I had read Celia Iriart’s work on biomedicalization previously and was so impressed I emailed congratulations to her. Hence I am not surprised but still thrilled to see the stunningly sophisticated use of biomedicalization as a set of analytic tools in this paper written with Emerson Merhy. When we wrote about biomedicalization¹1. Clarke AE, Shim J, Fosket J, Fishman J, Mamo L. Technoscience and the new biomedicalization: western roots, global rhizomes. Sci Soc Sante. 2000; 18(2):11-42.

2. Clarke AE, Fishman J, Fosket J, Mamo L, Shim J. Biomedicalization: technoscientific transformations of health, illness, and U.S. biomedicine. Am Sociol Rev. 2003; 68(2):161-94.

3. Clarke AE, Shim J, Mamo L, Fosket J, Fishman J, editors. Biomedicalization: technoscience and transformations of health and illness in the U.S. Durham: Duke University Press; 2010.^-44. Clarke AE, Shim J. Medicalization and biomedicalization revisited. In: Pescosolido B, Martin JK, McLeod JD, Rogers A, editors. Handbook of the sociology of health, illness, & healing: blueprint for the 21st century. New York: Springer; 2011. p. 173-200., we intended not only to describe a series of changes from the rise of medicine to medicalization to biomedicalization⁵5. Clarke AE. From the rise of medicine to biomedicalization: U.S. healthscapes and Iconography c1890-Present. In: Clarke AE, Fosket J, Mamo L, Shim J, Fishman J, editors. Biomedicalization: technoscience and transformations of health and illness in the US. Durham: Duke University Press; 2010. p.104-46., but also to provide a set of analytic tools with which to assess whether, when, and how such changes have happened under different “conditions of possibility” in different nations and regions⁶6. Clarke AE. Epilogue: biomedicalization in its transnational travels. In: Clarke AE, Fosket J, Mamo L, Shim J, Fishman J, editors. Biomedicalization: technoscience and transformations of health and illness in the US. Durham, NC: Duke University Press; 2010. p. 380-406.. Our own case studies and the book “Biomedicalization” all focused on the U.S. with its distinctive “non-system” or chaotic and rapidly changing situation of health care provision. We knew some trends in biomedicalization would appear elsewhere, but knew too that such manifestations would be distinctive to their locales, histories and regimes of governmentality. This paper provides an excellent overview of health care developments in Latin America.

Iriart and Merhy put the concepts of biomedicalization to work in various valuable ways. To me most important is their deepening of a sectoral approach “within” capital and their analyses of struggles and negotiations among participating entities. They extend the primary actors to include not only various providers and patients/consumers and their subjectivities (under considerable and at times coercive pressure), but also pharma and most important, they carefully distinguish the financial sector. In the U.S. this might be called or at least include venture capital, the financial sector seeking new products and markets in which to invest in order to extract.

The authors also take up the significant targeting of “providers” as well as the transformation of “patients into consumers”, both important. The overall degradation of the professional autonomy of medicine has occurred fairly rapidly in the U.S. But it is primary care physicians and internists (and nurse practitioners and related upper level non-physician providers) who are particularly targeted vis-à-vis promotion of particular drugs and treatments and diagnostic changes precisely because they have the most contacts with patients/consumers. In the U.S. this has resulted in dramatically fewer physicians pursuing such medical practices. In short, the cheapest doctors are squeezed hardest, while more expensive specialists using more expensive biomedical technologies generate more profit for the venture capital sector.

The shift from patient to consumer and the increased responsibilitization of the consumer within the health care realm has been intense. Supermarkets were early progenitors, requiring the shopper rather than a store clerk to assemble the goods desired. But the shift from patient to consumer has been complexified (at least in the U.S.) by a simultaneous and often seductive enhancement of patient access to medical knowledge and involvement in medical decision-making. But buyer beware! Of course, these are double edged swords, and we increasingly feel the burdens of more direct involvement. And some are now clerical! I recently made an appointment with a new provider and was sent the patient forms electronically so that I would do that “paperwork” for the practice rather than the physician having to pay a medical clerk!

Excellent analytic tools offered by Iriart and Merhy include their “soft, soft/hard and hard technologies” in health care. Their inclusion of “soft technologies,” those produced in the relational spaces between users and providers, is especially valuable. I am reminded of a now classic sociology article by Granovetter⁷7. Granovetter M. The strength of weak ties. Am J Sociol. 1973; 78(6):1360-80. “On the Strength of Weak Ties,” which points to the intense valence of relationalities in all kinds of decision-making. Simply stated, any tie is usually better than no ties. As Iriart and Mehry ably point out, these are sites of our greatest vulnerability to manipulation and coercion. The increasing reach and sophistication of the mediatization of society only deepens such vulnerabilities (e.g., Couldry & Hepp⁸8. Couldry N, Hepp A. The mediated construction of reality. London: Polity Press; 2017.).

One of my few disappointments with this wonderful paper was that while it promised discussion of lines of flight toward alternatives that open up what care can be and do, such discussion was very limited. I hope the authors will write an article on this soon, and there are a few works I want to mention which might be useful vis-à-vis these topics. The first is a recent feminist theoretical intervention. In conceptualizing “the economization of life,” Murphy⁹9. Murphy M. Economization of life: calculative infrastructures of population and economy. In: Rawes P, editor. Relational architectural ecologies: architecture, nature and subjectivity. London: Routledge; 2013. p. 139-56.^,1010. Murphy M. The economization of life. Durham N.C.: Duke University Press; 2017. noted that she:

Murphy’s “economization of life” offers another superb toolbox with which to examine health care.

Further, social marketing and other media are used to manipulate affect and engender desired actions in health care and two exceptional recent books take this up. Like Iriart and Merhy, Briggs and Hallin’s¹¹11. Briggs C, Hallin D. Making health public: how news coverage is remaking media, medicine, and contemporary life. London: Routlege; 2016. “Making Health Public: How News Coverage is Remaking Media, Medicine, and Contemporary Life” uses the biomedicalization toolbox, but they studied “biomediatization”, its patterns and consequences. Research in this vein on Latin Americas sites would be most provocative. Couldry and van Dijck’s¹²12. Couldry N, van Dijck J. Researching social media as if the social mattered. Soc Media + Soc. 2015; 1(2):1-7. “Researching Social Media as if the Social Mattered” furthers our capacities to unpack social media not only as individualistic but as social and discursive, relentlessly constructing new social realities (see also Couldry & Hepp⁸8. Couldry N, Hepp A. The mediated construction of reality. London: Polity Press; 2017.).

I was also delighted that Iriart and Merhy found the method of situational analysis¹³13. Clarke AE, Friese C, Washburn R. Situational analysis: grounded theory after the interpretive turn. 2nd ed. Thousand Oaks CA: Sage; 2018.^,1414. Clarke AE, Friese C, Washburn R, editors. Situational analysis in practice: mapping with grounded theory. London: Routledge; 2015. distinctively useful as well. It is a relentlessly empirical approach to qualitative inquiry which makes it particularly flexible hence able to travel well.

In sum, this is a powerful and important synthetic article breaking new ground in the study of intra-capitalist negotiations in the formations of health care in Latin America. Iriart and Merhy’s work should also travel well and widely, and provoke excellent further work. The time has come for more ambitious “comparative” national and regional research on neoliberalism and its manifestations in health care. The toolbox provided by Iriart and Merhy will be invaluable in such endeavors.

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