Modernization and Medicalization

Commencing in the 17th century, European and North American modernization fostered an "engineering mentality," one manifestation of which was a concerted effort to establish increased control over the vagaries of the natural world through the application of science. As a result, by the 18th century, health came to be understood by numerous physicians and by the emerging middle classes alike as a commodity, and the physical body as something that could be improved upon. At the same time, legitimized through state support, the consolidation of medicine as a profession was taking place, together with the formation of medical specialties and the systematic accumulation, compilation, and distribution of new medical knowledge. Systematization of the medical domain, in turn, was part of a more general process of modernization to which industrial capitalism and technological production was central, both intimately associated with the bureaucratization and rationalization of everyday life.

Medical interests expanded in several directions during the 18th and 19th centuries. First, there was an increased involvement on the part of medical professionals in the management not only of individual pathology but of life-cycle events. Attending birth had been entirely the provenance of women, but from the early 18th century in Europe and North America, male midwives trained and worked at the lying-in hospitals located in major urban centers to deliver the babies of well-off women. These accoucheurs later consolidated themselves as the profession of obstetrics. By the mid-19th century other life-cycle transitions, including adolescence, menopause, aging, and death had been medicalized, followed by infancy in the first years of the 20th century. In practice, however, large segments of the population remained unaffected by these changes until the mid-20th century.

Another aspect of medicalization can be glossed in the idiom of "governmentality" proposed by Michel Foucault. With the pervasive moves throughout the 19th century by the state, the law, and professional associations to increase standardization through the rational application of science to everyday life, medicine was integrated into an extensive network whose function was to regulate the health and moral behavior of entire populations. These disciplines of surveillance, population "bio-politics" as Foucault (1979) described it, function in two ways. First, everyday behaviors are normalized so that, for example, emotions and sexuality become targets of medical technology, with the result that reproduction of populations and even of the species are medicalized. Similarly, other activities, including breastfeeding, hygiene, exercise, deportment, and numerous other aspects of daily life are medicalized—largely by means of public health initiatives and with the assistance of the popular media.

The medical and public health management of everyday life is evident not only in Europe and North America, but also in 19th-century Japan and to a lesser extent in China. In India, Africa, South East Asia, and parts of the Americas, medicalization was intimately associated with colonization (Comaroff, 1993). Activities of military doctors and medical missionaries, the development of tropical medicine and of public health initiatives, designed more to protect the colonizers and to "civilize" the colonized than to ameliorate their health, were integral to colonizing regimes. As with medicaliza-tion everywhere, large segments of the population remained untouched by these activities until well into the 20th century (Arnold, 1993).

From the late 18th century, yet another aspect of medicalization became evident. Those populations labeled as mentally ill, individuals designated as morally unsound, together with targeted individuals living in poverty were for the first time incarcerated in asylums and penitentiaries where they were subjected to what Foucault termed "panopticism." Inspired by Jeremy Bentham's plans for the perfect prison in which prisoners are in constant view of the authorities, the Panopticon was, for Foucault, a mechanism of power reduced to its ideal form—an institution devoted to surveillance.

These changes could not have taken place without several innovations in medical technologies, knowledge, and practice, among which four are prominent. First, the consolidation of the anatomical pathological sciences whereby the older humoral pathology is all but eclipsed so that belief in individualized pathologies is essentially abandoned in favor of a universal representation of the "normal" body from which sick bodies deviate. Second, introduction of the autopsy enabling systematization of pathological science. Third, the routinization of the physical examination and of the collection of case studies. Fourth, the application of the concept of "population" as a means to monitor and control the health of society, central to which is the idea of a norm about which variation, which can be measured statistically, is distributed. The belief that disease can be understood as both individual pathology and as a statistical deviation from a norm of health becomes engrained in medical thinking as a result of these changes. Treatment of pathology remains, as was formerly the case, the core activity of clinical medicine, but the new epistemology of disease causation based on numeration gradually gained ground. Public health and preventive medicine, always closely allied with the state, made the overseeing of the health of populations its domain.

Other related characteristics of medicalization, well established by the late 19th century, and still evident today, can be summarized following Rose (1994), into "dividing practices," whereby sickness is distinguished from health, illness from crime, madness from sanity, and so on. With this type of reasoning certain persons and populations are made into objects of medical attention and distinguished from others who are subjected to different authorities including the law, religion, or education. At the same time various "assemblages" are deployed: a combination of spaces, persons, and techniques that constitute the domain of medicine. These assemblages include hospitals, dispensaries, and clinics, in addition to which are government offices, the home, schools, the army, communities, and so on. Recognized medical experts function in these spaces making use of instruments and technologies to assess and measure the condition of both body and mind. The stethoscope, invented in the early 19th century, was one such major innovation, the first of many technologies that permit experts to assess the condition of the interior of the body directly, rendering the patient's subjective account of malaise secondary to the "truth" of science.

Several noted historians and social scientists argue that from the mid-19th century, with the placement in hospitals for the first time not only of wealthy individuals but of citizens of all classes, the medical profession was able to exert power over passive patients in a way never before possible. This transition, aided by the production of new technologies, has been described as medical "imperialism." Certain researchers limit the use of the term medicalization to these particular changes, whereas other scholars insist that the development of hospitalized patient populations is just one aspect of a more pervasive process of medicalization, to which both major institutional and conceptual changes contribute. Included are fundamentally transformed ideas about the body, health, and illness, not only among experts, but also among populations at large.

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