The Pro-Innovation Paradox: Social inequalities and health in an age of technological transformation
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INTRODUCTION TO THE PARADOX Technology is power and control. It can give life and it can take life. It can strengthen existing social hierarchies, or it can rewrite them. Society, in many ways, is a product of our technological innovations. They are often seen as both a sign and a source of social progress. While we are continually reminded of their benefits, their consequences are becoming increasingly obvious. At the very same time, global socioeconomic inequalities are at historic levels. And on the rise. This includes inequalities in health and welfare, within countries and across continents. While our technological innovations are often defended as public health miracles, improving health and welfare throughout society, they are also a valuable resource like any other, unequally distributed across society. And it is this collection of resources that in large part determines health both at the individual and population level. Therefore, health provides a valuable means of understanding and analyzing social inequality. An interest in investigating whether or not our technological innovations are contributing to a reduction or an increase in these health-related inequalities therefore presents a possible paradox. A ‘pro-innovation paradox’ suggests the possibility that our blind faith in technological innovations as unquestionable tools of social salvation may very well be contributing to a culture completely unaware of the possibility that the unintended and undesirable consequences of these innovations is undermining the benefits, and aggregate social value, that we have come to expect from our technological innovations. Using data from the Norwegian population as a case, the overall aim of this thesis, therefore, is to provide a greater understanding of how innovative technologies are (conceptually and empirically) linked to health and social inequality. Central objectives include reviewing the range, nature, and extent of relevant research exploring the influence of innovative health technologies on social inequalities and health, with specific focus on a deeper understanding of the variables used to measure this connection and the pathways leading to the (re)production of inequalities (Papers I & II). And moreover, to provide a broad framework supporting a deeper scientific understanding of the mechanisms and pathways explaining the complex social and political relationship between technological innovations, social inequality and health (Papers III & IV). THEORY &BACKGROUND Defining both technology and innovation have been crucial to achieving the aims of this thesis. Therefore, using various interdisciplinary definitions of technology and a broad understanding of public health, the following working definition is reflective of much of the work in this thesis: Technological innovations in health are: A design for instrumental action that reduces the uncertainty in the cause-effect relationship involved in achieving a desired outcome, which: 1) includes both a hardware and software component, 2) is perceived as new by an individual or other unit of adoption, and 3) which emerges in contexts of, and related to, public health. A three-type classification of technologies (developed in Paper II), furthermore, illustrates a model of understanding technological innovations in health as they relate to mechanisms driving status-based inequalities in access and use. Type 1 (direct end-user) technologies are directly accessed and used by end-users, type 2 (direct-use gatekeeper) are accessed by way of a gatekeeper but used by the end-user, and type 3 (indirect-use gatekeeper) are both accessed and used by someone other than the end-user. Understanding technological innovations in health in this way allows the academic literature to move beyond simply defining health technologies as medical technologies confined to society’s health care institutions (as has often been tradition in these fields) and incorporating, instead, a broad conceptual understanding that captures the widespread effects of these innovations on society. Theoretically, the work in this thesis has been largely inspired and informed by two major sociological and social epidemiological theories: the diffusion of innovations theory, developed by Everett M. Rogers, and the fundamental cause theory, developed by Bruce G. Link and Jo C. Phelan. The diffusion of innovations theory is a theory that has been widely used, and accepted as central to explaining the ways in which innovations spread throughout society. It is responsible for popularizing the traditional diffusion S-curve and the classification of adopter categories. The fundamental cause theory (FCT), on the other hand, is a theoretical understanding of mechanisms of social stratification that unequally (re)distribute the resources that (re)produce health, or in other words, of the social distribution of health inequalities. Empirical tests of the theory have offered support to its assumptions, largely relying on investigations that illustrate the unequal effects on health of relevant innovations. The fundamental cause theory, and its highly ‘social’-ized (rather than individualized) perspective on the (re)production of inequalities in health is the result of many decades of developments in fields of epidemiology and sociology. These modern developments have contributed to increased attention on the structural mechanisms that determine individual and population health. These influential structural theories have been complimented by, integrated with and further developed using a number of other theoretical and empirical, scholarly contributions, including in large part Pierre Bourdieu’s work on capital, habitus and field. Bourdieu has recognized that important sources of both economic and non-economic forms of capital (i.e. ‘symbolic’ capital) are often misrecognized as legitimate forms of unequal power and social dominance (i.e. ‘symbolic’ violence). Bourdieu’s work has provided a foundation by which to further develop the fundamental cause theory and the diffusion of innovations theory and contributed to revealing the subtle ways in which seemingly nonthreatening technological innovations in health may influence mechanisms that (re)produce (dis)advantage and inequality across society. METHODOLOGY Data sources for the empirical work in this thesis have included diabetes data from the Norwegian Health Survey in Nord-Trøndelag (HUNT) and demographic data from the Norwegian population registry, as well as Norwegian State policy and planning documents. Empirical methodology has relied on a ‘methodological polytheistic’ approach. This approach is grounded in a Bourdieusian approach to developing both a ‘theory of practice’ and a ‘practice of theory’, or in other words, a methodologically pragmatic and reflective approach necessary for building broad conceptual understanding. This thesis therefore relies on the use of scoping review methods (Paper II), quantitative statistical regression analyses (Paper III), and qualitative critical discourse analysis (Paper IV) to build a comprehensive understanding of the influence of innovative technologies on social inequalities and health. RESULTS & CONCLUSIONS Papers I and II have offered an overview of relevant literature and a classification of technological innovations central to perspectives interested in understanding their role in the reproduction of health and inequality. Paper III tests an empirical model for analyzing adoption and diffusion patterns of health technologies from a social inequalities perspective. Paper IV provides insight into dominant political discourse and its relevancy for the implications of technological innovations on public health and inequality. Furthermore, Papers II, III and IV provide evidence for a broad range of mechanisms, and potential pathways, illustrating how variations in access and use of innovative technologies (re)produce relevant inequalities. And, lastly, all papers provide relevant theoretical and philosophical discussions for further developing relevant scientific discovery. The findings from this work have provided a foundation for developing a broad conceptual model that can be used to further investigate, discuss, empirically test, and understand the ways in which technological innovations, health, and inequalities are interrelated. The HEAL-TecH model presents a spectrum demonstrating the strength of observed inequalities as a product of the sum of several dominant characteristics of a technology’s position in society. Moreover, the model illustrates that the type of technology importantly determines the mechanisms most influential in (re)producing (or reducing) relevant inequalities. Using the findings from the HEAL-TecH model as a conceptual foundation, there is reason to believe that generous welfare States such as Norway, who are actively promoting effective innovation, have the economic and political means to stimulate the adoption of innovations at the national level, and remain vulnerable to SES-based variations in the use of these technological innovations (regardless of the rate of diffusion), will continue to experience the (re)production of relatively high levels of health-related inequalities. In other words, based on the findings from this thesis, it is possible that developments in and around technological innovations in health in Norway (and possibly other Nordic states) are responsible for explaining much of what has been deemed the ‘Nordic Paradox’ (i.e. surprisingly high inequalities in health in the Nordic welfare states). Further findings suggest that technological innovations in health have the potential to improve public health but that these technological innovations do not benefit all social groups equally. These innovations are important mediators of mechanisms that influence the (re)production of systematic inequalities. This is a result of the (increasing) importance of technological innovations for accessing and exploiting the benefits of valuable institutions, services, and forms of capital in society. Technological innovations in health, importantly, appear to have the power to either increase or decrease inequalities. The direction and magnitude of this relationship is shaped by a number of mechanisms at various levels of the social spectrum, which are dependent on important technological and socio-political contextual factors. In other words, technological innovations in health must be understood not just as powerful instruments for universal social ‘progress’ but also as an equally powerful actor in the shaping of the social order. The implications for public health and inequalities of an increasingly technologized society include unequal burdens associated with the increased techno-medicalization of society, false empowerment discourses and the ‘desocialization’ of modern public health efforts (where more responsibility is transferred to the individual). These consequences will only be strengthened by a pro-innovation culture, where national identities and economic superiority are increasingly associated with technological innovation. Misrecognizing the potential benefits of technological innovations in health for early adopters and high SES individuals as universal goods for equal social welfare and general social progress has significant ethical and practical implications for the ways in which social inequalities are (re)produced. Moreover, the philosophical, theoretical and epidemiological findings in this thesis have the potential to make a number of concrete contributions to future developments in both research and practice. First, they defend an understanding of technology as value-laden and therefore non-neutral. Second, they build on relevant theoretical and empirical findings, contributing a comprehensive overview of the mechanisms through which innovative technology either increases or decreases social inequalities (something which has not yet before been scientifically conceptualized or adequately investigated empirically). And lastly, they defend a more conscious and aware engagement with the development and adoption of technological innovation, its position in society, and its potential consequences. Engaging with technological innovation in this way is a prerequisite to challenging, and transforming, current assumptions and guaranteeing equal access to health as a universal basic human right.
Has partsPaper 1: Weiss, Daniel; Eikemo, Terje Andreas. Technological innovations and the rise of social inequalities in health. Scandinavian Journal of Public Health 2017 ;Volum 45.(7) s. 714-719 https://doi.org/10.1177/1403494817711371
Paper 2: Weiss, Daniel; Rydland, Håvard T.; Øversveen, Emil; Jensen, Magnus Rom; Solhaug, Solvor; Krokstad, Steinar. Innovative technologies and social inequalities in health: A scoping review of the literature. PLOS ONE 2018 ;Volum 13:e0195447.(4) s. 1-20. https://doi.org/10.1371/journal.pone.0195447 This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0)
Paper 3: Weiss, Daniel Albert; Sund, Erik; Freese, Jeremy; Krokstad, Steinar. The diffusion of innovative diabetes technologies as a fundamental cause of social inequalities in health. The Nord‐Trøndelag Health Study, Norway. Sociology of Health and Illness 2020. https://doi.org/10.1111/1467-9566.13147 This is an open access article under the terms of the Creative Commons Attribution (CC BY 4.0)
Paper 4: Weiss, Daniel Albert. Round hole, square peg: a discourse analysis of social inequalities and the political legitimization of health technology in Norway. BMC Public Health 2019 ;Volum 19.(1) s. 1-15. https://doi.org/10.1186/s12889-019-8023-3 This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0)