Videos of the talks
Summary by Clare Chandler
March 2014 saw the London School of Hygiene & Tropical Medicine hold its first symposium on social science, entitled Social Science Shaping Heath, to coincide with a report which showcases some of the varied work under a broad social science umbrella from across the School. The event was well attended by staff and students from LSHTM and a few visitors, and hopefully marks the start (or renewal) of cross-faculty thinking about what social science at LSHTM is, might become, and how it can be strengthened.
We were lucky to start and end our afternoon with inspirational talks from two outstanding social scientists with substantial experience working in health – Charlie Davison and David Armstrong. For many of us this was our first chance to hear, and meet, these ‘greats’ from within our field and I hope we’ll host more such luminaries in the near future. It was also the first chance for many of us to hear what colleagues from other social science disciplines have been working on within the School. We heard from representatives of five disciplines (sociology, geography, history, anthropology and political science) and then had a series of seven speed talks to provide a flavour of specific projects worked on across the School.
Charlie Davison gave the first talk, focused on how we currently think about behavioural change health promotion, and how we might change this. With reference to Pierre Bourdieu’s theories of habitus, field and capital alongside the salient case of Uncle Norman (and ‘the last person’), Charlie illustrated how existing and novel health behaviour change strategies appeal to different forms of capital – intellectual, social, emotional, symbolic. He drew our attention to the limitations of basing behaviour change strategies directly on epidemiological evidence of risk, which often assume that people will respond to alerts that their current ‘normal’ (such as a waist size of 32 inches) is actually dangerous. Uncle Norman, an ‘outlier’ by epidemiological standards due to his long life filled with drinking, smoking and lack of exercise, is evoked frequently in ‘lay epidemiology’ and such personal experiences and interpretations are more powerful than ‘danger’ warnings about everyday normal activities or body shape. He suggested alternatives that have been used in public health campaigns – appealing to emotional capital (such as the ‘kissing a smoker is like snogging an ashtray’ campaign) and appealing within the existing habitus and field of the ‘target group’ (such as the Australian ‘drinking, do it properly’ campaign). But, he warned that these strategies also run the risk of ‘going native’ – missing the health point, or becoming complicit in the behaviour itself.
Judith Green gave the next talk on Sociology at LSHTM. She reviewed the history of sociology at LSHTM, which she argued reflected the wider challenges within the discipline of constantly balancing structure and agency. She credited Margot Jefferys, the first LSHTM sociologist (in the 1950s), for the current integration of sociology at medical schools. However we were also alerted to the lack of change in some areas of health in which sociology has been working since Professor Jeffrey’s time, such as the consumption of medicines. Professor Green called for us to pay attention to the mundane and taken for granted categories in our research, with illustrations from LSHTM work of the use of electric toothbrushes and the symbolism of street ‘lights going out’.
Steven Cummins gave us insights into the role of geography in studying public health, and the need to attend to both the natural and social world, with possibilities for this by looking at how people move and use spaces. He argued that geography matters because of the uneven distribution of health, ill health and deaths in space and over time. He illustrated his arguments with some maps but argued that geography is about more than just maps. Geography as a discipline can move us beyond looking at people or place to the interactions between the two. He exemplified this with ongoing work at LSHTM around the regeneration of eastern London for the Olympics.
Alex Mold represented history, and argued that while ‘we wouldn’t be here without history’, people often attempt to draw lessons from the past too simplistically and in line with particular agendas. For example, ‘prohibition failed’ is a contestable statement but is often pointed to as fact in current debates about cannabis, and alcohol regulation. She argued that history can rarely be used to provide a definitive example of what should be done now. But, she suggested that by attending to context, continuity and change we may be able to build up a more nuanced understanding of the past. The audience was introduced to some of Alex’s recent work at LSHTM on the history of patients as consumers and the way this can be used to contextualise current discourses on patient rights, for example in the NHS constitution. In sum, Alex argued that ‘history is as much about the present as the past.’
Simon Cohn, recently appointed as Reader in Medical Anthropology at LSHTM, shared some of his insights into what anthropology does that is different to other disciplines surrounding health, particularly biomedicine and biology. He drew out a useful metaphor of objective science as attempting to achieve vision – by maintaining distance between observer and observed, detaching from ‘observations’ of reality through methods such as systematic reviews – and compared this with a metaphor for anthropology of touching. He drew our attention to the desire for anthropology to be situated, proximal, in touch with those we aim to understand. In touching another, he argued, we are both touching and being touched, and therefore unable to distinguish subject and object; indeed this becomes irrelevant. Therefore the questions and claims of anthropology are inevitably distinct from others within public health, where detached vision is valued. How can anthropologists work in public health? He encouraged us to move on from the debate of anthropology being either in or of biomedicine to conceiving interdiscipliniarity as points of contact that might stimulate new ideas and ways of thinking through intellectual interference by proximity and interaction.
Justin Parkhurst represented political science at the School. He pointed out that the terminology and function of this work varies and therefore is not easily unified as a discipline. But drawing these studies together is an awareness and investigation around policy making that is not just about evidence but is about politics. He drew our attention to the ubiquitous relevance of values in any policy or politics endeavour. An example was the comparison between horse riding and taking ecstasy as equally dangerous but the values of politicians and others entering the debate about drug regulations, exhibited as pro-horses and anti-drugs, revealing that evidence is only one component of a decision. He also drew a distinction between ‘makers’ and ‘takers’ of policy, exemplified by his own work on the politics of evidence around the ABC campaign for HIV in Uganda. His bottom line: policy making is not just about getting evidence together – there is more to it, and values play a big role.
Discussion. The panellists from the first part of the event assembled for audience questions, which revolved around the relationship between social science and epidemiology, and social science’s role in shaping health, as well as a reflection on what it means that almost all speakers made reference to the USA. Panellists were also asked to consider how we get issues onto the agenda that are not easily solved, such as stress and social relationships, which also damage health. Ideas emerging from the panellists were that we should be providing a seed of thought that is used across disciplines, that this can be seen in the way social science has kept the overall public health agenda from excesses of the health imperative, that although we have known health is social for a long time, we have achieved little to tackle this, and a suggestion that social science and existing disciplines in public health are insufficient, for example we are missing engineering as an approach to public health.
The first three speed-talks in the afternoon focused on the currently popular notion of citizenship in health. Alicia Renedo, a social psychologist, showed how her work with others at LSHTM has highlighted that patients being invited to participate in health programming is insufficient to develop participatory citizenship as these are already scripted. However, their study found that patients reconfigured these invited spaces to enlarge the scope of their involvement by making connections and webs of participation across different activities and creating new opportunities to change their health care.
Tim Rhodes, Professor of Public Health Sociology, presented work that investigated why people with hepatitis C in the UK often don’t access treatment. He questioned whether the notion of therapeutic citizenship developed elsewhere in reference to mobilisation around access to HIV treatment, was relevant in this setting. His study found that there was a culture of rationed expectation, of gratitude rather than entitlement. The performance required to become patient citizens required stabilising drug use and wanting to recover, and in this sense citizenship was both exclusionary as well as inclusionary. Janet Seeley, recently appointed Professor in Medical Anthropology at LSHTM, presented her work on the longitudinal perspective of notions of people living with HIV being therapeutic citizens. She highlighted that citizenship involves not only a right to treatment but a responsibility to adhere to the precious commodity. While for some, the discovery of a ‘positive’ status is managed through transforming into therapeutic citizens, for many in the long term people this is unsustainable. Janet raised the issue of implications for the ‘treatment as prevention’ idea, which is dependent on the responsibility of the patient to keep up treatment, to maintain motivation and momentum for life.
The final four speakers turned the gaze back on our own public health practices and research practices. Melissa Parker, recently appointed as Reader in Medical Anthropology at LSHTM shared her experience of working within a field with massive momentum towards a particular health activity and the struggles to articulate a dissenting voice in representing on-the-ground realities. Neglected tropical diseases cause significant morbidity and mortality and huge resources have been mobilised to control these infections, primarily through mass drug administration (MDA). The findings of Melissa and colleagues’ anthropological research suggested that the one-size-fits all policy formulated in Seattle, London and Geneva was not being as successfully rolled out as reported. The way these results were taken on, and refuted or contradicted, sheds light on the way evidence can be used and not used and research done and not done. Sociologist Oliver Bonnington, Research Fellow in Sociology at LSHTM, summarised his work on home energy efficiency measures, and his attempts to theorise people and their contexts in relation to this. He utilised the notion of reflexivity, splitting this into communicative, autonomous, meta- and fractured reflexivity. Claire Snowdon shared some insights into her work in neonatal clinical trials, having recognised a bias in the way these studies were done in not addressing deaths. She described how both clinical staff and parents reported that discussing the death of their child in relation to trial participation would not have been easy immediately after the event but in subsequent years parents said they intermittently rekindled interest in the trial and almost all wanted to know the results.
Gemma Jones, a social anthropologist, described her ‘research of research’ work in rural Kenya, where research activities of local biomedical research institutes had become a part of every day life and a feature of modern life in Kenya, not only on a day-to-day basis but in plans and imagined futures.
When asked ‘what should LSHTM do to promote your type of research and integrate it into our thinking?’ these panellists suggested (i) engagement with social theory, which seems lacking, (ii) identifying funding possibilities for this sort of work (iii) reproducing anthropologists (iv) uniting the social scientists across the school into a critical mass.
David Armstrong gave the final talk of the day, entitled ‘being subversive’. He encouraged us to step back and recognise that what is ‘real’ in medicine is socially constructed. For example, knowledge that a picture represents a cancer cell is handed down through generations, and we know what it is because of the social consequences – people die when they have these cells, which renders them abnormal or pathological.
Therefore, there is a social judgement over what is beneficial or harmful, which shapes our diagnostic categories (eg. Shyness as a pathology). Taking this into consideration, shifting definitions of what is real and what is pathology as a way of ‘encoding social norms’ means we should challenge the results of research based on these notions of reality. He proposed three rules of subversion:
- Biological phenomena are socially encoded
- Ask about effect sizes (often very small – and ‘most medicines don’t work’)
- Don’t believe all the rhetoric of biomedicine (genetic, neuroscience, or biomarkers)
The day was closed by Richard Smith, Dean of Faulty of Public Health and Policy, who encouraged high quality social science – and recommended the strengthening of critical perspectives within social sciences rather than just being within biomedicine. He cautioned social scientists not to ‘go native’ in the School and risk losing touch with our parent disciplines, and we should follow the examples of the presentations given to strive for high quality social science in its own right as well as being relevant to public health.