of most of the very poor people around the world?

There is much more to be done, but it’s cool to see these methods yielding an interesting story, and perhaps explanation to why we see NCDs of the poorest continually marginalized in the global health policy debates.

Why we are unionizing at Boston University

bu-grad-students-union Here’s some exciting, positive news: colleagues at BU and I are launching a campaign to unionize graduate student workers at Boston University with the Service Employees International Union (SEIU)!

This August, the National Labor Relations Board authorized “student workers” (basically everyone from graduate students to teaching and research assistants) the right to collective bargaining and unionization. Although the implications of unionization efforts by graduate students is yet unknown, many graduate students are taking up the cause at universities across the country. So far, I believe, only NYU has actually “won” their union and have negotiated a contract with their university administration. But, there are at least 23 other universities that are also launching campaigns to unionize their graduate student workers as well including Brandeis University, Brown University, Columbia University, Pennsylvania State University, Tufts University, University of Chicago, University of Virginia, and Yale University.

Here is our open letter about forming the union at BU:

grad-student-letter

I see this as an incredibly important opportunity for a few reasons. First, as I’m beginning to learn firsthand, academic labor is precarious. There is next to zero job security (unless you are able to land a coveted tenure-track job) and the compensation for graduate student employees (who provide the vast majority of teaching labor at a university like BU where tuition can top $50,000 per year) comes to be less than minimum wage (about $22,000 per year). Because we as graduate student teachers and research assistants do provide the academic labor backbone for most universities, we should be able to engage in collective negotiations with our administration. We must be able to work together to demand fairer compensation, health insurance, and other forms of support to make this vocation and commitment to academic life more manageable, especially for those who do not have pre-existing financial means. Collective action is necessary to advance fairness and justice for academic laborers across the U.S.

Second, collective action and unions will be desperately needed to combat the oncoming tidal wave of Trumpism. Action such as the fight for $15 amongst fast food workers and other efforts to advance worker rights are going to be under attack from what is certain to be a kleptocratic regime that will attempt to crush workers rights. Graduate student unions have the potential to be a useful source of ally power. We will have unique sets of resources, relationships, access, etc to bring to bear in working with people struggling for basic social and economic rights.

Finally, as academics, many of us will work in public policy, government, think tanks, non profits, etc. Having a generation of academics, thinkers, policy makers, and NGO leaders with deep experience in collective action, organizing, and unions potentially could bode well for the labor movement in the future. If more people have a personal experience with unions, see the value of this type of collective action, we could imagine a comeback for unions. But, this is also the big danger: it’s reasonable to think that Trump will be hell bent to crushing collective labor. He’s had a long history of harming his own employees workers’ rights. In fact, unions are already bracing for policy shifts.

So, now is the time to act. We’ve got to move quickly at BU and I hope that other schools can make big gains in organizing and unionizing in the coming months. The future of collective bargaining, and social justice for workers across industries and fields, may be at stake.

A Critical Engagement

A dialogue on advancing justice in health