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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
Essen
Germany
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.
Abstract
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.
Prospects
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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