Other topics

Social inequalities and orders of justification in the health care system

June 28, 2021 15:00
June 28, 2021 16:30

Rainer Diaz-Bone, University of Lucerne; Valeska Cappel, University of Lucerne


Karolin Kappler, FernUniversität Hagen; Valeska Cappel, University of Lucerne

Stefan Janković, University of Belgrade; Milica Resanović, University of Belgrade

Giovanni Matera, EHESP French School of Public Health

Health care has become one of the most important economic and political spheres, in which issues of governance and social justice are core. Seen from the neopragmatist institutionalism of economics of conventions (in short EC), one can identify a plurality of institutional logics, which are the foundation how to evaluate health and justice. Therefore, economics of convention opposes a simple view of only one efficient way or only one possible just way how to organize health care.  Instead EC studies the tensions and critiques, which rise out of the pluralist constellations of institutional logics. These institutional logics are also the foundations for knowledge production about health and its evaluation and interpretation. Digitalization and neoliberalism are changing health care massively. The upcoming danger is an erosion of the solidarity principle and a concentration of power/knowledge at private companies. Civil societies and parliaments tend to lose their influence in the deliberation about health care principles and lose access to digital data bases about human behavior and health practices. 

The contemporary COVID19 pandemic has demonstrated the inequal distribution of risks. Social inequalities intensified, because disadvantaged occupational status groups and underprivileged class fractions suffer greater risk of infection. These are the groups, which are targeted by neoliberalist politics of transforming statist structures into market structures. Traditional collective structures (as industrial labor relations) and precarious new collectives (as creative class fractions, self-entrepreneurs) are being dissolved and the COVID19 pandemic contributes to the fragilization of their collective structures. Although the COVID19 pandemic has shown the importance of statist regulation and foresight, statist regulation is criticized because of the restrictions of individual freedom and public life. 

The planned workshop will gather presentations, which study the institutional transformations of the health care systems in times of digitalization and the COVID19 pandemic. Seen from EC, digitalization and the COVID19 pandemic introduce more asymmetries and inequalities in the health care system and reduce the plurality of health conceptions and health care institutions.

The perspective introduced by economics of convention it to focus the empirical tensions and critiques, which are present in society. The claim is that EC is an empirical approach to the normative quarrels about justice and inequality the health care system is currently facing.

Trade-offs and conflicting goals in the digitization of health - Presentation of the anthology "Health - Conventions - Digitization”.

Karolin Kappler, FernUniversität Hagen; Valeska Cappel, University of Lucerne

Regarding digitization, new technologies have emerged in the health system in recent decades. These technologies are changing organizational processes and general “thinking” and “doing” about health. The keywords telemedicine, eHealth, digital health, smart health and big data describe these new developments. In our anthology "Gesundheit – Konventionen – Digitalisierung. Eine politische Ökonomie der (digitalen) Transformationsprozesse von und um Gesundheit”, we, together with 22 authors, show that these developments create new tensions and conflicts in the health system and in dealing with health. In the contributions to the anthology, the Economie des conventions (EC) was introduced as a pragmatic approach to analyzing trade-offs between technologies, definitions of health or justifications as well as conflicting goals in the health system. In our presentation, we will first give an overview over these central trade-offs and conflicting goals that have emerged across most of the contributions in the anthology, referring in our examples to their development during the current situation of the corona pandemic. Second, we will describe the trade-offs and conflicting goals in two selected and exemplary field, which we analyzed with the EC:  The first study deals with how tensions and conflicts arise when using health apps in everyday life (e.g. Corona warning app). The second analysis shows the conflicts that emerge in measuring moods and diets. Both examples refer to conventions and the regimes of engagement as central categories of the EC. Based on these findings, we will as a last step reflect on the consequences for social inequality, such as the discrimination of certain groups by data practices or disadvantages due to lack of transparencies.

Breaking through the Pandemic Incertitudes: From Hazy Health Care Instruction to Commensuration of Worths among Serbia’s Young Professionals.

Stefan Janković, University of Belgrade; Milica Resanović, University of Belgrade

Rather cumbersome ontological situation initiated with the 2020 pandemic has created a great amount of unease within common worlds, particularly in terms of health risks and hazy healthcare instructions. A series of uncanny and confusing moments both have been sparked by possibly deterrent effects coming with infection and transmission risks, as well as by being abridged for effective tools such as standards and procedures for coping with the virus. Exactly this triangle formed between familiar engagements and resettling within pandemic reality, incertitude brought with infection risks and hazy healthcare procedures, along with overall discrepancies in civic response to pandemic, was a principal subject of our research. Namely, we intended to discern how the uncertainty brought with the puzzling intrusion of the COVID-19 was confronted by young professionals in Belgrade, Serbia, particularly having in mind their social status.

Based on 20 interviews conducted during the first months of the pandemic in the spring of 2020, our exploration traces both the attempts to consolidate the familiar environment anew into coherent arrangements and to commensurate worths as specific normative principles deployed in these operations. Inspired by pragmatic sociology and more specifically, Thévenot’s concept of regimes of engagement, we first explore the adaptations evolving within familiar arrangements. Principally, we denote that confronting with the uncertainty embodied in a mute presence of the virus meant conducting a fragile politics of beings within this regime, molded through personal bonds, care and intimacy. Particularly, we describe how the hygienic “purifying” was guided not only by a fear of being contaminated, but also has induced a rather vigilant mode of communication with the “intruder” and “drifting” through hazy instructions. Later moment indicates a plurality of assessments of the healthcare itself: for this, highly educated cohort, it meant a critical assessment of instructions, a dose of distrust for medical experts due to fuzzy instructions given in the media and the general reliance on DIY strategy, which involved exploration of “valid” procedures on the Internet.

Albeit this lack of referential stability was eventually consolidated into specific pandemic objectivity, surrounded with disinfectants and thresholds put in immediate spaces, a plurality of engagements also evolved into principal tension between this “protective shield” in which the domestic world was wrapped and the civic world. The second problem that we analyze therefore encompasses a commensuration of worth performed by our informants and their judgmental attitude towards actions that might harm the familiar arrangement. Namely, our findings show that this purifying politics targeted a situated, materialized endeavor in order to solve the basic tension: how to protect and solidify familiar environment by drawing upon an ethical corpus of “taking care of family”. Thus, in conclusion we illustrate how this “pandemic deontology” involved a tense encounter with “aberrations” found in civic polity as these, assumedly, have distorted the common principle of equivalence. Specifically, we describe three major criticisms targeting the civic world: excessive hoarding of goods, improper wearing of masks and a lack of responsibility for others. Overall, these critiques targeting the civic world have both put to scrutiny the healthcare system in Serbia seeing it as unreliable, but also had an aim to protect it against excesses that would further harm it.

Hospitality, Migration and Mental Health. Engaging a pluralist perspective to study the treatment of migrant persons suffering from mental illness.

Giovanni Matera, EHESP French School of Public Health

In this presentation I will introduce an approach that draws on an innovative intersection between cultural sociology and the pragmatic sociology of hospitality developed by Joan Stavo-Debauge. New perspectives in pragmatic and cultural sociology draw on the classical sources with a more comprehensive outlook. The study of cultural boundaries, culture in interaction approach, neo-institutionalism and French pragmatic sociology have focused on patterns that connect individual action to cultural structures. Their common assumption is that actors do not put culture into action unconsciously or for hidden personal interest, but that they act through a plurality of patterns, grammars, institutional logics, repertoires or styles. I will discuss a research proposal that draws on my PhD thesis in which I applied the framework of French pragmatic sociology to the study of community psychiatry. This research proposal focuses on the “stranger” person who appears for the first time in an urban community and can be perceived as a newcomer ready to become a member. This is a unifying conception that can help organize social support as a network to respond to the newcomer's needs. In the recent years mental healthcare has developed community treatment services that facilitate the inclusion of a mentally ill person. The COVID-19 crisis has drawn increasing attention to the multiple layers of difficulties which migrant persons can be faced with. Asylum seekers who are victims of forced migration have proved to be more likely to suffer from forms of mental illness. On its part, the COVID-19 pandemic is bringing new threats to both asylum seekers and persons suffering from mental distress. In case of an asylum seeker who suffers from mental illness, due to the bureaucratic functioning which tends to prioritize the attainment of a legal residency status and delay the objective of social inclusion, the overlap of community mental healthcare services and asylum support services can trigger a selection mechanism that does not actually fulfill the latter objective. Indeed, social inclusion requires the integration of social and medical services but also reinforces the role of the community-building capacity of the involved actors. From the newcomer's side, receiving specific mental health support is a right that legitimates a form of positive selection. In my presentation, I will introduce the following set of questions and formulate some hypothesis drawing from an ongoing preliminary research between Switzerland and Greece: what does a network of services do to maintain the objective of social inclusion and the person's right to be treated? Given the expectation that community members have the capability to learn from a form of social organization such as community psychiatry, that has proved beneficial, can this overlap of services be a means for an effective knowledge transfer, and be conceived as part of a grammar of hospitality? Can the overlap become both a determining factor for social inclusion and a therapeutic factor for the recovery of a migrant person suffering from a mental disorder?