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Modern Societies as Knowledge Societies: The Implications for Health and Health Care

Nico Stehr
Center for Advanced Cultural Studies
Goethestr. 31

Email: nico.stehr@gkss.de

Paper presented April 25, 2001 at the CRICS V Conference "Knowledge for change: Information and Knowledge for Health Equity", Havana, Cuba.


The lecture explores the various novel prospects for modern society and its actors as the social order of industrial society, and the knowledge used to comprehend it, complete their assignment. The foundations of the emerging social world are best described as based on knowledge. New realities require a new perspective. It is not that times of rapid change are new; what is new is the nature of the social transformations we are experiencing. In as much as knowledge becomes constitutive not merely for the modern economy and its productive processes but also for social relations, social cohesion and integration generally and as the primary source of the modern society's problems and conflicts, the term 'knowledge society' becomes appropriate as a designation for the nature of modern societies' forms of life. The implications of the transformation of modern society into knowledge societies for health and healthcare are explored.

El tema de mi presentación es: sociedades modernas como sociedades de conocimientos: consecuencias para la salud e higiene pública. Me gustaría empezar con la siguiente observación general: la salud es una forma y componente del (entre comillas) "capital" sanitario individual y colectivo. Toda persona y toda sociedad nace con un stock inicial de salud, el cual se va disminuyendo con la edad. Este abastecimiento se reduce en el curso de la vida, pero puede crecer si se invierte de diferente maneras. Dado el tema de mi presentación, quisiera enfatizar la importancia de invertir en el "conocimiento" de los actores en el stock del capital sanitario individual y colectivo.

Modern Societies as Knowledge Societies: The Implications for Health and Health Care

1. Introduction

Health is a form and component of social and human capital. Individuals and society inherit an initial stock of health. The initial stock of health depreciates with age. It depreciates at an increasing rate in the later course of life of a person. Health capital can be increased by various investments. Given the topic of my presentation, I will emphasize the unique importance of investing in the "knowledgeability" of actors for the stock of individual and collective health capital.

2. Overview

New social realities require a new perspective. In advanced societies, the capacity of the individual to say no has increased considerably. At the same time, the ability of the large social institutions that have significantly shaped the nature of the twentieth century to get things done has diminished in the last couple of decades. Or, appropriating astute insights of the economist Adolph Lowe, we are witnessing a change from social realities in which "things" at last from the point of view of most individuals simple "happened" to a social world in which more and more things are "made" to happen. In this contribution, these new realities are described as representing the emergence of advanced societies as knowledge societies.

I use the terms "human" and "social" capital in loose association to their original context in human capital theory introduced and elaborated in economic discourse (see Schultz, 1961; Becker, 1964) and social capital theory as suggested in sociological discourse (see Bourdieu [1983]
1986 ). Human and social capital theory roughly corresponds to the difference of individual and collective; in this context, I stress the interaction between human and social capital. A critique of human and social capital theory may be found in Stehr, 2001b. A discussion of health capital from an econometric perspective may be found in Grossman, 1999.

I will describe some of these transformations that constitute a real and unprecedented gain from the perspective of the individual and small groups but also as a rise in the fragility of modern society. First, I will refer to the concept of knowledge societies and examine the notion of knowledge. I propose to define knowledge as a capacity to act and as a model for reality. I will describe the reasons for the importance of scientific knowledge as one among various forms of knowledge in advanced societies. The transformation of modern societies into knowledge manifests itself most importantly in the sphere of economic activities. Economic capital -- or, more precisely, the source of economic growth and value-adding activities -- increasingly relies on knowledge. The transformation of the structures of the modern economy by knowledge as a productive force constitutes the "material" basis and justification for designating advanced modern society as a "knowledge society". However, the significance of knowledge grows in all spheres of life and in all social institutions of modern society.
I therefore very briefly describe some of the features of the changing economy before turning to those consequences of the advancing "knowledgeability" of actors in modern society that give rise both to the growing fragility of modern society but also has significant repercussions in many other areas of life including health and health care.

3. Knowledge Societies

Both the greatly enhanced social, political and economic significance of science and technology and the often narrow, even scientistic conception of knowledge generated by modern science call for a careful sociological analysis of knowledge itself. Knowledge has of course always had a major function in social life. That human action is knowledge-based might even be regarded as an anthropological constant. Social groups, social situations, social interaction and social roles all depend on, and are mediated by, knowledge. Power too has frequently been based on knowledge advantages, not merely on physical strength. Societal reproduction, furthermore, is not just physical reproduction but has always also been cultural, i.e., it involves reproduction of knowledge.
The historical emergence of "knowledge societies" does not occur suddenly; it represents not a revolutionary development, but rather a gradual process during which the defining characteristics of society change and new traits emerge. Even today, the demise of societies is typically as gradual as was their beginning, even if some social transformations do occur in spectacular leaps. But most major social changes continue to evolve gradually, at an uneven pace, and they become clearly visible only after the transition is already over. The proximity of our time to significant social, economic and cultural changes, however, makes it highly likely that what is now beginning to come into view is of extraordinary present and future significance.
Moreover, knowledge societies do not come about as the result of some straightforward common pattern of development. They are not a one-dimensional social figuration. Knowledge societies become similar by remaining or even becoming dissimilar. New technological modes of communication break down the distance between groups and individuals, while the isolation of particular regions, cities and villages remains. The world opens up and creeds, styles and commodities mingle; yet the walls between incompatible convictions about what is sacred do not come tumbling down. The meaning of time and place erodes even while boundaries are celebrated.
Until recently, modern society was conceived primarily in terms of property and labor. Labor and property (capital) have had a long association in social, economic and political theory. Work is seen as property and as a source of emerging property. In the Marxist tradition, capital is objectified, encapsulated labor. On the basis of these attributes, individuals and groups were able or constrained to define their membership in society.
While the traditional attributes of labor and property certainly have not disappeared entirely, a new principle, "knowledge", has been added which, to an extent, challenges as well as transforms property and labor as the constitutive mechanisms of society.
In retrospect, even some ancient societies (Rome, China, the Aztec Empire), that gained and maintained power in part as a result of their superior knowledge and information technology, may be described as knowledge societies of sorts. Ancient Israel was founded upon its lawlike Torah-knowledge, and in ancient Egypt religious, astronomical and agrarian knowledge served as the organizing principle and basis of authority. In this sense knowledge has had an important function throughout history, and humans have always lived in "knowledge societies".
But in present-day society knowledge has clearly become much more fundamental and even strategic for all spheres of life, greatly modifying and in some cases replacing factors that until recently had been constitutive of social action.
Thus, and despite the fact that there also have been societies in the past that were based on knowledge-intensive action, the idea that modern society increasingly is a knowledge society is meaningful and has practical relevance. It is as meaningful to refer to modern society as a knowledge society as it made sense to refer to industrial societies even though there had been past social systems that were based on the work of "machines".

4. Knowledge as a capacity for action

Knowledge may be defined as a capacity for action. The use of the term "knowledge" as a capacity for action is derived from Francis Bacon's famous observation that knowledge is power (a somewhat misleading translation of Bacon's Latin phrase: "scientia est potentia"). Bacon suggests that knowledge derives its utility from its capacity to set something in motion. The term potentia, that is: capacity is employed to describe the power of knowing.
The definition of knowledge as capacity for action has multi-faceted implications and consequences. Capacity for action signals that knowledge may in fact be left unused, or that it may be employed for "irrational" ends. The definition of knowledge as capacity for action strongly indicates that the material realization and implementation of knowledge is open, that it is dependent on or embedded within the context of specific social, economic and intellectual conditions. Knowledge, as a capacity for action, does not signal that specific knowledge claims always possess a fixed "value" or even a distinct practical dimension. We cannot, as result, stipulate a priori that some knowledge claims, for example those that issue from disciplines in the humanities, are less practical than knowledge that originates in the natural sciences. Inasmuch as the realization of knowledge is dependent on the active elaboration of knowledge within specific networks and social conditions, a definite link between knowledge and social power becomes evident because the control of conditions and circumstances requires social power. The larger the scale of a project, the greater the need for social power to control the actual realization of knowledge, that is, of knowledge as a model for reality.
Knowledge is a peculiar entity with properties unlike those of commodities or of secrets, for example. Knowledge exists in objectified and embodied forms. If sold, it enters other domains -- and yet it remains within the domain of its producer. Knowledge does not have zero-sum qualities. Knowledge is a public as well as private good. When revealed, knowledge does not lose its influence. While it has been understood for some time that the "creation" of knowledge is fraught with uncertainties, the conviction that its application is without risks and that its acquisition reduces uncertainty has only recently been debunked. Unlike money, property rights and symbolic attributes such as titles, knowledge cannot be transmitted instantaneously. Its acquisition takes time and often is based on intermediary cognitive capacities and skills. But acquisition can be unintended and occur almost unconsciously. Neither the acquisition nor the transmission of knowledge is always easily visualized. The development, mobility and reproduction of knowledge are difficult to regulate. It is "troublesome" to censor and control knowledge. It is reasonable to speak of limits to growth in many spheres and resources of life, but the same does not appear to hold for knowledge. Knowledge has virtually no limits to its growth, but it takes time to accumulate. Despite its reputation, knowledge is virtually never uncontested.
Scientific and technical knowledge, while clearly representing such "capacities for action", do not thereby become uncontestable, no longer subject to challenge and interpretation. Scientific and technical knowledge is uniquely important because it produces incremental capacities for social and economic action or an increase in the ability of "how-to-do-it" that may be "privately appropriated", at least temporarily. The greater the tempo with which incremental knowledge ages or decays, the greater the potential influence of those who manufacture or augment knowledge, and correspondingly, of those who transmit such increments. If sold, knowledge enters the domain of others, yet remains within the domain of the producer, and can be spun off once again. This signals that the transfer of knowledge does not necessarily include the transfer of the cognitive ability to generate such knowledge, for example the theoretical apparatus or the technological regime that yields such knowledge-claims in the first place and on the basis of which it is calibrated and validated. Cognitive skills of this kind, therefore, are scarce.

5. Individual and collective social conduct in knowledge societies

The emergence of knowledge societies signals first and foremost a radical transformation in the structure of the economy. The most common denominator of the changing economic structure is a shift away from an economy driven and governed by "material" inputs into the productive process and its organization, toward an economy in which the transformations of productive and distributive processes are increasingly determined by "symbolic" or knowledge-based inputs.
But the transformation of modern societies into knowledge has profound consequences aside from those that pertain to its economic structure. One of the more remarkable consequences is the extent to which modern societies become fragile societies. This observation has to be qualified. Modern societies tend to be fragile from the viewpoint of those large and once dominant social institutions that find it increasingly difficult to impose their will on all of society, to give direction and determine the fate of its individual components. From the perspective of small groups and social movements more and uncoupled from the influence of the traditional large-scale social institutions, however, modern societies are not particularly fragile at all. For such groups and social movements, the social transformations underway mean a distinct gain in their relative influence and participation, even if typically mainly in their ability to resist, delay and alter the objectives of the larger institutions. I regard precisely the growing importance of such knowledge in modern society as the prime and immediate reason for the enlargement of the capacity of individuals and social movements to assert themselves in traditional as well as new contentious circumstances. The increase in the "knowledgeability" of actors and the decrease or static capacity to act of large collectivities have to be seen as complementary developments since the decline in the ability of large institutions to impose their will is linked to the enlargement of the capacity to act by individuals and small groups in society, for instance, in their capacity to say no or mobilize effective strategies of contention.
The fragility of modern societies as described here, however, is a unique condition. Societies are fragile because --- propelled by a marked enlargement of their capacities to act - individuals are capable, within certain established rules, to assert their own interests by opposing or resisting the -- not too long ago - almost unassailable monopoly of truth of major societal institutions. That is to say, legitimate cultural practices based on the enlargement and diffusion of knowledge enable a much larger segment of society to effectively oppose power configurations that turn out or are apprehended to be tenuous and brittle.
However, much of social science discourse has been preoccupied with the opposite phenomenon, namely the probable and dangerous enlargement of the ability of modern social institutions, especially various state institutions but also the economy, to more ruthlessly impose its will on its citizens. Thus, the classical social theorists as well as many of their more recent successors were concerned with discovering the conditions that produce and reproduce domination and repression rather than greater autonomy, freedom and independence. Modern science and technology typically were viewed, in the context of such analyses, as the handmaidens of regressive civilization developments.

6. Knowledgeability and health

The site in which a transformation from a society in which things merely happen to a society in which they are made to happen on the basis of the greater knowledgeability of actors perhaps can best be observed is the world of health. In knowledge societies in particular, the general level of knowledgeability of every individual is elevated. In other words, the condition for the possibility of greater and more broadly based agency is knowledgeability or a bundle of more widely accessible social competencies and their impact on the stock of social including health capital individuals commands.
As the definition of knowledge I have advanced already signals, knowledge as a capacity for action is not confined to scientific and technological knowledge. Other forms of knowledge, including what sometimes is called "indigenous knowledge" (Sefa et al, 2000) form such capacities for action, even in modern societies though scientific and technical knowledge clearly play a dominant and authoritative role among the range of circulating stocks knowledges.
But that benefits or disadvantages associated with one's ability to mobilize the resource knowledge are not strictly confined to the productive deployment of scientific knowledge can be shown most convincingly, I believe, in the area of health. Knowledge commands health. Knowledge as a socially stratified bundle of competencies, for example, as the capacity of avoidance and therefore of a strategy that ensures that certain health risks are minimized is among these generalized capacities. Knowledge must be seen as a facility to master one's life (see Stehr, 1999).
I will refer to two pieces of empirical evidence that underline the linkage I have stipulated. (1) The decline in mortality from infectious diseases is the most significant medical achievement of modern times, and it is commonly assumed that this achievement is a product of applied science. A detailed examination of the historical record shows that medical science has made but a marginal contribution. For example, mortality from whooping cough, typhus or cholera and related diseases began to decline from the 1870's and therefore long before specific medical measures in the form of medication influenced the decline (cf. Mulkay, 1984:88-90). (2) Extensive reviews of the accumulated empirical evidence of more recent years, conducted by Grossman and Kaestner (1997) suggest that completed years of formal schooling is the most important correlate of good health.


One of the intended, for example as the result of education and unintended

As Galdston ([1932] 1957:294) for example points out, the social movement for health education precedes applied medical science: "In the last quarter of the nineteenth century there also developed the realization, based on the knowledge that most infectious diseases are preventable or controllable, that education in regard to the necessity for health protection is as essential as legislation. This philosophy was adhered to in the face of many difficulties, including the attitude of the medical profession."
This finding "emerges whether health levels are measured by mortality rates, morbidity rates, self-evaluation of health status, or physiological indicators of health, and whether the units of observation are individuals or groups" (Grossman, 1999:64-65).

outcomes, for example as the transformation of modern societies into knowledge societies of investing in the knowledgeability of actors is a significant increase in the individual and collective stock of health. More knowledgeable people are more efficient producers of health which in turn could lead to a decrease or at least to a slowing in the increase of health demanded.
History has by no means ended, but it certainly has changed. The old rules, certainties and trajectories no longer apply. Of course, there are few opportunities of fresh starts in history. Nonetheless, the future of modern society no longer mimics the past to the extent to which this has been the case. That is to say, the future is made from fewer fragments of the past. As a result, sentiments with respect to history that are becoming more pervasive are those of fragility and dislocation. History will increasingly be full of unanticipated incertitudes, peculiar reversals, proliferating surprises, and we will have to cope with the ever-greater speed of significantly compressed events. The changing agendas of social, political and economic life as the result of our growing capacity to make history will also place inordinate demands on our mental capacities. The fit or lack of fit between our knowledgeability and what society, the economy and culture mentally demand is one of the major challenges of knowledge societies.


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