Showing papers in "International Journal of Health Services in 1988"

Corporatization and the Social Transformation of Doctoring

Abstract: Corporatization of health care is dramatically transforming the medical workplace and profoundly altering the everyday work of the doctor. In this article, the authors discuss recent changes in U.S. health care and their impact on doctoring, and outline the major theoretical explanations of the social transformation of medical work under advanced capitalism. The adequacy of the prevailing view of professionalism (Freidson's notion of professional dominance) is considered, and an alternative view, informed by recent changes, is offered. While the social transformation of doctoring is discussed with reference to recent U.S. experience, no country or health system can be considered immune. Indeed, U.S. experience may be instructive for doctors and health care researchers in other national settings as to what they may expect.

Women and children at risk: a feminist perspective on child abuse.

Abstract: Viewing child abuse through the prism of woman battering reveals that both problems originate in conflicts over gender identity and male authority. Data indicate that men, not women, typically commit serious child abuse. A study of the mothers of child abuse victims shows that battering is the most common context for child abuse, that the battering male is the typical child abuser, that the battered mothers have no distinctive pathology in their backgrounds, and that clinicians respond punitively to the battered mothers. The child abuse establishment assigns responsibility for abuse to mothers regardless of who assaults the child, and responds punitively to women, withholding vital resources and often removing the child to foster care, if women are battered or otherwise fail to meet expectations of "good mothering." The combination of male control, misleading psychological knowledge about women's propensity for "bonding," and sanctions used to enforce gender stereotypes of motherhood combine to increase the entrapment and inequality from which battering and child abuse originate, a process termed "patriarchal mothering." The best way to prevent child abuse is through "female empowerment."

Social Class and Cardiovascular Disease: The Contribution of Work

Abstract: Low social class has been identified as a risk factor for coronary heart disease in highly industrialized countries. The authors discuss the social class concept in relation to psychosocial working conditions. Most of those psychosocial work characteristics that are of relevance to cardiovascular risk, namely, skill discretion, authority over decisions, and social support at work, are unevenly distributed across social classes--the lower the social class, the fewer the resources for coping with psychosocial stressors. Furthermore, biomedical risk factors for cardiovascular illness are also unevenly distributed across social class and associated with psychosocial work characteristics. The main conclusion is that part of the association between social class and cardiovascular illness risk may be due to differences in psychosocial work conditions. The psychosocial work conditions may affect the risk through either neuroendocrine mechanisms or lifestyle. Excessive tobacco smoking, for instance, may be enforced by poor working conditions.

Medical metaphors of women's bodies: menstruation and menopause.

Abstract: Implicit, underlying imagery in medical descriptions of menstruation and menopause is exposed, beginning with 19th century views. Contemporary medical texts and teaching reveal two fundamental assumptions about women's bodies. First, they assume that female reproductive organs are organized as if they form a hierarchical, bureaucratic organization under centralized control. Given this assumption, menopause comes to be described negatively, as a process involving breakdown of central control. Second, they assume that women's bodies are predominantly for the control. Second, they assume that women's bodies are predominantly for the purpose of production of desirable substances, primarily babies. Given this assumption, menstruation comes to be seen negatively, as a process involving failed production, waste products, and debris. Alternative imagery that works from our current understanding of physiology, but avoids denigration of women's bodies, is suggested.

Lay evaluation of medicine and medical practice: report of a pilot study.

Abstract: Sociologists appear to differ in the way they portray the public's ideas about modern medicine. Some argue that the public accepts that modern medicine is effective, and others say that as a whole ...

The Development of Canadian Nursing: Professionalization and Proletarianization:

Abstract: In this article, the development of nursing in Canada is described in terms of three major time periods: the emergence of lay nursing, including organization and registration, 1870–1930; the move to the hospital, 1930–1950; and unionization and the routinization of health care, 1950 to the present. This development is viewed in the light of the orienting concepts of professionalization, proletarianization, and medical dominance (and gender analysis). This historical trajectory of nursing shows an increasing occupational autonomy but continuing struggles over control of the labor process. Nursing is now using theory, organizational changes in health care, and credentialism to help make nursing “separate from but equal to” medicine and to gain control over the day-to-day work of the nurse. Nursing can thus be viewed as undergoing processes of both professionalization and proletarianization. As nursing seeks to control the labor process, its occupational conflicts are joined to the class struggle of white-co...

"Your time or mine?" An anthropological view of the tragic temporal contradictions of biomedical practice.

Abstract: The symbolic construction and use of time in health care is examined both in relation to social control of patients and to the power/powers accorded to and claimed by physicians. After reviewing classical medical sociology approaches of Zerubavel and Roth, it is suggested that an anthropological approach using concepts of disease, illness, and sickness and especially the last make it possible to produce a more adequate analysis. The cultural performance of sickness is seen in a framework of power, space, and time, and comparisons drawn between preindustrial and industrial patterns of healing (including Hahn's detailed ethnographic account of the practice of an internist in the United States). It is argued that medicine as it is at present practiced in industrial society inevitably requires health workers and especially physicians to distance themselves in time from the experience of their patients by taking the present-tense account of perceived illness (the history), which they initially share, and trans...

Social epidemiology and the work environment.

Abstract: A major theme in virtually all of Bertil Gardell's work is that the social and work environment affects health and well-being. This concern with the social environment has been a major influence in...

Polypharmacy: its cost burden and barrier to medical care in a drug-oriented health care system.

Abstract: In order to determine the economic and therapeutic implications of the prescriber habit in a drug-oriented health care system, data were collected on the provisional diagnosis, prescribed drugs, and their cost and procurement pattern among 1450 pediatric outpatients in a Nigerian University Teaching Hospital. It was found that on average, about five drugs were prescribed for each patient, and there was a tendency to prescribe more expensive and sometimes unnecessary drugs. The more the number or higher the cost of drugs prescribed, the less patients procured them. It is therefore recommended that health care authorities and physicians in similar settings should review their drug policies and prescribing habits in order to discourage polypharmacy and the high cost of chemotherapy, with their attendant barrier to medical care.

The Retreat of the State and its Transfer of Responsibility: The Intergenerational War

Abstract: In this article, the socially constructed nature of the conflict between the generations, or the “intergenerational war,” is explored, with a description of the two major fronts of this battle: a health care financing axis and a caregiving axis. Basic to the health care financing axis is the assumption that certain individuals and populations represent an increasing and unreasonable social burden; the caregiving axis gives ideological support to familial and filial responsibility. The politics of mystification perpetuates the idea that these two axes are unrelated and that generational transfers are independent rather than interdependent. Both permit abdication of the state from social responsibility for human needs and massive budgetary reallocations to defense and tax cuts for the wealthy. An alternative approach derives from the principle of universal life-course entitlement to basic human needs.

Overlooked, overworked: women's unpaid and paid work in the health services' "cost crisis".

Abstract: Dewaging shifts work from the marketplace to the household. The shift seems a short-term strategy used by capitalists, governmental policy-makers, and managers to reduce the wage bill for service workers in such areas as schooling, retailing, health services, and banking. In health services, the expansion of women's unpaid nursing in the household and a new labor process among paid nursing workers are necessary for new corporate and federal cost-containment strategies. Registered and licensed nurses, nurse's assistants and aides see their jobs eliminated, expanded, or moved from one work site to another. Increased use of outpatient clinics, in-and-out hospital stays of less than one day, and shortened hospital stays mean sick people in their homes, not hospitals. The work of caring for the sick does not disappear, however, though people may go without. Much nursing work is shifted to patients and to their families, and even to friends and neighbors. Within the family, women's unwaged work is central, supporting the new labor process among paid nurses. Wives, mothers, daughters, friends, etc., do the work once done for pay in clinics and hospitals.

Rigor in Health-Related Research: Toward an Expanded Conceptualization

Abstract: When the research process is viewed not merely as a set of methods for data collection and analysis but, instead, as an integrated series of arbitrary choices made by the researcher, it quickly becomes apparent that the prevailing conceptualization of rigor is much too narrow; indeed, the way rigor is currently conceptualized may well be responsible for the many errors that are commonly made in the research process. An expanded conceptualization of rigor is presented, and its implications for research into some critical health issues are discussed in some detail.

Racism, the National Health Service, and the Health of Black People

Abstract: Racism has been and is central to an understanding of the health of black people in Britain. Black people have played and are playing a central role in the National Health Service (NHS). Their role...

Occupational Health Risks for Mexican Women: The Case of the Maquiladora along the Mexican-United States Border

Abstract: International reports of morbidity among female workers in Mexico's border zone have raised concern about the occupational health of female workers in maquiladora plants (foreign-owned border industries with special tariff benefits). Commentators have suggested that U.S. industries may be exploiting workers by transferring work to nations with less stringent health and safety regulation through the maquiladora program. Using data from a larger evaluation of the effectiveness of Project Concern and a specially developed questionnaire, this study investigated the extent to which female workers reported higher morbidity rates than women with other employment and women not employed outside the home in seven colonias (communities) in Tijuana, Baja California, Mexico. Results showed essentially no difference in many short-term self-reported symptoms of illness among maquiladora workers and two other groups. Women who worked exclusively in the home reported the greatest number of symptoms. These results suggest ...

Democratizing occupational health: the Scandinavian experience of work reform.

Abstract: Concepts such as alienation, dissatisfaction, and stress have been in use for several decades to indicate a major field of problems in working life, pertaining to the psychosocial aspects of work. In spite of the fairly broad recognition of the problems, it has proved difficult to create an effective strategy for work reform. The purpose of this article is to indicate some reasons for this difficulty and to attempt to deal with psychosocial issues that emerged as part of the Scandinavian work environment reforms of the 1970s. Although these reforms were only partly successful, they verified the point that efforts should not be limited to the semi-private sphere of the individual enterprise only, but must encompass legislation and other general parameters that arise from larger societal processes. The legislation, however, cannot be of the conventional kind. While it is necessary to bring the regulatory parameters of society to bear on such issues as the organization of work, innovations within the field of legislation are also needed. Language: en

Learned helplessness at work.

Abstract: The development of theory and research on learned helplessness is reviewed and criticized on some points, e.g., for its reliance on artificial laboratory experiments. Some empirical findings are presented, indicating a connection between certain work characteristics and learned helplessness. Other research traditions have emphasized the importance of job qualifications, freedom of action, and development possibilities for well-being and health. There is, however, hardly and research on learned helplessness at work. Learned helplessness hypotheses should be tested on data from real life; if applied to work environment research, the theory of learned helplessness could generate important results.

Accommodation for elderly persons in newly industrializing countries: the Hong Kong experience.

Abstract: The newly industrializing countries seem set to follow many developed countries with a rapid growth in numbers of elderly people. This will throw considerable strain on their resources, particularly in the provision of services and accommodation for this group in society. Hong Kong is a leader amongst the newly industrializing countries, both in terms of its aging population (more than 11 percent of its people are now over 60 years of age) and in terms of economic growth. It has, however, only relatively recently embarked upon a comprehensive and integrated program to provide a wide range of accommodation for the elderly. This includes sheltered housing within Hong Kong's well-known public housing schemes, old people's homes, care-and-attention homes, and infirmaries. The private sector has also been growing rapidly in the 1980s with a considerable recent increase of old people's homes. A voluntary code of conduct for this sector was introduced in late 1986, but concerns remain about the quality of care and the rapid growth of private homes in the territory. The approaches to the provision of accommodation for the elderly are set in the context of Hong Kong's overall social policy development. Whilst the experience of relatively wealthy Hong Kong may not prove to be of relevance for the majority of Third World countries, it is argued that it may provide a model for other newly industrializing countries.

The selection and training of primary health care workers in Ecuador: issues and alternatives for public policy.

Abstract: Quantitative analysis was used to evaluate the effectiveness of the health care worker (CHW) training program used by the Ministry of Public Health in Ecuador. The study 1st assesses CHW knowledge in the areas of prevention maternal-child health 1st aid and treatment of common illnesses. CHWs retained 50% of what they learned 1 year after graduation. Demographic factors accounted for some variance in performance. Higher levels of community organization were associated with improved CHW knowledge. The presence of a health committee was also an important factor. The 2nd phase of the study was designed to assess the community impact of the program. Surprisingly neither the demographic characteristics of the health worker nor his or her level of competence affected the impact of the program on the community as measured by patient satisfaction utilization indices and adoption of preventive health behaviors. It was the characteristics of the beneficiaries themselves that accounted for the variance in community impact. With regard to the adoption of health behaviors it is clear that the primary health care (PHC) program has had only limited success in convincing villagers to adopt these practices. The mean index of adoption of these practices by the 7 families interviewed in each village was 15.61 of a total of 56 possible behavior changes. Clearly if the CHWs performance is not a major determinant of this phenomenon then other factors must be responsible. In some cases economic factors may intercede. For example in areas where wood is scarce peasants are unlikely to use it to build fires for boiling drinking water. Cultural or demograhic factors cannot be ignored when searching for the causes of the low level of adoption of these behaviors.

Workplace democracy and worker health: strategies for implementation.

Abstract: A large body of literature documents that increased worker participation leads to improvements in the working environment. This article identifies the Swedish and Norwegian sources of some of this research and notes the link with social policy, namely, legislative reform in those countries. In contrast, the United States has resisted legislative solutions, but that may be changing. New strategies to democratize the workplace are a result of global economic competition, desire to reduce job stress and compensation costs, and more successful application of new technologies at work. These are examined and some conclusions are drawn about next stages in the reform efforts.

Hidden Menace in the Universal Child Immunization Program

Abstract: At Alma Ata in 1978 all the countries of the world agreed that there should be "health for all by the year 2000" and that this goal was to be attained through primary health care. The Alma Ata Declaration was a victory for the people of the Third World countries. It would give health care back to the people through the democratization of health services involving the people in policy formulation planning programming and implementation of the health services in which technology would be subordinated to the needs of the people. No longer would the rich Western nations by exerting pressure on international organizations be able to impose upon the oppressed people of the Third World their ill-conceived technocentric vertical programs with large urban medical institutions that corner the bulk of those countries health budgets but serve only a small elite fraction of the people. This imposition of selective health care began innocuously enough in 1979 when J.A. Walsh and K.S. Warren published a poorly formulated and flawed critique of a weakly conceived health project in Haiti (N Engl J Med 1979;301:967-74) in which they claimed that comprehensive primary health care is well beyond the reach of most Third World countries. Citing this flawed paper powerful organizations such as the Rockefeller Foundation the World Bank the UN Childrens Fund and the US Agency for International Development launched several selective health care programs including the GOBI (Growth charts Oral rehydration therapy Breast feeding and Immunization) program and the Child Survival Development Revolution. More recently the UN Childrens Fund launched its Universal Child Immunization to all by 1990 (UCI-90) program. This is another of the prepackaged overpriced inappropriate and irrelevant packages of high technology medicine which have been thrust upon the people through massive propaganda campaigns euphemistically called "social marketing." This gigantic program has been launched without benefit of even the most basic data about infectious diseases or adequate facilities for refrigeration. It takes no account of the massive failures of previous vertical programs such as the BCG Campaign and the National Malaria Eradication Program. It is totally unrealistic to expect field workers to provide effective immunization coverage to the over 24 million children born every year in India. Finally the Universal Child Immunization Program is in direct conflict not only with the Alma Ata Declaration but also with the Antwerp Manifesto for Primary Health Care.

The Mandwa Project: An Experiment in Community Participation:

Abstract: The project at Mandwa was designed to study the problems of health in rural India and the delivery of health care by the existing public and private health systems. The results demonstrate the important role of socioeconomic and political factors not only in vital areas such as nutrition water supply sanitation and housing but also in the delivery of health services. The private sector showed a predominantly curative and monetary orientation while the public sector demonstrated a lack of accountability to the people it was designed to serve. Under these conditions an attempt was made to test the possibility of training local women in self-help with a minimal supportive service. The results reveal that adequate knowledge and technology exist for most of the prevalent problems of health and illness in developing countries and that semiliterate villagers have the capacity to use these effectively if they are provided in a simple manner. This experiment also demonstrates the opposition from local vested interests to any change of the status quo even in the relatively noncontroversial field of health. Mandwa can either be seen as a failure of a community health project or as an experiment that demonstrates how knowledge can help people to overcome their fears and encourage self-reliance. Whether this knowledge and technology can be spread through an organized movement or in a nonformal manner or combination of both remains to be seen.

Racial inequalities in health: a challenge to the British National Health Service.

Abstract: The existence of racial inequalities in health in the United Kingdom is examined using both indirect and direct data The evidence strongly supports the view that the health experience of black and other ethnic minority groups is worse than that of the indigenous white population Ways of improving this situation are outlined; they indicate the need for a coordinated Health service response incorporating planning, training, and equal opportunities in both service provision and employment practices

Causes of health and safety hazards in Canadian agriculture.

Abstract: Agriculture remains one of the most hazardous occupations in the world, even in industrialized countries. One of the major differences between Canadian agriculture and most other sectors of the economy is that the vast majority of farmers are self-employed. Consequently their particular relations of production are expected to have an impact on the issue of work health and safety. After a review of the nature and extent of work accidents, deaths, illness, and injuries in farmers and farm workers, the article focuses on the causes of such hazards. These causes are analyzed with reference to individual, institutional, and structural factors. The author argues that institutional and structural factors seem to be of paramount importance in explaining the severity of farm health hazards.

Toward a transformation of health and aging policy.

Abstract: Millions of Americans are plagued by serious problems of inadequate health care benefits, limiting their access to services and creating hardship. For those under 65 years of age, the problem is the lack of insurance for many working poor and others. For the elderly, the problem is one of underinsurance in terms of both cost and coverage, particularly for long-term care. Policies of cost containment and cost shifting to consumers have exacerbated these problems, and current health policy proposals offer little respite. Arguments are made for a program of public national health care. Health policy interventions are considered at four levels: incrementalism, modification, alteration, and transformation. A proposal is presented for universal health benefits that are organized and operated to eliminate for-profit medical care and to promote social and preventive care.

Free care: a quantitative analysis of health and cost effects of a national health program for the United States.

Abstract: We estimate the health and cost effects of instituting a National Health Program (NHP) in the United States that would provide universal, comprehensive free care. Based on empiric studies of the relationship of health service use to cost and health outcomes, we estimate that an NHP would increase use of health services by 14.6 percent and save between 47,000 and 106,000 lives annually. Because the United States faces a growing surplus of hospital beds and physicians, additional services could be provided at low cost. Simplifying the health bureaucracy that currently enforces unequal access to care would also result in substantial savings. Consequently, an NHP would actually decrease costs 2.4 percent, $10.2 billion annually, since the $35.7 billion spent for additional services would be offset by $45.9 billion saved on bureaucracy.

The profitization of health promotion.

Abstract: In this article the author argues that not only is the marketplace an ineffective arena for health development, it is currently generating decision-making paths that obscure more effective perspectives and directions to promote Americans' health. To illustrate this premise, available evidence is presented that suggests that the use of “health promotion” by the proprietary sector, as well as the commercialization of health promotion, is creating decision-making processes that are not accountable to those whom they affect. This emerging infrastructure is characterized by organizations, programs, delivery channels, and evaluative criteria that do not give people's health priority over organizational interests. These developments require critical examination and work on alternatives if the promotion of health is to result in more health than hype.

Workers' participation and occupational health: the French experience.

Abstract: In France, workers' participation in occupational health was organized for the first time in 1947, when Hygiene and Safety Committees were created. However, these committees remained ineffective in many firms for more than 20 years. Their role and power were greatly extended in 1976; in 1982, the Auroux Laws gave wage-earners new rights, mainly rights of expression. Here too, the way these laws have been put into operation varies a lot. Generally speaking, a great many regulations and laws exist that should give workers very good protection, but control systems are weak, and wage-earners' information on health is insufficient. Workers' participation is generally set up through trade unions, which are more often nationwide than locally organized. Workers' membership in unions is rather weak. The recent creation and development of quality circles in many firms, controlled by the company, give a false impression of workers' freedom of speech and do not really improve participation. But recent social movements have shown that people increasingly wish to express themselves and to deal with their own employers without any go-between. Nevertheless, participation will become effective only if workers' knowledge is taken into account, if they are trained in analysis and expression, and if their suggestions are seriously considered.

Torture as intensive repression in Latin America: the psychology of its methods and practice.

Abstract: The practice of torture in Latin America is fundamentally an activity of the state and part of a larger program of repression. In this article, the author analyzes, in general, the psychology of the methods and practice of torture, and, in particular, the psychological defenses likely activated by the torturer when confronting the victim. The contradictions in the relationship of torturer to tortured are seen in the light of larger social contradictions within the scheme of domination.

AIDS funding: competing needs and the politics of priorities.

Abstract: Despite the Department of Health and Human Service's 1983 claim that AIDS is the nation's “number one health priority,” funding for AIDS research, prevention, and treatment remains inadequate. Wors...

Sex education in Cuba: an interview with Dr. Celestino Alvarez Lajonchere [interview by Elizabeth Fee].

Abstract: This article is an interview with Dr. Celestino Alvarez Lajonchere, Director of the National Institute of Sex Education in Havana, Cuba. The topics of discussion include reproductive rights issues, contraception, and abortion law; sex education in Cuba, homosexuality, and national policy on AIDS.