6.

Biomedicalisation revisited: concepts and

practices
Adele E. Clarke, Melanie Jeske, Janet K. Shim, and
Laura Mamo

INTRODUCTION

This chapter introduces the concept of biomedicalisation, developed c2000 as a critical expan-
sion and critique of the classic medical sociology concept of medicalisation, asserting that
medicalisation insufficiently addresses the importance of sciences and technologies to the
dramatic elaboration of biomedicine in the U.S. since c1985. The chapter then traces the career
of this concept including the development of related concepts including pharmaceuticalisa-
tion, and geneticisation. We then review studies of biomedicalisation in practice since 2010,
highlighting research outside the U.S. to demonstrate its widening impacts. Our foci include
(1) biomedicalisation and the media, (2) biomedicalisation and biomedical technologies (e.g.,
algorithmic care—AI, electronic health records, and predictive technologies; biomedical
technologies and the expanding clinic; and technologies in the lab), and (3) biomedicalisation,
precision medicine, and precision public health, with a related section on stratified biomedi-
calisation in/of precision medicine and precision public health. In conclusion, we briefly note
other anticipated future directions of biomedicalisation research transnationally.

THE DEVELOPMENT AND CAREER OF A CONCEPT

The collective development of the concept of biomedicalisation and its processes began in the
late 1990s as a group of medical sociologists at the University of California, San Francisco
started meeting as a collaborative writing group.1 Our independent projects focused on then-
emergent phenomena in late-20th-century biomedicine in the U.S.2 Individually and collec-
tively, we struggled with what we were finding to be various inadequacies of medicalisation
theory (e.g., Zola 1972; Conrad 1975). Medicalisation, the pioneering theory of the disci-
pline of medical sociology, posits that the jurisdiction, authority, and practices of profes-
sional Western medicine have been expanding to include many conditions not previously
considered “medical” (e.g., the medicalisation of badness to sickness, per Conrad). We fully
agreed that such jurisdictional expansions were continuing. But we also found that the con-
cept inadequately engaged the exceptionally dramatic expansions of technoscience, including
the profound implications of computer and information sciences for the very organisation of
biomedicine itself. Also of concern to us was the lack of connections between medicalisation
theory and important new conceptual developments in medical sociology, medical anthropol-
ogy, history, and in interdisciplinary fields such as science and technology, feminist, body, and
cultural studies.

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92 Handbook on the sociology of health and medicine

To address these shared concerns, we began developing a collaborative analysis of the shift-
ing processes of biomedicine and its key elements that were producing “the biomedicalisa-
tion of life itself (human, plant, and animal)…often imaged as a juggernaut of technological
imperatives” (Clarke 1998, p. 275). We defined biomedicalisation as the increasing reliance of
medical organisations, clinical practices, and treatments on technoscientific innovations (e.g.,
MRIs, CAT scans, new pharmaceuticals) and the reorganisation of biomedicine itself through
applications of computer and information sciences (e.g., computerised patient records; auto-
mated appointments and reminders).
The heart of our biomedicalisation argument was that biomedicine broadly conceived
is increasingly and rapidly transforming from the inside out. The life and technosciences
which undergird and inform biomedicine were similarly being technically and organisation-
ally remade. Significantly, both biomedical practices and institutions were and are still being
transformed through old and new social-organisational-technological (especially digital)
means (e.g., Cruz 2018). Together these new practices intervene in health, illness, healing,
the organisation of medical care, embodiment, and how we think about and live “life itself.”3
We then published conceptual articles on the five key processes of biomedicalisation
(Clarke et al. 2000, 2003), a co-edited book of empirical medical sociology studies focused
on the U.S. (Clarke et al. 2010),4 and articles and books on our individual research analyses.5
Conceptually, biomedicalisation travelled widely, increasingly taken up both across disci-
plines and transnationally. Google Scholar lists c7140 publications under the concept (search
performed 9 March 2022) since our earliest publication in 2000.
To highlight selected developments in the career of this concept, we turn briefly to a dis-
cussion of biomedicalisation, focusing on its five key and interactive processes, we then care-
fully show some of its uptake in other disciplines, countries, and languages. We then explore
three major topics extensively examined by other scholars through biomedicalisation lenses:
the media; medical devices and technologies; and (often overlapping) precision medicine
and precision public health. Together, these topics demonstrate precisely how the five key
processes of biomedicalisation are specifically and unevenly manifest. Significantly, these
topics also demonstrate deepening patterns of stratified biomedicalisation—the exacerba-
tion of health and other social inequalities due to differential access to and use of high-tech
biomedicine and its organisation. To conclude, we discuss current and anticipated issues
in stratified biomedicalisation transnationally, especially regarding COVID-19 and other
emerging issues.

THE CONCEPT OF BIOMEDICALISATION

Biomedicalisation was intended as the conceptual next generation of medicalisation. We

carefully noted that earlier patterns producing medicalisation and its practices do not simply
disappear but instead shift and/or are displaced (Clarke et al. 2000, 2003). In our historiog-
raphy, the rise of Western scientific medicine fully established the medical sector of the U.S.
political economy by the end of World War II, the first “social transformation of American
medicine” (e.g., Starr 1982). Next, in ongoing processes called medicalisation, the jurisdic-
tion, authority, and practices of medicine began expanding, redefining areas once deemed
moral, social, or legal problems (such as alcoholism, drug addiction, and obesity) as medi-
cal problems (e.g., Zola 1972; Conrad 1975, 2007)—the second transformation. Since c1985,
 Biomedicalisation revisited 93

largely technoscientific changes in the constitution, organisation, and practices of biomedicine

have dramatically coalesced into biomedicalisation, the third major transformation in the U.S.
Our view originally (Clarke et al. 2010), and now, is that while biomedicalisation is on the
increase, both medicalisation and demedicalisation (Fox 1977) also continue.
As we were elaborating on biomedicalisation c2000–2010, there was discussion (at times
heated) about whether this was basically a U.S.-based or more transnational phenomenon. This
is an important question that continues, yet has also been answered by a number of studies
from many disciplines and across the globe that have demonstrated the presence and effects
of biomedicalisations (plural) in their now considerable geopolitical variation. We highlight a
range of such studies as part of the career of biomedicalisation, noting especially how com-
mon stratified biomedicalisation is transnationally and how its variations are manifest in all
five of its key processes. The five processes of biomedicalisation outlined in our early work
continue to characterise biomedicalisations today. These are:

1. a new biopolitical economy of medicine, health, illness, living, and dying forming
increasingly dense and elaborate arenas in which biomedical knowledges, technologies
(including pharmaceuticals), devices, services, and especially biocapital are ever more
co-constituted;
2. an intensifying new focus on health (in addition to illness, disease, and injury), on optimi-
sation and enhancement of bodies and health by technoscientific means, and an elabora-
tion of risk and surveillance at individual, group,6 and population levels;
3. technoscientisation of biomedical practices whereby interventions for treatment and
enhancement increasingly rely on sciences and technologies, are ever more promptly
applied, often displacing lower tech and less costly alternatives (and often with a distinc-
tive gloss of “modernity”);
4. transformations of biomedical knowledge production, information management, distri-
bution, and consumption especially through applications of computer and information
sciences and enhanced media coverage (discussed below); and
5. transformations of bodies and production of new technoscientific identities, again at
individual, group, and/or population levels, potentially foundational for social movement
formation.

Together, these five processes constitute and produce “biomedicalisations,” and account for
extensive variation, especially geopolitically.
In doing research, these five processes may also be used as analytics, as heuristics to think
with. Specifically, a researcher can ask whether and how each of these processes pertains to
their topic, anticipating and attending to variations. Thus we view these five processes as what
Strauss (1987) would call empirically-based substantive theorising. The processes are wide
open to contingencies, differences, shifts, and even contradictions that await empirical speci-
fication through research (Clarke et al. 2010, pp. 14–19).
Moreover, while medicalisation practices typically emphasise exercising control over med-
ical phenomena (diseases, illnesses, injuries, bodily malfunctions), in contrast, biomedicali-
sation practices emphasise transformations of such medical phenomena and of bodies. Such
transformations are accomplished largely through sooner-rather-than-later technoscientific
interventions increasingly for the prevention, enhancement, and digitised means of monitor-
ing, as well as more conventionally for treatment.
94 Handbook on the sociology of health and medicine

Signalled with the prefix bio, our concept of biomedicalisation is synthetic. First, it indi-
cates the increasing importance of biological sciences to biomedicine. Second, it signals that
issues of biopower and biopolitics theorised by Foucault (e.g., 1991) are integral to biomedi-
calisation. Third, the bio informs our key process of a new biopolitical economy of medicine,
health, and illness. Like the concepts of “bioeconomy” and “biocapital,” we capture how
capital is (re)conceptualised vis-à-vis life itself through its imbrications with the biological
sciences and technologies, biomedicine, megacorporate pharmaceutical and biotechnologi-
cal industries (e.g., Cooper 2008; Sunder Rajan 2017). In sum, biopolitics, bioeconomy, and
related concepts (e.g., vital politics, clinical labor, and life itself) together form emergent and
already dense theoretical webs within which our concept of biomedicalisation and its five key
processes make even deeper sense. In short, the trends we identified in 2003 have not only
been sustained but elaborated. Importantly, they have been taken up by many scholars to
delineate empirical specificities through research.
In our 2010 edited book, Biomedicalisation: Technoscience, Health and Illness in the U.S.,
empirical articles examined emerging domains of biomedicalisation including new transla-
tions of risk into diagnostic and treatment practices (Shim, Shostak, Orr); use of pharmaceu-
ticals, devices, and technologies for newly defined medical subjects (Mamo, Fishman, Fosket,
Kahn); and impacts of digital imaging and visual cultures on (bio)medicine (Clarke, Joyce).
The 2010 book presaged the three major topics in recent biomedicalisation scholarship we
review below.

THE CAREER OF BIOMEDICALISATION

The concept of biomedicalisation has been widely taken up across geopolitical boundaries
and in multiple and interdisciplinary spaces. Since c2000, following our own early conceptual
work (e.g., 2000, 2003, 2010) which focused solely on the U.S., there have been many journal
special issues as well as books centred on research on biomedicalisation, largely from non-
U.S. projects.
In addition to interrogations and applications of the concepts of medicalisation (Zola 1972;
Conrad 1975, 2007) and biomedicalisation (Clarke et al. 2000, 2003, 2010), two additional
“isations” are significant for analysing processes of social transformation in medicine. These
are the concept of geneticisation (Lippman 1991; Hedgecoe 1998) and pharmaceuticalisation
(Williams et al. 2008), worthy of short descriptions for their shared analytic concerns as well
as significance to biomedicalisation.
Geneticisation, coined by Lippman (1991, p. 19) in North America, signifies when “indi-
viduals are reduced to their DNA codes, with most disorders, behaviors and physiological
variations defined, at least, as genetic in origin … Through this process, human biology is
incorrectly equated with human genetics.” Geneticisation was at the heart of critiques of the
U.S. Human Genome Project (Bell and Figert 2015, p. 31).
Pharmaceuticalisation designates key dynamics related to expansions of pharmaceutical
jurisdiction: redefinition of health “problems” as having pharmaceutical solutions, including
in the media and popular culture; creation of new consumer markets; producing new techno-
social identities; and mobilisations of patient/consumer groups around drugs (Williams et al.
2011, p. 710). Pharmaceuticalisation features the outsized role of the pharmaceutical indus-
try in the dissemination of information, research, and actual provision of biomedicine and
 Biomedicalisation revisited 95

over-the-counter (OTC) as well as direct-to-consumer (DTC) healthcare, initially especially

in the U.K. While physicians remain gatekeepers to medicine in most places, pharmaceutical
advertising is rampant—including to physicians themselves. OTC medications and products
are increasingly available and profitable. Anthropological studies across the globe have exam-
ined intersections of pharmaceutical industries, clinical medicine, NGOs, and patients that
produce individual well-being as a commodity. While providing distinct improvements for
some (e.g. Whitmarsh 2008), others dwell in clinical limbo or altogether outside the treatment
realm (Biehl 2006; Petryna and Kleinman 2006). This is stratified biomedicalisation.
To us, the concept of biomedicalisation generically subsumes geneticisation and pharma-
ceuticalisation, especially through its constitutive processes of technoscientisation and trans-
formations of biomedical knowledge production and consumption. While both concepts, in
principle, engage technoscience-based forms of biomedicine, and are hence subparts of the
more inclusive concept of biomedicalisation, at times foci on their specific processes can be
important to illuminate specific trends. That is, biomedicalisation in no way automatically
displaces geneticisation or pharmaceuticalisation (or any other technoscientific transforma-
tion) analytically. Rather, the specific process having primacy of analytic place should always
be an empirical question in research, especially since situations vary so much geopolitically.
With their valuable co-edited book, Reimagining (Bio)medicalisation, Pharmaceuticals
and Genetics, Bell and Figert (2015) waded into this complex fray. Rather than pitting these
concepts against each other, Bell and Figert judiciously discuss them as “the 4 ’izations.’”
Most striking about their volume—and related literatures—is the relentlessness of stratifying
effects accomplished through all “the 4 ’izations’” and how this is sustained transnationally.
An array of journal special issues since 2010 has focused on biomedicalisation, diversely
engaging the concept and further shaping its career. First, Joyce and Loe (2011) expanded
U.S. ageing studies with Technogenarians: Studying Health and Illness through an Ageing,
Science, and Technology Lens. Here elders creatively adapt technologies to fit their needs and
challenge the rise of anti-ageing medicine.
Second, “The Biomedicalisation of Brazilian Bodies: Anthropological Perspectives,” guest
edited by Löwy and Sanabria (2016), examined how biomedical techniques are taken up
across the highly diverse structural constraints afforded in a country with both private and
public healthcare systems. Foci here included the careers of abortion drugs as they travelled
beyond biomedical control; the politics of psycho-pharmaceuticalisation; stratified access to
obstetric ultrasound; and the blurring of enhancement and health in a body-centric culture.
This special issue makes visible sites where the consumption of “things medical” becomes a
distinctive marker of modernity and citizenship. The heavily stratified practices of biomedi-
cine in Brazil span from lavish extremes of “boutique biomedicalisation for optimization” to
bare life and “letting die” (e.g., Biehl 2013).
A third journal special issue is titled “Is the 21st Century the Age of Biomedicalisation?”
Guest editors Moyer and Nguyen (2016, pp. i–ii) asked: “What if biomedicine, or to be more
precise ‘biomedicalisation’ (Clarke et al. 2003), is to the 21st century as industrialisation was
to the nineteenth? … [C]an we posit that biomedicalisation indexes another such transfor-
mation, one that also is hinged on how harnessing vital bodily substances produces value?”
Building on Cooper and Waldby’s (2014) analysis of clinical labour, they focus on how forms
of biovalue are today harnessed as vital bodily substances generated by biomedicalised inter-
ventions in reproductive processes, thereby displacing previously dominant accumulation of
surplus labour in industrial settings. Their focus is largely but not only on Europe, and reports
96 Handbook on the sociology of health and medicine

on a number of research projects. We were deeply gratified that our work provoked such seri-
ous theorising, and we find such analyses prescient.
Several other major contributions regarding biomedicalisation in its transnational travels
deserve mention. Hsu (2013) studied the complicated biomedicalisation of trans bodies and
kinship in Northeast Asia, finding a “sheen of sexual modernity” glistening where male-
to-male sex is legal, and trans citizens can obtain legal documentation of current gender.
However, to obtain such documents, all the involved governments require reproductive steri-
lisation of the applicants for new “citizen bodies.” Thus reproductive rights are wholly denied
to trans citizens. Type 2 diabetes is the focus of Armstrong-Hough’s (2018) project comparing
the U.S. and Japan this century. She demonstrates how distinctive, long-sustained “local biolo-
gies” (Lock 2001) regarding both etiology and proper treatment endure among both patients
and physicians—despite intensifying biomedicalisation.
Last, five ongoing projects are in progress under the rubric “Biomedicalisation Inside Out”
sponsored by the Institute of Health and Society, University of Oslo, Norway.7 They note that
“the power to set the boundaries of normal and pathological has been increasingly uncoupled
from the profession of medicine itself.” The five biomedicalisation projects focus on transgen-
der; drug use; forensic psychiatry; death and dying; and the implications of biomedicalisation
for the future of social medicine. An array of other research on biomedicalisation continues
across disciplines and transnationally beyond present scope.

BIOMEDICALISATION IN PRACTICE: RECENT AREAS OF EMPHASIS

Three major substantive areas where biomedicalisation has recently been empirically pursued
transnationally are: (1) the media; (2) medical devices and technologies; and (3) precision
medicine and precision public health.

Biomedicalisation and the Media

In our edited volume, Clarke’s chapter (2010a) argued that developments of “things medi-
cal” in the past and present U.S. are not only accompanied by and reflected in popular visual
cultural iconography, but also continue to be in part generated and produced by and through
them. As images and objects become constitutive of biomedicine, they become healthscapes:
patterned ways of grasping and legitimating patterned changes in sites of health and medicine.8
In 2016, using our biomedicalisation lenses, Briggs and Hallin (2016) coined the term
biomediatisation as the core process examined in their book Making Health Public: How
News Coverage is Remaking Media, Medicine, and Contemporary Life. Biomediatisation is
the co-production of medical objects and subjects through complex entanglements between
epistemologies, technologies, biologies, and political economies. They found it relentless
and pervasive. Briggs and Hallin provocatively asked (2016, p. 5): “What would happen
if we imagined ‘the media’ as taking up residence in clinics, hospitals, pharmaceutical
corporations, and public health offices, seeing health professionals as embedded in media
spheres?”
Years before COVID-19, they grasped biomediatisation as routinely integrated into our
contemporary world, and that media and health domains are transforming one another. News
coverage of health constitutes a high proportion of all news, and even before COVID-19, about
 Biomedicalisation revisited 97

half of the people studied carefully attended to that news. Implications of biomediatisation for
social justice are elaborated.
Italian scholars Neresini et al. (2019, pp. 8–9) developed a quantitative means of testing
our biomedicalisation hypothesis. They found an overall “trend toward the ‘biomedicalisa-
tion of the press’” in reporting on health and medicine in newspapers in both the UK (The
Guardian) and Italy (la Repubblica) from 1984 to 2017. This was accompanied by heightened
framing of health and medicine issues as matters for technoscientific intervention. Neresini
et al. (2019) found media discourse on biomedicalisation grew on three dimensions: (1) health
and well-being as matters of individual commitment to self-monitoring and self-surveillance
(governmentality through optimisation); (2) biomedicine as a large, technoscientific enter-
prise emerging from entanglements among research and its technological products; and (3)
tensions in national health systems vis-à-vis trade-offs between levels of fiscal sustainability.
Individually, media provide resources for gaining “somatic expertise” (Rose 2007), important
in generating “the quantified self” (Lupton 2016).
There is also a literature on how pharmaceutical advertising is co-produced with public
relations, social media, and other “tech” firms effectively producing an ethos of biomedi-
calisation as cultural and “lifestyle” engagement. In sum, the media are not only of signal
importance in enhancing biomedicalisation, but are also co-constitutive of biomedicalisation
processes and are central to its ongoing legitimation.

Biomedicalisation and Medical Devices and Technologies

The accelerating introduction of new biomedical technologies across the spectrum of

biomedicine—from the lab bench to patients’ bedsides, homes, and bodies (e.g., via wearable
devices, and home DNA testing)—continues to reshape what we call the technoscientisation
of biomedicine. Over the past half-century, biomedical technologies have profoundly shaped
how we understand, intervene in, and actively resist technoscientific approaches to bodies and
lives.
While Clarke et al. (2003) discussed several areas of technoscientisation, much has since
changed within biomedical infrastructures and practices. In this section, we consider three
broad domains of technologies that drive biomedical knowledge production: data technologies
used in healthcare clinics; biotechnologies in the expanding clinic; and those used in biomedi-
cal research laboratories.

Technoscientific care: artificial intelligence and predictive technologies

Recent scholarship has attended to automated and predictive technologies, such as artificial
intelligence (AI), and the ways they exacerbate social inequalities through the automation of
discrimination and racism (Benjamin 2019; Eubanks 2018; Noble 2018). In the past two years
alone, we have witnessed increasing social awareness of the role of race in clinical algorithms
and healthcare decision-making (Vyas et al. 2020). Increasing datafication of society, that
is mobilisation of data for various social means, has led to mounting hype surrounding the
potential of data to solve societal problems.
In healthcare, the introduction of datafication processes and technologies raises impor-
tant questions about which technologies, created by and for whom, for what ostensible pur-
poses, impose what sorts of anticipated and unintended consequences, as well as the values
and power relations they make visible. Efforts to integrate disparate patient electronic health
98 Handbook on the sociology of health and medicine

record systems, for example, and the mining of these data to offer new insights on the nature
of patient and population health, allow for seemingly ever-expanding data sets to be aggre-
gated and analysed by health systems.
Yet these developments also raise serious issues of data privacy and potential misuse. Public
health entities also utilise internet search trends, cell phone GPS data, and other personal data
to track flows of people, exposures, and movements of health risks. Technology product com-
panies are becoming the new faces of public health, as digital temperatures and biometric
data are combined with cell phone information into a new “internet-of-things”—triangulated
data collection strategies to specify sites of risk and illness. The hype surrounding datafication
drives often invisible data collection, analysis, and use in social institutions including educa-
tion, law enforcement and criminal justice, surveillance, and healthcare. The combination of
data-related skills and technologies and the ability to aggregate, analyse, visualise, and make
available high-quality data, larger or linked, in close to real time, are the heart of precision
public health (Weeramanthri et al. 2018, p. 3), discussed below.
Moreover, these data technologies enable the ostensibly “automatic” generation of risk:
simply by entering data in these systems, patients are flagged as being at risk for conditions
often unrelated to the purpose of their visit, thereby triggering new forms of risk assessment
and consequent illness management. As genomic testing results are increasingly integrated
into electronic health records, new questions emerge about the reach of these data forms and
privacy. As ethics organisations, committees, and some bioethicists take up narrow questions
of informed consent, provider-patient relations, etc., others are calling for a more incisive bio-
ethics that addresses questions of community care and social justice (e.g., Mamo and Fishman
2013; Nelson 2016; Reardon 2017).
Further, such data systems extend far beyond collecting data on patient health and out-
comes; increasingly they are used to further organisational and economic ends. As healthcare
costs rise, hospital systems seek data-driven methods to ensure quality care and harness costs.
Cruz’s (2018) work, for example, describes how anxieties over the performance, quality, and
value of social institutions have resulted in the quantification of performance metrics. This
pattern has turned to “data-driven” accountability reform through the quantification of qual-
ity in healthcare systems. Often incentivised by federal health agencies and their regulatory
powers, such efforts also discipline a wide array of clinicians’ work, and create new forms of
governmentality affecting patients (Martin et al. 2013; Winslow 2020; Darling 2016).

Biotechnologies and the expanding clinic

Over the past 20 years, do-it-yourself (DIY) care and data collection technologies have become
prominent in how people practice health and medicine in the U.S. (Greene 2016). Both bio-
tech companies and healthcare systems have harnessed this culture of health and wellness for
their own purposes. While “lay” people have long developed their own approaches to caring
for themselves, at times embracing or rejecting biomedicine, harnessing the DIY approach
has become important for those both working in and capitalising on new and vast biomedical
markets. Here innovators push for expanding (and expanded insurance coverage of) at-home
diagnostic technologies (e.g., doc-in-a-box, direct-to-laboratory testing for HPV and high-risk
genotypes), virtual systems for care delivery (e.g., telehealth services), and tracking technolo-
gies that report health measurements to clinicians and/or data centres for remote monitoring.
Alongside explicitly healthcare-related data tools, an innovative new array of “lifestyle health
data” collection tools has emerged. Highlighting the ever-expanding reach of biomedicine,
 Biomedicalisation revisited 99

the ability to track, manage, and optimise health has been built into the very technological
infrastructures of daily life (Rab Alam 2016).
Yet, while DIY efforts might seem to promote the democratisation of biomedicine,
expanded coverage, and decreased utilisation of certain clinical services, physical healthcare
facilities are still primary sites for seeking and receiving healthcare, and clinicians continue
to be gatekeepers for accessing diagnoses and care regimens (Lupton and Jutel 2015). As such,
healthcare remains a key site of stratification and inequality, particularly as new technolo-
gies reshape how care is accessed and delivered. Particularly in the wake of the COVID-19
pandemic which legitimated it as a sociological “side-effect,” telehealthcare is an increasingly
attractive option for managing healthcare costs, both reducing “unnecessary” clinical visits
(Oudshoorn 2011), as well as an alternative in times of crisis when healthcare facilities pose
new risks and for the disabled more generally. Writing this chapter amid COVID-19, we wit-
nessed a historic moment in which demand for telehealth skyrocketed. In a matter of weeks,
the rate of using various tele applications in large healthcare systems which had hovered at
2–3% of patient visits leapt to 55% (ACP Hospitalist 2020). Many predict telehealth is here to
stay (Nature 2021).
Of course, the availability of alternatives to in-person healthcare, as well as healthcare
proliferating into communities and homes, raises crucial questions about who has access to
human care, and who defaulted to distanced and automated services, despite evidence showing
human interaction may be critical to effective care (Pugh 2018). As new technologies medi-
ate (and may substitute for) interpersonal interaction, quality care relies heavily on patients to
properly use technologies to care for themselves. Increasingly, telehealth is also shifting the
interpretation of results, long the fiercely protected domain of physicians, to these patients/
users, creating new burdens for them (Oudshoorn 2011).
Indeed, these biomedicalised developments also raise new questions about what will be
expected of patients and how patients will need to engage with providers (Timmermans
2020). The ability to perform as “expected,” and to maximise healthcare encounters has been
described as a regime of patienthood (Joyce et al. 2020; Joyce and Jeske 2019). It requires
what Shim (2010) has called “cultural health capital.” Shim’s concept highlights how the posi-
tionality and articulateness of patients impact patient-provider interactions. Patients’ abilities
to signal their concerns, competencies, and compliance have implications for how providers
approach and invest time in them.

Biomedical technologies in the lab

Biomedicalisation also turns analytic attention to less obvious spaces where new biomedical
technologies shape how and what we know about human health and disease. Since the 1980s,
advances in biotechnology and genetic engineering have dramatically changed the landscapes
of the biosciences (Sunder Rajan 2012, 2017; Thompson 2013). In bioscience laboratories,
human cells and models take on new meanings as they stand in as proxies for the complexities
of the human condition (Landecker 2007; Nelson 2018). Such advances promise to increase
the detection of risk factors for disease, and to treat diseases faster and more effectively—cre-
ating a regime of hope and hype in which we are always already anticipating the benefits of
such advances (Adams et al. 2009).
The significant expense of these technologies and procedures, alongside uncertainties of
such investments, results in deepening public-private partnerships and imperatives toward
commercialisation of academic biomedical research; this is exacerbated by pharmaceutical
100 Handbook on the sociology of health and medicine

and biotechnology companies defunding their own research and development arms (Croissant
and Smith-Doerr 2008; Robinson 2019). The promotion of new partnerships and arrange-
ments in recent translational medicine initiatives makes visible how industry interests are
increasingly intertwined with state and academic agendas, while the absence of investment
in other areas (such as those subsumed under the rubric of “public health”) is often invisible
(Jeske 2021).
Biomedical technologies in laboratory settings include models, devices, and tests used to
understand human health and disease. They are often quite separate from living human bod-
ies, represented instead by proxy non-human model organisms or, if human materials are
present, by fragmented forms of DNA, cells, or tissues (Jeske 2022; Landecker 2007; Nelson
2018). Yet the knowledge created using these tools produces the knowledge base for much of
what we know about human conditions.
Unpacking the construction of these models and tools, and how they do and do not capture
social difference, has been a critical contribution of biomedicalisation scholarship, highlight-
ing the inherently social nature of biomedicine. Well-documented decisions about inclusion
in biomedical research and the structure of clinical trials shape to whom results are applica-
ble, and who we have and do not have knowledge about (Epstein 2007; Fisher 2011, 2020).
Moreover, beliefs about difference become embedded within biomedical tools, akin to the
algorithms discussed above.
Biomedical laboratories and their technologies have become key sites where inequalities
are exacerbated (Benjamin 2013; Braun 2014). Moreover, such technologies become danger-
ously invisible, seemingly objective tools, parts of the hidden infrastructures of biomedical
research. Yet they have been profoundly shaped by historical decisions about what is worthy
of modelling and which differences matter (Jeske 2022). Thereby, stratifications have been
“built-in” to biomedicine, and to biomedicalisation itself.

Biomedicalisation, Precision Medicine, and Precision Public Health

The concept of biomedicalisation has been taken up to understand shifts in medicine and pub-
lic health knowledge and practices, especially how biomedicalising processes are constitu-
tive of clinical and population health sciences. Precision medicine (PM) and precision public
health (PPH) mobilise information technology and data science to assess and improve health
at individual and population levels (Dowell et al. 2016; Khoury et al. 2016; Weeramanthri
et al. 2018).
This datafication—big data approaches to medicine and public health (discussed above)—
includes both clinical and genomic information. As well, social, environmental, and
behavioural determinants of health are often brought together and integrated through epi-
demiologically driven approaches. While PM emphasises the use of genomic data in clinical
care, PPH emphasises technoscientific forms of public health surveillance. Both exemplify
biomedicalisation.
In recent years, both have intensified in form, reach, and scope. PPH, for example, inte-
grates multiple data sets and uses technosciences often in real time to prevent, track, and
respond to disease outbreaks. In fact, tracing and understanding where and how biomedicali-
sation is enacted in and through PM and PPH reveals that in the 21st century, the two domains
of clinical medicine and medical science on the one hand, and public health research and
practice on the other, are increasingly continuous and mutually constitutive.
 Biomedicalisation revisited 101

Reflecting on biomedicalisation processes, PM and PPH together shape what kinds of

subjects, “risks,” and responsibilities come to matter, what problems are deemed important,
which solutions are framed (e.g., Marshall 2009), what technologies are built, based on which
assumptions (Benjamin 2013, 2019), and ultimately what kinds of futures are deemed possible
and desirable. PM and PPH are biomedical imaginaries ultimately shaping what many hope
for, expect, and fear from science, technology, and medicine (McNeil et al. 2017, p. 457F).
Moving from “one-size-fits-all” medicine to so-called tailored or personalised treatments and
prevention, the biomedicalisation of PM and PPH drive ongoing investments in bioinformatics
and data infrastructures (Juengst 2016; Meagher et al. 2017; Tutton 2014).
Enacting biomedicalisation, the imaginary of “precision” in medicine and public health
shapes concrete practices as well as subjectivities and identities. The precision imaginary
belongs to a particular “anticipatory regime” wherein new technologies promise to lead to bio-
medical breakthroughs, and “such anticipations are not only diagnostic; they are productive”
(Adams et al. 2009, p. 257), generating investments. Thus, biomedicalisation can be seen “in
action” in medicine and public health approaches where pharmaceutical, biotech, healthcare,
and technology companies invest in each other and sell and distribute products, commodities,
and information to individuals, entities, and governments that can most afford to pay.
Currently and likely escalating, data from multiple sources may be integrated and brought
to bear on pressing public health issues. For instance, epigenetic data could be brought together
with environmental data on air quality, and local epidemiological data to address asthma rates
as well as environmental injustices that disproportionately affect low-income communities
and communities of color (Auffray et al. 2016).
Epidemiological data (e.g., surveillance data, registries, surveys) has long been a crucial feature
of public health research and practice. In contrast, information-driven, technologised strategies
termed PPH emerged as new biomedicalised approaches. They include “digital epidemiology”
(Salathé et al. 2012), “infodemiology” (Eysenbach 2009), “digital pharmacovigilance” (Salathé
2016), and others. As Norton (2013) demonstrates, public health surveys have become instru-
ments of biomedicalisation. Finally, expertise is reimagined as data collection performed by
many “self-collectors” willing to be made into subjects and objects of biomedical surveillance.
The COVID-19 pandemic reveals these dynamics in real-time as PM and PPH approaches
were immediately ramped up to surveil, contain, and prevent the further spread of the pan-
demic. Researchers utilising the virus’s genomic signatures tracked their spread globally, as
well as identified potential therapeutic targets for treatments. Disparities in COVID infec-
tion and outcomes have predictably led to possibilities of genetic variations in susceptibility.
Genomic databases, enhanced by artificial intelligence data mining platforms, now seek to
identify potential genetic variants that might confer differential risks of infection or sequelae.

Stratified Biomedicalisation in/of Precision Medicine and Precision Public Health

Stratified biomedicalisation serves as a framework for examining power relations and inequi-
ties in the processes and outcomes of biomedicalisation, most often focusing on the mutual
imbrications of race, gender, sexuality, class, age, and other social categories of difference.
Sociologist Troy Duster (2006) described biomedicine generally and precision medicine spe-
cifically as processes that sort and stratify. Biomedicalisation thus provides a twinning logic
for cooptation and disciplining, inclusion and exclusion, which selects for and promotes dif-
ferent differences for scrutiny, intervention, or neglect.
102 Handbook on the sociology of health and medicine

The uneven distribution of access to biomedicalised interventions across social groups con-
stitutes a defining feature of 21st-century biomedicine and public health, both sustaining and
elaborating on past patterns of inequity (Whitmarsh 2008; Fisher 2020). Many communities,
especially Black, Indigenous, people of colour, immigrants, low-income, and people with dis-
abilities in the U.S., have long been subjected to medical neglect and exclusions of various
kinds, under-resourced in terms of medical and other healthcare services. Simultaneously,
they are overexposed to medical harms that include both racism and racist claims about bodies
(e.g., Kahn 2013), and exploitative practices in medical research (e.g., Reverby 2012), or what
Washington (2006) refers to as “medical apartheid.”
The social lives of technosciences, including DNA, have profoundly reshaped public health,
implicating race and racism, ability and disability, and the containment and surveillance of
risk and disease, identities and bodies, and lives and communities. Nelson (2016) innovatively
analysed how Black people use direct-to-consumer genetic testing for community justice
goals. They anticipated potential harmful use by law enforcement and criminal justice, while
carefully moving forward to leverage “data” for purposes that re-centre justice and power,
specifically for reparations or reconciliation.
Similarly, Bliss (2015, p. 177, 2018) has shown how “classification in public health, govern-
ment-sponsored industry, and the public creates a system in which people are recognised by
and recognise themselves in terms of new biomedical technologies of the gene.” She argues
that individuals and groups simultaneously understand themselves to be in need of biomedical
expertise and intervention, yet are also prevented from seeing the social and political condi-
tions shaping their health and lives.
Leveraging a biomedicalisation lens, Hatch (2016) too traces scientific racism embedded
within the rise of a metabolic fetish and politics. As the costs of diabetes and its “risk fac-
tors” become “a political problem for those who govern” (2016, p. 7), the state, research-
ers, and healthcare institutions are seeking to combine new forms of molecularisation, risk
assessment, surveillance, and individual- and population-level interventions. However, this
simultaneously produces ideas about metabolic syndrome and racial difference. While the
accompanying rhetoric centres on equitable access to pharmacologic and other treatments, it
also promotes the notion that race is biological and genetic and elides the unequal impacts of
racialised agricultural capitalism and food politics.
Kahn (2013) examined how precision medicine as racialised medicine has a decidedly phar-
macological bent. BiDil was the first drug approved by the U.S. Food and Drug Administration
with a race-specific indication—to treat heart failure among “Black” patients. Conditions of
possibility for making BiDil a racially specific drug included a biopolitical economy where
biomedical knowledges, biotechnologies, health services, and biocapital are increasingly co-
constituted, and focus on population-level differences is intensified. BiDil became a model for
analysing data by race and using categories of race and ethnicity to exploit niche markets and
promote commercial interests.
Even where precision medicine has explicitly sought a more expansive and inclusionary
ambit by also including behavioural, environmental, and social determinants, research has
fallen short. For example, Shim and colleagues (2014a, 2014b) found that genomic research
including social determinants of health (formerly the purview of public health) actually
undermined the validity of self-defined sociocultural affiliations and the explanatory poten-
tials of social inequalities as causes of health inequalities. Ultimately, scientists’ expansive
conceptions of social and environmental determinants of health yielded to imperatives to
 Biomedicalisation revisited 103

molecularise: environmental phenomena affecting disease incidence were thereby redefined

solely in terms of their molecular components (Darling et al. 2016).
The technosciences of precision medicine and public health drive both a meticulously
molecularised and datafied quest for essential biological differences simultaneously paired
with the elision of the social—here racialisation and racial hierarchies as sources of health
disparities. These domains encode and reinforce deeply racialised and historicised under-
standings of health and its production and distribution. If cooptative inclusion and strategic
exclusion are modes of racialised (or racist) medicalisation, then the double-sided molecu-
larisation and elision of race in precision medicine are preeminent modes of 21st-century
biomedicalisation.
Alleviating health disparities has been central to proposals for both PM and PPH.
Significantly, this vision for a more equitable future requires large-scale investments in data
infrastructures and analytic capacities, so that “large swaths of seemingly disparate data sets”
(Precision Public Health Summit 2016, p. 14) can be integrated and shared among diverse
stakeholders. Yet such increased investment in data collection and infrastructure for precision
approaches may ultimately not be the best approach for addressing health disparities or creat-
ing health equity. They leave the social determinants of health and root causes of unjust health
disparities largely untouched.
Biomedicalisation, with its concomitant big data technosciences, may be able to target
interventions spatially, genomically, and by population. But it is also crucial to anticipate
other harmful travels. The solutions offered by PM and PPH—increased surveillance
and data gathering, customised biomedical interventions, and targeted risk-reduction
strategies—may in fact exacerbate the very inequalities they seek to address. They may
well further stigmatise already marginalised individuals and populations without changing
their social and economic circumstances. Moreover, they will shift funding and attention
away from strategies for addressing health disparities that are not framed explicitly in terms
of biomedicine or bioinformatics (Kenney and Mamo 2019). Indeed, as Kenney and Mamo
(2019) have recently demonstrated, geo-mapping, geomarkers, and geotargets are conjoined
with bio-mapping, markers, and targets in precision public health, garnering considerable
funding.

CONCLUSIONS: LOOKING AHEAD

Going forward, we anticipate continued elaborations of biomedicalisation—and research on

it, on “bio,” “medicine,” and on the “in between” that is increasingly both transdisciplinary
and transnational (Löwy 2011). Significantly, the scientisation of medicine has been uneven
across specialties, hence we anticipate that clinical sites will become as rich in future as the
laboratory has been (e.g., Latimer 2013).
The COVID-19 pandemic has all too vividly demonstrated how profoundly stratified health-
care is, especially access to advanced biomedicine and its technoscientific tools. Moreover,
such stratifications have been exacerbated in the pandemic (e.g., Villarosa 2020). Hence we
anticipate a flood of “pandemic” science, seeking further biomedicalisation of risks as well as
treatments (e.g., Fisher 2021; Fosket 2004, 2010). While we cannot know whether COVID-19
will become endemic, we can be certain that vast inequities—in exposure, protection, treat-
ment, and vaccination—will surely continue to stratify in ways that cut across racial, income,
104 Handbook on the sociology of health and medicine

and global/local divides. We urge analyses that examine these issues through the lenses of
stratified biomedicalisation.
Indeed, perhaps the most fundamental issues are transnational political-economic choices
regarding intensified investment in the potential of high-tech biomedicalised PPH com-
pared with investment in basic public health strategies. As research on biomedicalisation has
become more globalised, we are discerning patterns of “biomedicalisation for those who can
afford it,” intensifying stratification. In contrast, those who cannot afford it increasingly yearn
for such interventions as symbols of “achieving modernity,” rendering “affording biomedi-
calisation” a desired regional or national accomplishment. Sadly, the basic infrastructures on
which biomedicine itself is built (e.g., clean water, electricity, education, transportation), are
rarely prioritised for wider distribution. Hence, stratified biomedicalisation is displacing other
global health initiatives such as clean water, sanitary housing, waste management—and, quite
radically, clean air and soil—pursued to avoid further stratifying biomedicalisation.

NOTES
1. Four of us were doctoral students working on dissertations (Fishman, Fosket, Mamo, and Shim),
and the fifth was a faculty member (Clarke). Among our current group of authors, Jeske is a post-
doctoral researcher and the rest of us are faculty.
2. Clarke (1998, 2000, 2010a) studied history of reproductive sciences; Mamo (2007) studied con-
ception among non-heterosexual people; Shim (2014) studied the politics of risk and inequality in
heart disease research; Fosket (2004, 2010) studied a pioneering clinical trial of a chemoprevention
drug for breast cancer; and Fishman (2004), Fishman and Mamo (2002), and Mamo and Fishman
(2001) studied the development and dissemination of Viagra.
3. For an overview, see Table 1: “The Shift from Medicalisation to Biomedicalisation” (Clarke et al.,
2003, pp. 168–169; 2010, pp. 53–54).
4. Clarke (2010b) offered an “Epilogue: Thoughts on Biomedicalisation in its Transnational Travels,”
to encourage others to take up some of the five key processes as analytic tools with which to exam-
ine potential biomedicalisation issues elsewhere. Subsequent publications demonstrate how they
have done so!
5. See note 2.
6. On “niche standardization,” see Epstein (2007).
7. See https://www.med.uio.no/helsam /english /research /projects/biomedicalisation-inside-out/.
8. This was inspired by Appadurai’s (1996, pp. 33–35) scapes.

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