Showing papers in "Sociology of Health and Illness in 1995"

The rise of surveillance medicine

Abstract: Despite the obvious triumph of a medical theory and practice grounded in the hospital, a new medicine based on the surveillance of normal populations can be identified as emerging in the twentieth century. This new Surveillance Medicine involves a fundamental remapping of the spaces of illness. This includes the problematisation of normality, the redrawing of the relationship between symptom, sign and illness, and the localisation of illness outside the corporal space of the body. It is argued that this new medicine has important implications for the constitution of identity in the late twentieth century.

Theorising class, health and lifestyles: can Bourdieu help us?

Abstract: What is the relationship between class, health and life-styles, and to what extent does health-related knowledge influence subsequent behaviour? These issues have been a source of considerable debate for medical sociologists and others concerned with promoting ‘healthier’ life-styles over the years. Yet despite a wealth of empirical material, there has been little attempt to theorise this relationship between class, health and lifestyles and the associated issues of structure and agency, accounts and action it raises. This paper attempts to rectify this lacuna through a critical discussion of the work of Pierre Bourdieu, and its relevance to the class, health and life-styles debate. In particular, attention is paid to Bourdieu's analysis of the logic of practice, his concepts of habitus and bodily hexis, and the search for social distinction in the construction of (health-related) life-styles. The paper concludes with a critical commentary on these issues and the relative merits of Bourdieu's analysis for the sociology of health and illness. It is argued that despite certain limitations regarding issues of agency and ‘choice’, Bourdieu's analysis does indeed shed important light on the health and lifestyles debate, and that further bridge-building exercises of this nature between mainstream theory and the sociology of health and illness are both necessary and fruitful.

Renegotiating identity: cancer narratives

Abstract: We frame the work of living with cancer as one which is identity-altering. Interviews with a heterogeneous group of cancer patients of varying sites and stages were used to conceptualise the identity work as involving disrupted feelings of fit, renegotiating identity, and biographical work. Patient narratives reflect these categories depending on their stage of illness and their experiences in medical institutions.‘Identity work’ is used to describe the process of patients' evaluations of the meaning of their illness within the actual context of ongoing, organised social relationships, including the medical system. We discuss the implications for narrative analyses in the social sciences.

From biographical disruption to biographical reinforcement: the case of HIV‐positive men

Abstract: In-depth interviews were conducted with 44 asymptomatic HIV-positive men infected through homosexual relations or medical treatment for haemophilia. The objective was to better understand interrelations between: the consequences of infection on everyday life; the meanings given to being HIV-positive; and the reconstruction of identities. The consequences for everyday life are examined in relation to: the importance of keeping one's immune status secret; self-imposed restraints and the constraints ensuing from the immune status; and the resources interviewees tapped to cope with their new situation. The meanings given to infection arose as these men reinterpreted their individual and collective pasts. This biographical reconstruction reinforced components of identity that, prior to HIV-infection, had been built around haemophilia or homosexuality. This is what is called biographical reinforcement, a notion developed in relation to biographical disruption.

Transcending the dualisms: towards a sociology of pain

Abstract: Theories of pain have traditionally been dominated by biomedicine and concentrate upon its neurophysiological aspects, both in diagnosis and treatment. Hence, scientific medicine reduces the experience of pain to an elaborate broadcasting system of signals, rather than seeing it as moulded and shaped both by the individual and their particular socio-cultural context. Although pain lies at the intersection between biology and culture, making it an obvious topic for sociological investigation, scant attention has been paid to understanding beliefs about pain within the study of health and illness. A major impediment to a more adequate conceptualisation of pain is due to the manner in which it has been `medicalised, resulting in the inevitable Cartesian split between body and mind. Consequently, the dominant conceptualisation of pain has focused upon sensation, with the subsequent inference that it is able to be rationally and objectively measured. Yet as well as being a medical `problem, pain is an everyday experience. Moreover, sociological and phenomenological approaches to pain would add to, and enhance, existing bodies of knowledge and help to reclaim pain from the dominant scientific paradigm. In this paper, it is argued, firstly, that the elevation of sensation over emotion within medico-psychological approaches to pain, can be shown to be limiting and reductionist. Secondly, we attempt to show how insights from the newly-emerging sociological arenas of emotions and embodiment provide a framework which is able to both transcend the divide between mind and body and to develop a phenomenological approach to pain. Finally, in order to bring the meaning of pain into fuller focus, we draw attention to the importance of studying theodices and narratives, as well as the cultural shaping and patterning of beliefs and responses to pain.

'A healthy lifestyle might be the death of you': discourses on diet, cholesterol control and heart disease in the press and among the lay public.

Abstract: In Australia and other western countries, research on the relationship between dietary intake and coronary heart disease has attracted wide news media coverage. One of the most recent issues to receive media attention is the role of cholesterol control in reducing the risk of coronary heart disease. News reports on cholesterol and diet have vacillated confusingly from supporting health promotional orthodoxy in warning individuals to monitor carefully their intake of certain substances such as fats, salt and cholesterol, to questioning the validity of such dietary control. This paper presents the findings of a study investigating media coverage of and the responses of members of the lay public to recent diet and cholesterol control controversies. Analysis found that while the participants commonly articulated concern about their diet, they also expressed a high degree of cynicism both in the news media's coverage and health promotional advice on diet and cholesterol control. Respondents drew upon discourses relating to the pleasurable nature of indulging oneself in eating, but also expressed moralistic discourses concerning the need to ‘work’ at being healthy, thus juggling the dialectic of health as control and health as release. The adage that ‘everything in moderation’ was the way to live one's life, regardless of official advice concerning dietary regulation, was commonly expressed as a strategy of coping with the confusions around diet.

Parkinson's Disease as a problem of shame in public appearance

Abstract: Using life stories as data, the research problem was to find patterns in the interpretations of Parkinson's Disease. In one of the patterns—found in 12 of the 23 life stories—Parkinson's Disease is interpreted as a problem of ‘shame’. The interpretation of shame could partly be explained by other elements of the pattern. Shame is said to arise from the assumed rule-breaking character of the signs of the disease. Not all rule-breaking behaviour, however, is said to be an explanation for shame. Three conditions are mentioned. The first is the social importance of the rules broken. The rules which are said to cause shame are considered as socially sensitive, as related to important social values. The value particularly pointed to is described as ‘social competence’. The second condition is the ‘visibility’ of the behaviour. Particularly, rule-breaking in public is said to arouse shame. The third condition is the assumption of being labelled as a ‘deviant’ because of the rule-breaking behaviour. In this pattern of interpretation two consequences are drawn. In the first the life world is divided into a ‘private’ and a ‘public’ domain. In the second, found in almost all the life stories in which shame is mentioned, the informants say they feel inclined to ‘retreat’ from the public domain.

Threats to the good death: the cultural context of stress and coping among hospice nurses

Abstract: This study uses Australian data based on interviews with nurses and participant observation in an in-patient hospice and a community based hospice service to demonstrate how hospice nurses perceive stress in their work environment and cope with caring for dying patients. Stressors are discussed within a cultural context and are viewed as threats to the nurses' shared system of values which centres on the Good Death. The Good Death is conceptualised as a series of social events that involve the dying person as well as the other interactants who may include family, friends and health professionals. The death is defined as ‘good’ if there is an awareness, acceptance and preparation for death by all those concerned. The nurses' coping strategies and social supports are negotiated within the context of the hospice environment, and relate directly to the protection and affirmation of the nurses' shared value system.

Bringing back the body without the blame?: the experience of ill and disabled people at work

Abstract: This paper tussles with the policy question, that of integrating people with arthritis into employment, in terras of a dialectic between trouble and trust. It suggests that disability theorists' emphasis on the ‘social model of disability’ as the definitive explanation for disabled people's unfavourable position in the labour market is limited without an understanding of the body as a set of relationships linking self and outer world together. For disabled people, longterm illness in a public domain such as work may profoundly disrupt expectations about biographical and social integrity, and normative order. Using an indepth qualitative approach, this paper focuses on the differing employment experiences of two informants disabled by rheumatoid arthritis. Their accounts illustrate some tensions between the breakdown of trust, its constitution as trouble, and attempts to restore ‘business as usual’ in the workplace. The wider social and cultural significance of illness in the workplace, and the need to adopt a more discriminating approach to ‘discrimination’ are discussed.

Ethnicity: not a black and white issue. A research note

Abstract: Les dangers d'utiliser la « race » comme concept analytique dans la sociologie de la sante et de la maladie sont soulignes dans cet article. Puis l'A. examine la facon dont les termes « racisme » , « racialisation » et « ethnicite » peuvent etre definis dans le but de distinguer entre les minorites ethniques, les majorites ethniques et les minorites racialisees dans la Grande-Bretagne d'aujourd'hui. Il est soutenu que par l'usage de cette terminologie, les implications du racisme, des pratiques culturelles et des facteurs biologiques en ce qui concerne les differences de sante entre les groupes ethniques peuvent etre specifiees

The art of surveillance or reasonable prevention? The case of cervical screening

Abstract: In this article data are presented and analysed which identify and explore a white male working class discourse on cervical screening. This discourse was recounted by women who participated in nine discussion groups held as part of a project concerning the views of working class women on cervical screening. The cervical screening service is often viewed as a valuable component of preventive health services and one which recognises the unique health needs of women. In fact it is now a major component of the GP contract with service provision linked to target payments. However cervical screening does pose a number of risks, not solely medical, for service users. In particular the results of this study demonstrate that the female body, in this case the cervix, is a site for state, professional and male surveillance and control, through a preventive service which many feel obligated to participate in.

‘Panic bodies’: discourses on risk and HIV antibody testing

Abstract: Si plusieurs etudes sociologiques recentes ont cherche a comprendre les raisons qui poussent les personnes a ne pas se considerer comme exposees au virus du SIDA, peu sont en fait destinees a la comprehension des raisons relatives a la decision de passer le test de depistage du SIDA. Cet article presente les resultats issus d'entretiens semi-directifs aupres d'adultes, residant a Sydney (Nouvelle-Galles du Sud, Australie), qui ont fait un ou plusieurs tests. Les aspects relatifs aux dimensions socio-culturelles du test pour ceux qui l'ont effectue sont discutes, ainsi que les representations de la seropositivite et du SIDA dans les campagnes de prevention des medias, l'evaluation des partenaires et les notions de risques et de contagion dans le contexte de personnification de l'epidemie

Socioeconomic mortality differentials in men and women according to own and spouse's characteristics in Finland

Abstract: This paper compares the magnitude of differences in mortality according to own and spouse's socioeconomic characteristics and assesses the importance of cross-classifying these characteristics. The analysis covers all 35–64 year-old married Finnish men and women in the period 1981–85. Relative mortality rates were obtained from Poisson regression models. The analysis shows that socioeconomic mortality differentials within each sex are more or less equally large according to both own and spouse's education or occupational characteristics for a wide range of causes of death. Moreover, among both women and men cross-classifications between own and spouse's socioeconomic status do not indicate important mortality differentials over and above those already displayed by its two separate parts, i.e. there were no important interactions between own and spouse's socioeconomic characteristics. The results call into question the argument that the mortality of married women should be analysed on the basis of their husband's socioeconomic characteristics because these characteristics better describe both spouses' socioeconomic standing and are thus more powerful predictors of men's and women's mortality than women's socioeconomic characteristics. It is further concluded that the advantages of cross-classifying both spouses' socioeconomic characteristics in mortality analysis are very limited when these characteristics do not interact with each other. Moreover, cause-specific comparisons between men and women showed that married women's mortality differentials by own educational as well as occupational status were roughly as large as those obtained for men. The larger total mortality differentials among men than women are mainly due to cause of death structure.

Inequalities in health: the interaction of circumstances and health related behaviour

Abstract: This paper derives its main hypothesis from results of the Health and Lifestyle Survey as reported in Blaxter's mono- graph Health and Lifestyles. In this book it is argued that in a favourable social environment a healthy lifestyle matters but in a unfavourable social environment a healthy lifestyle does not make much difference. This hypothesis is tested with data from health surveys from the Netherlands and Denmark. The Dutch data showed a highly significant relationship of unfavourable material and social circumstances with both poor health and an unhealthy lifestyle. In turn, an unhealthy lifestyle was also related to poor health. The Danish study showed similar, although generally weaker, associations. When the British findings would apply to Denmark and the Netherlands, we should find an interaction between material and social circumstances and health related behaviour in their association with health and illness. Neither the Dutch nor the Danish data showed an interaction of the type that the British study assumes. The paper concludes with a discussion of the reasons why the findings from the UK could not be replicated.

The fracturing of medical dominance in British psychiatry

Abstract: Medical dominance is not a transhistorical and invariant property of the medical profession. Rather it is a set of occupational privileges that can be invoked or revoked according to changing alignments of political, economic and cultural power. Using the example of British psychiatry in the context of the health service reforms of the 1980s, it is argued that medical dominance may be fracturing as a result of the policy switch towards community mental health care and the managerial reorganisation of the health services. Knowledge claims and medical procedures that have legitimated the dominant position of psychiatry within the mental health services - a medico-eclectic ideology, a view of doctor superiority over other mental health professionals and the extensive use of physical treatments—are outlined and contrasted with the conflicting ideas and authority structures of community care and health service management. Challenges to medical dominance in mental health, it is contended, are represented by the legislative empowerment of a range of previously subordinated groups of professionals and para professionals. This paper draws primarily upon two sources of data; an ethnography and in-depth interview study of 40 psychiatrists and managers in the Bristol area in 1989–90 and an analysis of the writings of psychiatrists in the professional press.

Appraisal of health risks: the roles of masculinity, femininity, and sex

Abstract: The study examined the relationship between gender role orientation and appraisals of health risks. A random sample of college students from a U.S. university responded to the Bem Sex Role Inventory (BSRI). Subjects also were presented with sets of scenarios that depicted health-threatening events. They rated the extent to which different environmental events and the degree to which immediate illness symptoms posed a threat to their health. The ratings did not differ significantly between men and women or between individuals who were above versus below the median on the masculinity dimension. The one consistent result was an interaction between femininity and sex of subject - highly feminine men exhibited the highest health concern ratings compared to the other subgroups. Additional analyses ruled out potential confounding variables. The findings suggest that the extent to which males are socialised toward greater femininity appears to lead to a heightened sense of awareness and concern about health compromising circumstances. Our results are consistent with a growing body of psychosocial literature showing the beneficial effects of femininity on health and illness outcomes.

Health inequalities as policy issues ‐ reflections on ethics, policy and public health

Abstract: Social class differences in health have been found in all societies that have looked for them. In spite of an apparently stable historical pattern of upper social classes living longer and faring better than lower ones, there is a certain amount of variation in the size, trends and nature, even the direction of such differences, indicating that they might be modified by policy and social change. Social class differences in health, as well as other health inequalities, have in fact become a part of the political agenda. But policymaking in this area is weak and unconvincing in most countries. There is little consensus as to why policies to reduce health inequalities are important. Should they be pursued for the reason that health is a ‘right’, as suggested by some writers, and often in the political rhetoric? Or because they are important for a country's level of health in general? The purpose of this article is firstly, to examine some of the moral justifications for the reduction of health inequalities and, secondly, to suggest that the public health policy agenda can be improved by focussing on the public health significance of health inequalities. It is argued that the reduction of health inequalities may represent a great potential for improving the health of the population, but there is a moral justification for equal distribution of health, risks and health resources even if this did not contribute greatly to improved general health.

Adding insult to injury: homelessness and health service use

Abstract: This qualitative study considers why homeless people in the least secure forms of accommodation make little use of the primary health care services provided by the National Health Service. Current approaches to this question have tended to develop in a sociological vacuum, unaffected by relevant developments in medical sociology and broader social theory. An approach informed by Alfred Schutz's phenomenology has been used in this article to develop a more theoretical account of homeless people's use of health services than has hitherto been offered. Running throughout this article is the claim that, amongst rough sleepers, there is a distinct culture which makes use of mainstream health services unlikely. Sleeping rough, it is argued transforms the way mainstream health services are seen and renders inappropriate the rules of thumb which govern health and illness behaviour in wider society. In developing these arguments, the view, presented in previous work, that homeless people do not value their health and are apathetic about seeking health care is rejected. Rough sleepers, it is suggested, will use health services if they feel these are provided in an accessible and sensitive way.

Patient responses to benzodiazepine medication: a typology of adaptive repertoires developed by long‐term users

Abstract: Since the late 1970s there has been a marked decline in the prescribing of the benzodiazepines. Yet long-term use of this drug persists despite widespread media condemnation and growing professional concem. The study seeks to illuminate this phenomenon by deploying qualitative methods to investi- gate the meaning that such medication has for the users themselves and their styles of management. In-depth interviews were conducted with fifteen community-based users and seven members of a self-help group. From this material a typology was developed that reflected the relationship users had formed with their medication. The key dimensions in this typology were the degree of dependency on the drug, the perceived level of risk associated with it, and underlying attitude. The rela- tionships to the drug refiected in the typology were suggestive of a pattern of self-regulation and active management by users, rather than dominance and control by practitioners. Furthermore, the investigation indicated that characteristics of the medication regime itself- such as type of drug and dose - exert an infiuence on the attribution of meaning and the place of the drug in users' lives. While a characterisation of patient subculture has real potential for application in clinical practice, there are also implications within medical sociology for theories of medicalisation and social control-

'Sexy docs' and 'busty blondes': press coverage of professional misconduct cases brought before the General Medical Council.

Abstract: La sociologie medicale tendait a presenter la relation entre le medecin et son patient comme liee par des roles et des obligations sociales. Le medecin etait, dans ce cadre, concu comme emotionnellement detache et objectif. Ce modele a ete remis en cause comme idealise et remplace par un modele critique. L'A. presente un certain nombre de donnees collectees aupres du «Professional Conduct Committee», un organisme britannique, charge de statuer sur les manquements des medecins en matiere de deontologie. Il s'interesse a l'attitude et au langage des medias en ce qui concerne la presentation des situations de contentieux dans ce domaine

Musculoskeletal suffering: diagnosis and a variant view

Abstract: What acounts as relevant and valid information in a diagnostic context? A descriptive analysis of a first encounter from physiotherapy practice provides the background for a proposed response to this question. The encounter took place between a therapist and a patient suffering from muscular tension. It exemplifies the employment of dimensions of experience and knowledge other than those ordinarily accepted by scientific medicine. Prevailing notions of the body and the traditional distinction between ‘objective’ and ‘subjective’ knowledge are considered against this background. It is suggested that the tacitly accepted separation between the physical body and human experience be superseded by a new understanding. Conversely, the prevailing correlation between ‘patient/symptoms/subjectivity’ and less valid information on the one hand, and ‘clinician/signs/objectivity’ and valid information on the other, is shown to be counterproductive. Verbal and bodily information are not categorically different, belonging to the separate worlds of ‘res extensa’ and ‘res cogitans'. In real lives—and real bodies—they are complementary. It is argued that more complex interactional forms are better suited than standard diagnostic procedures to understand and deal adequately with patients’ often complex ailments.

Elitism and professional control in a saturated market: immigrant physicians in Israel

Abstract: Using Israel as a case study, Che paper considers the social mechanisms by means of which the medical profession seeks to maintain its boundaries and control in a social context characterised by the recent arrival of twelve thousand immigrant physicians from the former Soviet Union. This situation poses a threat to the veteran medical profession which is described as combining elitist and proletarian elements in an uneasy balance. In the past the principal mode of resolution with regard to this duality has taken the form of demonstrative assertions of the elitist component. With the large influx of immigrant doctors, three mechanisms geared to maintain control have been utilised: (1) the formal licensing examination for general practice; (2) full control of employment options in the health care system and (3) a widespread negative stereotype regarding the level of immigrant physicians' professional skills. The paper discusses these mechanisms and their implications for the profession.

Going against the grain: smoking and ‘heavy’ drinking amongst the British middle classes

Abstract: This paper examines the characteristics of those members of the British middle classes who ‘go against the grain’ of healthy living by both smoking and drinking alcohol over recommended levels. Using logistic regression procedures on GHS data, it concludes that there are significant gender differences, with men being much more likely to adopt such risky health behaviours than women. Further, the social correlates of such behaviours differ for men and women. For men, such behaviours are significantly associated with marital status, the experience of social mobility and region. For women, such behaviours are associated with the presence of dependent children, educational level and the number of hours worked in paid employment. The paper attempts some tentative interpretations of these results by drawing upon the available sociological literature.

Domestic labour and health: bringing it all back home

Abstract: This paper explores the relationship between unpaid domestic labour and health. Although the 'informal care' literature touches on the connection between aspects of domestic labour and health, sociologists have not engaged in a systematic analysis of the nature of this relationship. In the following discussion I examine i) the reasons why this relationship has been obscured, ii) possible ways forward in theorising the link and, iii) the under-recognised historical contribution made by domestic labourers to the improvement in the health status of the population in industrial Britain. In relation to the latter I critically examine the widely accepted 'McKeown thesis' (McKeown 1979) which postulates that falling mortality rates in late 19th and early 20th century Britain can be explained not by medical intervention but by rising standards of living and improved nutrition. I argue that in the McKeown thesis, and in the work of those like David Blane (1987) who have examined it, the explanation for falling mortality rates is incomplete because it has not accounted for a then developing and expanding area of social activity, namely, domestic labour.

The social‐interactional organisation of narrative and narrating among stroke patients and their spouses

Abstract: This study examines interviews with men who have experienced strokes.‘Control interviews' with persons who had experienced health problems not related to stroke were also conducted, and they are considered here as well. Unlike most studies of stroke patients' linguistic competence, which examine subjects in isolation and in clinical settings, these interviews were conducted in the patients' homes, with the patients' spouses present in all of the interviews. The analysis concerns the ways in which the spouses participate in the telling of narratives that describe the unfolding of the stroke event as such. At the beginning of every interview with stroke patients the interviewers asked what happened during the stroke proper. The spouses' participation in these stories is significant and sustained, whereas the patients' own mastery of such narratives is meagre although the narratives comprise details from their personal somatic experience. We specify several discreet interactional patterns that make up the stroke patients' dearth of agency in these tellings, compare the interactional dynamics in the interviews with ‘control’ patients, and discuss the significance of these interactional minutiae for the patients' well-being and also for sociological investigations of ‘the brain’ and related issues.

Surviving Psychiatric Institutionalisation: A Case Study

Abstract: This paper looks at the impact of psychiatric hospital treatment on the life of a man who spent almost forty years in a large mental hospital in Northern Ireland. Patient behaviour and staff experience of this behaviour are examined within the conceptual framework proposed by Erving Goffman. This man's story once again challenges the notion of the all-pervading power of the institution, and affirms the ability of some individuals to maintain a strong personal identity in spite of being officially labelled as deviants and separated from society because of this label. It also challenges the assumption that institutional living in itself, stigmatises and therefore isolates an individual from normal social networks. It is argued that in order to predict the impact of voluntary or compulsory institutionalisation, not only must the identity-construct of the individual be considered, but also the social position of the institution within the community.

The politics of occupational ill‐health in late nineteenth century Britain: the case of the match making industry

Abstract: Using the match making industry as a case study, this paper examines the politics of occupational health in late nineteenth century Britain. It argues that this industry had a high profile within the wider political struggle around the question of working conditions and their effect on workers' health. This was due to the identification of match making with a specific and particularly disfiguring industrial disease, phosphorous necrosis, and that one firm, Bryant and May, featured prominently in the struggles around health and safety. This paper examines the role of employers, the state, and those demanding reform. It suggests that medical and dental ‘experts’ were important both in relation to their ‘official’ role with respect to factory regulation, and also because industrial ill health was a site of professional politics. The extent to which gender issues entered into the politics of occupational health at this time is considered. It concludes that mediation, compromise and the different priorities of the various interests involved prevented the dangers to health in matchmaking as in other industries from being controlled and eliminated in this period.