Health in times of crisis. Temporalities, coalescence, alternatives
Seminar organised by Cermes3, the 2,3 and 4 October, 2019
Amphitheater François Furet, EHESS, 105 boulevard Raspail, 75006, Paris
Participation in the seminar is free but registration is obligatory (date limit: 20 September, 2019)
Between context, event, and notion, crisis, in the singular or plural form, seems to simultaneously be characteristic of particular moments, of "critical situations", of rupture and tipping points, thus destabilizing organized communities to the point of seeming to form a historical backdrop that is both political and discursive of our current societies. While economic crises have followed one another regularly since the early 1970s, impacting the fields of health to a greater or lesser degree, that of 2008 seems to have marked a shift by its ambivalent effects, provoking on one hand and in several ways, a questioning of social welfare and health systems, and appearing on the other hand as a chance accident, a "vicissitude" in the stumbling course of history. Beyond the economic field, crises have multiplied for the past twenty years, in both reality and in discourse: health crises associated with viruses, affecting people, animals or food, migration crises, humanitarian crises, ecological and environmental crises, democratic and political crises.... Crises have thus become the alpha and the omega of discourse "in an uncertain world"; their frequency, distribution, mutability and incommensurability making them incomprehensible. This situation leads to both radical measures and conservative reactions, which, in both cases, may jeopardise defining medium-term goals or organisational models with similar performance but clearly "alternatives".
Cermes3 has chosen to focus its new 5-year plan on issues related to the links between “crisis” and “health”, between “the crises” and “the universe of health”. The present symposium participates in this project. It wishes to re-examine the polysemic concept of crisis – as it has been used and studied in the humanities and the social sciences – by testing its pertinence as regards health. On the one hand, it’s a question of examining the concept: to question the temporal forms which are linked to it, to understand the way in which it helps or hinders explaining current transformations, to examine the link between crisis and judgment or between crisis and politics. It also aims to explore how the various crises are connected, meet, overlap, and, by combination, conjunction, distortion, reiteration ... produce tangible effects on different domains of health, whether these relate to public policies, strategies, actors, patients or health practices.
Proposals for communications around 5 themes are anticipated:
1. Practices and healthcare organisations
The social sciences have examined the way medical work – more broadly health care practices and the organisations that support these practices – has been changed over the past 40 years by the mobilisation of groups, the emergence of the patient-actor or the patient-expert, and the emphasis placed on experience, specific knowledge or patient rights. Within the framework of this symposium, we wish to place these changes side by side with the context of crises that appear to create stress for the actors engaged in healthcare practices by transforming their environment and working conditions; hence, our interest in more closely examining changes in health or medico-social organisations (kinds of organisation, diversification and fragmentation, management styles, position and form of the “hospital”, working conditions for professionals…). In addition, we will look at the status and role of persons involved in care work (“professionalisation” of lay persons versus lack of security for professionals, the blurring of boundaries and professional hierarchies, ambivalent empowerment of family caregivers…), and investigate the healthcare practices themselves (personalised care by way of standardisation, development of so-called “alternative” healthcare practices, both within and outside health and social facilities…) and more broadly, the instrumentalisation of the notion of care and values linked to a “caring society”.
2. Care, health and “the immigrant crisis”
The expression “immigrant crisis” is often used since 2015 to refer to the massive influx into Europe of populations from unstable countries, notably from countries at war (Syria, Afghanistan, Eritrea, etc.). The expression has emerged in the public debate, abolishing the complexity of the link between “health” and “migrations”. However, beyond popular representations of the phenomenon, and as long as we study them separately or in contrast to each other, it quickly appears that, in the era of globalisation, these migrations are of different durations, have varied profiles and are determined by very diverse factors (conflicts, famines, genocides, the effects of climate, etc.). Thus, the category of "immigrant" covers both undocumented immigrants, unskilled economic workers, immigrants through marriage, highly qualified persons ..., all of whom are actors in the transnational flow of knowledge, practices and products. To explore the link between "immigrant crisis" and health domains, two approaches appear relevant. The first examines the conditions of access to medical care and its use by immigrants This can certainly – but not always – reflect social inequalities in health, discrimination (ethno-racial, sexual, etc.), but can also refer to specific types of care: cross-border and transnational, teleconsultations, etc. The second approach concerns immigrant health professionals and their working conditions. It induces us to examine professional training, spatial mobility and the social trajectories of foreign practitioners and other professionals (nurses, carers ...), as well as the role and policy of foreign health professionals in hospital management and in healthcare organisations, and finally, the non-biomedical therapeutic knowledge conveyed by immigrant health professionals.
3. Social welfare systems in Northern and Southern countries
The crisis of the welfare State as announced in the 1970s continues to stimulate debate, to the point of raising doubts as to the relevance of the concept of a crisis to describe the fragility of a type of organisation designed to share and collectivise risks. While some analyses point to a shrinking of involvement by public authorities concerning public welfare, on the other hand others underline not a withdrawal but rather a rearrangement of the landscape (the increasing importance of private actors) and of financing for social welfare. These factors confer a new role for the State, that of strategist. Nevertheless, the increasingly tight control of social spending, particularly for health, creates situations of extreme tension, which increasingly affect working conditions of health professionals. How can one assess the current situation of the public hospital or the fears raised by the increasing prices of therapeutic innovations? Are they merely the aftershocks of uninterrupted "crises" over the past forty years or do they mark a deeper questioning of the model developed after the war, which may cost "an outrageous amount"? Privatisation, neoliberalisation, commodification, this part of the conference will clarify the importance and operational scope of these concepts in the humanities and social sciences but also for actors in Northern as well as Southern countries. The idea of a grand division between “high-income” affluent countries and low- and middle-income countries managing scarcity is losing its importance, as evidenced by debate on "universal health coverage" within discussions on global health, the management of chronic diseases, and the definition of guaranteed "care packages" or access to medicines.
4. Health, environment, ecological crisis
Manage pollution or save the planet? Although environmental health issues have been high on the health agenda since the 1980s – in particular because of public interrogations and controversies about the effects of recurrent exposures to chemical contaminants – for the past 10 years, ways of thinking about the links between environment and health have been largely pushed aside by increasing attention given to endocrine disruptors on the one hand, and the massive and divers effects of climate change on the other. In both cases, there is a feeling of an omnipresent crisis because they involve systemic effects difficult to control and potentially responsible for large-scale epidemiological changes. Depending on whether one works in the field of environment or in the field of health, however, the crisis covers very different diagnoses, methods of management and forms of intervention. In thinking about ways of linking these perspectives, we see that the processes they bring to the fore raise an issue all the more important for the social sciences of health in that it implies introducing ways of de-compartmentalising environmental studies.
5. Production of knowledge, forms of expertise, crisis of objectivity
The politics of ignorance, the fabrication of doubt, undone science: criticism of the ways knowledge is arrived at to render a problem real – or on the contrary to minimize or even simply to deny the existence of a problem – is an integral part of many contemporary public debates concerning health issues. The ways in which priorities in biomedical research are defined and, more fundamentally, the preference (or even exclusivity) accorded to some approaches to disease – to the detriment of non-Western or simply heterodox conceptions – are now the subject of intense debate. However, the main challenges relate to processes related to expert opinions, broadly speaking. A cross-cutting aspect of all these criticisms is what we are tempted to call the "crisis of objectivity". Despite all the difficulties it has raised since its appearance in the nineteenth century (if only because of its unattainability ...), the imperative of objectivity remains one of the main social norms structuring the production of scientific knowledge and, by extension, public expertise. So far at least, neither the injunction to take distance from interests and passions likely to skew judgment, nor the evaluation of measuring instruments and statistical analysis (to the detriment of the subjective assessment of impressions) has polarised thinking. Rather, most critics focus on two complementary aspects of the same problem: the permeability of scientific institutions – and a fortiori systems of expertise – faced with the plotting of organised economic or political special interests; and their symmetrical inability of giving full attention to demands and suggestions from people representing causes deemed (almost) unanimously legitimate – associations of patients, users, residents, etc. It appears important that the different aspects of this latent crisis deserve to be analyzed in detail (perhaps in part because of the absence of a clearly defined and publicly defended alternative)