Changing conceptions of health and life course concepts

Health as a social concept is very important in medical sociology. More complicated conceptions of health as a multi-dimensional concept have emphasized not only physical health status, but aspects of overall well-being. This article continues in the tradition of a multi-dimensional concept of health, but adds in the complexity of variation over the life course. As people age, chronic health problems become more common. Mobility and sensory limitations also increase. How does this impact how people view their health? How do more complicated understandings of the life course and variation by social factors link to an expanded model of health. This literature review article covers material on concepts of health and life course concepts. The concluding portions of the article focus on the need to improve measurement, to incorporate diversity related to social factors such as gender and race, and to incorporate a broader understanding of health problems into conceptions of health across the life course.

Health identities: from expert patient to resisting consumer

This article explores the formation of ‘health identities’: embodied subjectivities that emerge out of complex psychosocial contexts of reflexive modernity, in relation to data on health and illness practices among groups of people and patients using medical technologies including weight-loss drugs and the erectile dysfunction drug sildenafil ( Viagra). We examine a range of health identities, from the ‘expert patient’ - a person who broadly adopts a biomedical model of health and illness, to a ‘resisting consumer’, who fabricates a health identity around lay experiential models of health and the body. The understanding of health identities is developed within a theoretical framework drawing on previous work on body/self and the work of Deleuze and Guattari. It is concluded that the constellation of health identities reflects the diversity of relations in an industrialized, technology-driven, consumer-oriented and media-saturated society.

The genetic conception of health: is it as radical as claimed?

The so-called new genetics is widely predicted to radically transform medicine and public health and deliver considerable benefits in the future. This article argues that, although it is doubtful that many of the promised benefits of genetic research will be delivered, an increasingly pervasive genetic worldview and expectations about future genetic innovations are profoundly shaping conceptions of health and illness and priorities in healthcare. Further, it suggests that debates about the normative and justice implications of new genetic technologies thus far have been constrained by bioethics discourse, which has tended to frame questions narrowly in terms of how best to ensure the protection and promotion of the rights and freedoms of the individual. Sociologists and other social scientists can help broaden debate in this field by exposing the assumptions underlying the genetic conception of health and exploring the implications of associated developments.

Medical intelligence, security and global health: the foundations of a new health agenda

Medical intelligence, security and global health are distinct fields that often overlap, especially as the drive towards a global health security agenda gathers pace. Here, we outline some of the ways in which this has happened in the recent past during the recent Ebola epidemic in West Africa and in the killing of Osama Bin laden by US intelligence services. We evaluate medical intelligence and the role it can play in global health security; we also attempt to define a framework that illustrates how medical intelligence can be incorporated into foreign policy action in order delineate the boundaries and scope of this growing field.

Medical sociology as a vocation

This article extends Weber's discussion of science as a vocation by applying it to medical sociology. Having used qualitative methods for nearly 40 years to interpret problems of meaning as they arise in the context of health care, I describe how ethnography, in particular, and qualitative inquiry, more generally, may be used as a tool for understanding fundamental questions close to the heart but far from the mind of medical sociology. Such questions overlap with major policy questions such as how do we achieve a higher standard for quality of care and assure the safety of patients. Using my own research, I show how this engagement takes the form of showing how simple narratives of policy change fail to address the complexities of the problems that they are designed to remedy. I also attempt to explain how I balance objectivity with a commitment to creating a more equitable framework for health care.

The social origin of the illness experience--an outline of problems

INTRODUCTION AND OBJECTIVE

The main research objective is a study of social influences on the processes of experiencing illness in the sociological meaning of the term 'illness experience' focusing attention on the subjective activity inspired by being ill, taking into account interpretive (meaning-making) activity. The goal of the analysis is to specify 'social actors' jointly creating the phenomena of 'illness' and 'being ill', taking into consideration the evolution of the position of medical sociology on this issue. BRIEF DESCRIPTION OF THE STATE OF KNOWLEDGE: The ways of experiencing illness in contemporary society, including processes of creating the meanings of the phenomena of 'illness' and 'being ill', are the outcome of not only the application of biomedical knowledge, but are also parallelly a sociocultural 'construct' in the sense that they are under the impact of social and cultural influences. In the sociology of illness experience it is pointed out that illness experience develops in connection with experiencing somatic discomfort, this process occurring in the context of influences of culture, society and socially accepted norms and values. These relationships are interpreted by the sociological, interactionist model which presents illness as a 'social construct'.

CONCLUSIONS

Sociological studies on the social construction of 'illness' and 'being ill' construct a model of these phenomena, complementary to the biomedical model, conducive to the validation of the patient's perspective in the processes of medical treatment, and to the humanization of the naturalistically oriented, biomedical approach to illness, i.e. to adjust it more accurately to typically human needs manifesting themselves in the situation of being ill.

Six paths for the future of social epidemiology

Social epidemiology is now an accepted part of the academic intellectual landscape. However, in many ways, social epidemiology also runs the risk of losing the identity that distinguished it as a field during its emergence. In the present article, we scan the strengths of social epidemiology to imagine paths forward that will make the field distinct and useful to the understanding of population health in future. We suggest 6 paths to such a future, each emerging from promising research trends in the field in which social epidemiologists can, and should, lead in coming years. Each of these paths contributes to the formation of distinct capacities that social epidemiologists can claim and use to elaborate or fill in gaps in the already strong history of social epidemiology. They present an opportunity for the field to build on its strengths and move forward while leading in new and critical areas in population health.

To tell the truth. A critical trend in medical sociology--an introduction to the problems

INTRODUCTION AND OBJECTIVE

The presented analysis is a reconstruction of the origins, inspirations for development, and theoretical foundations of the critical and unmasking trend in Polish and Western medical sociology.

ABBREVIATED DESCRIPTION OF THE STATE OF KNOWLEDGE

As a part of the critical medical sociology initiated in Poland by Professor Magdalena Sokołowska, a diagnosis of the (dys)functionality of contemporary medicine is carried out, emphasizing pathologies in the realization of its basic social functions, both at the level of systemic and institutional solutions, as well as stressing their consequences which include inter alia social health inequalities. Within the critical sociomedical research orientation, the diagnoses of the social role of medicine and distortions in the ways it is exercised are placed in the broad structural, political, and cultural contexts, which makes it possible to point to the principal causes of the analyzed phenomena.

SUMMARY

The crucial 'value added' of critical sociological analyses of medicine and health policy are directives intended to humanize medicine and health systems in contemporary societies, taking social and cultural realities into consideration. We understand the humanization of medicine in terms of its better adjustment to human needs that emerge in the situations of illness and being ill, with the simultaneous guarantee of universal and equal access to medical services.

Standardising antisocial personality disorder: the social shaping of a psychiatric technology

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is one of the most influential and controversial terminological standards ever produced. As such, it continues to provide a valuable case study for sociologists of health and illness. In this article I take as my focus one particular DSM category: antisocial personality disorder (ASPD). The analysis charts the shifting understandings of personality disorders associated with antisocial behaviour in the DSM and in US psychiatry more broadly from 1950 to the present day. Memos, letters and minutes produced by the DSM-III committee and held in the American Psychiatric Association (APA) archives ground the discussion. Finally, the article explores more recent constructions of antisocial personality disorder and examines the anticipatory discourse pertaining to the rewriting of this category expected in the forthcoming DSM-5. In presenting an in-depth socio-historical narrative of the development - and potential future - of standards for pathological antisociality, this analysis casts new light on the ASPD construct. In particular, by considering it as a technology, I elaborate how processes of path dependency constrain innovation and how imaginaries of users and publics are implicated in the APA debates constitutive of this.

A sociological approach to ageing, technology and health

Abstract This special monograph issue builds on sociology of health and illness scholarship and expands the analytical lens to examine how old people, healthcare professionals, and technology designers create, use, and modify science and technology to negotiate and define health and illness. Far from passive consumers, elders are technogenarians, creatively utilising and adapting technological artefacts such as walking aids and medications to fit their needs. This publication adds theoretical and empirical depth to our understanding of the multiple and overlapping socio-historical contexts surrounding ageing bodies and ageing enterprises, including the biomedicalisation of ageing that includes the rise of anti-ageing or longevity medicine; and the rise of gerontechnology industries and professions -- fields that largely accept the ageing body as a given. This collection sociologically investigates how and where these two trends overlap and diverge in relation to a global context of ageing and ageism, and calls for further scholarship in this area. Combining science and technology studies and sociology of health and illness frameworks together provides an empirical basis from which to analyse technogenarians in action, as well as the stakeholders and institutions involved in the ageing, health, and technology matrix.

Progestins and medical treatment of endometriosis - physiology, history and society

The transitory effect of hormonal treatment is the alleged main reason to criticize progestins (PGS) and combined pills (OP) in the managment of endometriosis. To the contrary their poor efficacy in the long run is often underlined. As a result, medical treatment is too seldom advised in endometriosis. In this article, we shall focus on the analysis of the reasons of the paucity of the medical interest given to progestins, reasons, which are not of a scientific or objective nature. The ultimate aim of this analysis is to develop arguments in favour of continuous administration of hormones as to obtain not simply an anovulation but a state of prolonged amenorrhea much more efficacious than the simple suppression of ovulation too often advised. And, with an emphasis on the fundamental role of surgery in the treatment of endometriosis, to give the greatest consideration to the specific nature of this disease, which is a chronic disease, justifying the long duration of hormonal administration.

Developing public sociology through health impact assessment

The renewed interest in 'public sociology' has sparked debate and discussion about forms of sociological work and their relationship to the State and civil society. Medical sociologists are accustomed to engaging with a range of publics and audiences inside and outside universities and are in a position to make an informed contribution to this debate. This paper describes how some of the debates about sociological work are played out through a 'health impact assessment' of a proposed housing renewal in a former coal mining community. We explore the dynamics of the health impact assessment process and relate it to wider debates, current in the social sciences, on the 'new knowledge spaces' within which contentious public issues are now being discussed, and the nature of different forms of expertise. The role of the 'public sociologist' in mediating the relationships between the accounts and interpretations of lay participants and the published 'evidence' is described as a process of mutual learning between publics, professionals and social scientists. It is argued that the continued existence and development of any meaningful 'professional sociology' requires an openness to a 'public sociology' which recognises and responds to new spaces of knowledge production.

The afterbirth of the clinic: a Foucauldian perspective on "House M.D." and American medicine in the 21st century

Mirroring Michel Foucault's The Birth of the Clinic (1963), which describes the philosophical shift in medical discourse in the 19th and early 20th centuries, the Fox television series House M.D. illustrates the shift in medical discourse emerging today. While Dr. Gregory House is Foucault's modern physician made flesh -- an objective scientist who has perfected the medical gaze (le regard) and communicates directly with diseases instead of patients -- his staff act as postmodern foils. They provide a parable about the state of biomedicine, still steeped in modernity but forced into a postmodern, managed care world. House M.D., however, is more than a mere depiction of the modern-postmodern tension that exists in today's exam rooms. It is an indication of a transition period in American medicine. House M.D. nostalgically celebrates what once was and simultaneously questions what currently is, while what is about to be is in the midst of becoming.

Health policy approaches to population health: the limits of medicalization

Because of a strong tendency to "medicalize" health status problems and to assume that their primary solution involves medical care, policymakers often focus on increased financial and geographic access to personal health services in policies aimed at populations that are vulnerable to poor health. This approach has produced real public health gains, but it has neglected key social and economic causes of health vulnerability and disparities. Although access to care is a necessary component of population health, concerted policy action in income security, education, housing, nutrition/food security, and the environment is also critical in efforts to improve health among socially disadvantaged populations.

Locating ethnicity and health: exploring concepts and contexts

With the rapid development of ethnicity and health as a field of sociological research, this paper seeks to re-evaluate the development of ideas around ethnicity, 'race' and culture and consider how they have been applied to the question of health. Ethnicity as a social characteristic is contingent on the situation in which it is manifest. The process of marking 'other' ethnic groups includes stereotyping and racialisation, a process through which 'racial' or ethnic differences predominate to the exclusion of a consideration of social, economic and power relations. In the British context, the history of empire and medicine's justification of racist treatment of enslaved and colonised people, is relevant to understanding how ethnic and cultural differences have come to be essentialised and pathologised. Immigration to Britain only became a mass phenomenon after World War II, with settlement patterns following employment opportunities and kinship alliances. The state has a longstanding history of 'managing' diversity, sometimes essentialising differences between groups, at other times tackling disadvantage and discrimination experiences through policy action. Sociologists of health were slow to study ethnicity, with initial research coming from tropical disease specialists. The tendency of medicine to pathologise minority cultures is explored through case studies of the approach to rickets and the assessment of health risks associated with consanguineous marriage. Anti-racist approaches have encouraged the consideration of discrimination against and socioeconomic position of minorities. The field has developed with work on nomenclature and the operationalisation of ethnic identity, necessary to study health inequalities between ethnic groups and paying due heed to the contribution of socioeconomic position and racism to group experiences. Research into chronic conditions with complex analysis of a number of distinct contributory variables has been published of late. However, the excessive focus on South Asians and the record of measuring, analysing, but not necessarily tackling health disadvantage, are problems that remain to be addressed.

Silent voices: Women, complementary medicine, and the co-optation of change

Despite the prominence of complementary and alternative medicine (CAM) in public and policy debates, our knowledge of the relationship between CAM and gender remains undeveloped. By tracing two dominant strands of research involving the women's health movement and the implications of CAM's increasing popularity among women, this article draws attention to the need for research addressing the roles of women as practitioners and students of CAM. It is argued that the medicalization and co-optation of CAM has serious implications for women's health by constraining CAM's potential to challenge, resist, and transform the hegemony and inequalities of biomedicine.

Prescribing benzodiazepines in general practice: a new view of an old problem

General practitioner (GP) prescribing has been identified as an arena that has broad social and political implications, which stretch beyond individual outcomes for patients. This article revisits aspects of the controversy about prescribing benzodiazepines (or 'minor tranquillizers') through an exploration of contemporary views of GPs. In the 1980s the prescribing of these drugs was considered to be both a clinical and social problem, which brought medical decision making under public scrutiny. The legacy of this controversy for recent GPs remains a relatively under-explored topic. This article describes a qualitative study of GPs practising in the north-west of England about their views of prescribing benzodiazepines. The accounts of the respondents highlight a number of points about: blame allocation, past and present; clinical challenges about risk management; and deserving and undeserving patients. These GP views are then discussed in the wider context of psychotropic drug use. It is concluded that, while there has been a recent consensus that the benzodiazepines have been problematic, when they are placed in a longer historical context, a different picture is apparent because other psychotropic drugs have raised similar problems.

Therapeutic pluralism? Evidence, power and legitimacy in UK cancer services

The integration of complementary and alternative medicine (CAM) into cancer services is increasingly discussed as a potential part of UK health policy but as yet there has been little sociological research examining this process. This paper examines the results of a study on the provision of CAM to cancer patients in two distinct organisational contexts: the hospice and the hospital. It is based on interviews with medical specialists, nursing staff and CAM therapists. This paper focuses on how integration is managed in each organisation, examining professional boundary disputes and inter-professional dynamics. Discussion focuses on the rhetorical and practical strategies that are employed by a variety of differently positioned interviewees to negotiate the complexities of the interface of CAM and biomedicine. The results show significant differentiation in how differently positioned cancer clinicians view and utilise the biomedical hierarchy of evidence. We argue that the integration of CAM should not be conceptualised as a mere challenge to biomedicine, or, as resulting in a linear process of de-professionalization. Rather, it should be seen as producing a complex array of processes, including strategic adaptation on the part of medical specialists and NHS organisations.

Health-related quality of life and the transformation of symptoms

This paper traces the development of health-related Quality of Life instruments over the last half century. It identifies the emergence of key components of quality of life measurement in other health status questionnaires between about 1950 and 1980 and their formalization in Quality of Life instruments in the mid 1980s. The common developmental thread that linked these Quality of Life instruments and their precursors was the identification of 'distal symptoms' that represented the impact of illness beyond its immediate bodily manifestations. The measurement of distal symptoms through Quality of Life instruments also served to detach symptoms from their customary patho-physiological referent. Other contemporary examples of these free-floating symptoms reinforce the argument that the nature and meaning of symptoms has been transformed over recent decades.

Body Mass Index, masculinities and moral worth: men's critical understandings of 'appropriate' weight-for-height

Based on the Body Mass Index (BMI, kg/m(2)), most men in nations such as the UK and USA are reportedly overweight or obese. This is authoritatively defined as a massive and growing problem. Drawing from embodied sociology, critical obesity literature and qualitative data generated during an Economic and Social Research Council funded project on masculinities and weight-related issues, this paper offers a critical realist contribution to the obesity debate. Rather than endorsing the institutionalised war on fat, and correcting so-called 'laymen' who dismiss medicalized weight-for-height recommendations, the following presents and honours men's justificatory accounts for levels of body mass that medicine labels too heavy (implicitly or explicitly too fat). Men's critical understandings, which are connected to their displays of moral worth, are considered under three headings: the compatibility of heaviness, healthiness and physical fitness; looking and feeling ill at a supposedly 'healthy' BMI; and resisting irrational standardisation. By empirically 'bringing in' men's meanings, sensibilities and culturally informed aesthetics, this paper casts a different light on medicalized measures that support potentially corrosive obesity epidemic psychology.

The democratisation of psychiatry

OBJECTIVE

To explore the decline in expertise of the consultant psychiatrist and its replacement by a range of professional colleagues.

CONCLUSION

Averting a devaluing of expertise in Australasia requires thoughtfulness, willingness to quietly and confidently contribute, and professional behaviour. There are early promising developments.

Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

This paper explores how current 'patient safety' reforms offer to change the regulation of medicine. Drawing on existing literature, it is argued that this policy agenda represents a new frontier in medical/managerial relations, introducing a disciplinary expertise within the health service that provides managers with the knowledge and legitimacy to survey and scrutinise medical performance, made real through procedures for incident reporting and root-cause analysis. The extent of regulatory change is investigated, drawing on an ethnographic case study of one hospital. It is shown that, as with other organisational and managerial reforms, doctors are resisting managerial prerogatives through seeking to subvert and 'capture' components of reform. I describe this as 'adaptive regulation' to account for how doctors seek to maintain their regulatory monopoly and limit managerial encroachment. It is speculated, however, that this process could signal the future 'modernisation' of medical professionalism where emerging managerial discourses, within the wider context of public sector reform, are increasingly internalised with medical practice and culture. This leads to new and rearticulated forms of self-surveillance, self-management or 'governmentality', ultimately negating the need for external groups to explicitly manage or regulate professional practice.

A birth centre's encounters with discourses of childbirth: how resistance led to innovation

An ethnographic study of a free-standing birth centre uncovered a site of intense contestation. Two prominent childbirth discourses attempting to inscribe their orthodoxies on staff and women users encountered stern and persistent resistance. Using postmodern theory, this resistance is conceptualised as nomadic activity, as space is made at the margins of discourse for a difference and diversity to manifest. The relationship between discourse and women's agency is layered and non-linear as the presence of dissonant data indicates. The birth centre, however, actualises a number of contrasting ways of 'being' and 'doing' that appear to serve the interests of staff and women well. In particular, 'nomadic' midwifery practice and a 'care as gift' orientation challenges the biomedical model that defines the parameters of normal and the 'vigil of care' discourse that regulates the professional/patient relationship. Birth centres may encourage novel and eclectic ways of providing childbirth care.

Peculiarities of medical sociology: application of social theories in analyzing health and medicine

OBJECTIVE

To reveal the peculiarities of medical sociology introducing the application of social theories in analyzing public health and medicine.

METHODS

Comparative and descriptive analysis of scientific references found and current situation.

RESULTS

During the last decade of the 20th century, the discussions about the sociology of health and medicine as separate discipline and its practical applications became more active. Main factors determined the growing importance of discipline were institutionalization of medicine and health care, changing patterns in doctor-patient relationships, different health perceptions, understanding of the influence of social factors on health, cardinal changes in the area of health technologies, consumeristic attitude towards health, appearance of market relationships within health care, and other global phenomena. In sociology, usual social theories such as structural functionalism, conflict, symbolic interaction, poststructuralism, feminist often attempt to explain the changes within health care. There is a relation of medical sociology and other types of sociology having common areas with medicine and health being analyzed in the article; social theories and their application in the field of health and medicine are being introduced attempting to explain the ongoing social changes in both Lithuania and the world.

CONCLUSIONS

More and more attention in various areas of medical activities is being paid to the social aspects (both individual and society levels) of these activities, and there is a shift from applied sociology towards medical one. Despite the cessations of the development of medical sociology as separate branch of sciences, the researches of recent years are demonstrating obvious approaching modern research issues and methods, which do exist in contemporary world. Such tendencies show the prompt approaching of the academic community of Lithuania the general scientific standards which are dominating in the globalization-effected world.

Off the couch and on the move: global public health and the medicalisation of nature

In May 2004 the World Health Organization (WHO) officially launched the 'Global Strategy on Diet, Physical Activity and Health'. Lying at its heart is the recognition that many of the risk factors associated with non-communicable diseases, particularly poor diet and physical inactivity, have begun to move beyond the confines of the West. It was this apparent shift in the epidemiological boundaries of such diseases, along with fears over the so-called 'double burden' that they presented to some nations, that finally prompted the WHO to develop such a far reaching strategy. This paper adds to the on-going debate surrounding this important issue by drawing on the concepts of medicalisation, governmentality and the spatiality of scientific knowledge to explore one particular element of it: namely, the identification of nature as a setting for the promotion of physical activity. We adopt this perspective because we are concerned to understand the ways in which the knowledge and practice of the 'new' public health travels. As our analysis reveals, in many Western nations the natural environment has emerged as an important 'transactional zone' where the governmental imperative for the production of fit and active bodies coalesces with the individual desire to be healthy. However, while it is apparent that this physical activity discourse increasingly operates throughout the globe, there is less evidence of an equivalent discourse that promotes the health-related benefits of nature. We argue that this is significant because it helps us to recognise that contemporary public health discourse has a distinct geography.

Running away with health: the urban marathon and the construction of 'charitable bodies'

The increase in fundraising through mass-participation running events is emblematic of a series of issues pertinent to contemporary conceptualizations of health and illness. This increasingly popular spectacle serves as an indicator of present-day social relationships and broader cultural and ideological values that pertain to health. It highlights contemporary discourses on citizenship; 'active citizens' can ostentatiously fulfil their rights and responsibilities by raising money for those 'in need'. Involvement in such events comprises an example of the current trend for drawing attention to illness, and sharing one's experiences with others. We examine these issues through a consideration of charity advertisements and offer a fourfold typology of runners in terms of their orientations to both mass-participation running and charity. We conclude that 'charitable bodies' are constructed out of the interrelationships between philanthropic institutions, sport and individual performance.

The making of health:: a reflection on the first 10 years in the life of a journal

This introduction to the Tenth Anniversary Issue surveys articles that have been published in health: since its launch. Reviewing the original aims of the journal, the editors discuss some of the main issues that authors have raised, both about health and illness. Focusing upon articles that have been published in this particular journal, we discuss the way that new medical technologies--particularly global ones--have shaped ideas about disease and its treatment, and in consequence about what 'good health' should be. Related to the growth in medical and other technology--not least the rise of the Internet during the life of this journal--is the number of articles that discuss the rights of patients and the establishment of what might be termed an 'illness culture'. We conclude that there continues to be more to health than it being the background to illness or disease, and ask the question: should the 'taken for grantedness' of health be taken for granted any longer?

Taking sociology seriously: a new approach to the bioethical problems of infectious disease

After a history of neglect, bioethicists have recently turned their attention to the topic of infectious disease. In this paper we link bioethicists' earlier neglect of infectious disease to their under-appreciation of the extent to which the problem of infectious disease is related to social factors and thus to questions of justice. We argue that a social causation of illness model - well-known to sociologists of medicine, but incompletely understood by bioethicists - will improve future bioethical analysis of issues related to infectious disease. By emphasising the relationships between social and economic structures of inequality and health, the social causation model provides a richer approach to ethical issues associated with infectious disease than the more commonly used biomedical model.

"Taming tradition": medicalized female genital practices in western Kenya

This article considers the question of female genital practices at the hands of health workers in western Kenya. Recent articles in Medical Anthropology Quarterly have critically engaged with the biomedical arguments condemning such practices. This article studies the case of medicalized circumcision in which biomedical concerns over health risks have become incorporated in their vernacular practice. Although some suggest that medicalization may provide a harm-reduction strategy to the abandonment of the practice, research in one region challenges this suggestion. It argues that changing and conflicting ideologies of gender and sexuality have led young women to seek their own meaning through medicalized practice. Moreover, attributing this practice to financial motivations of health workers overlooks the way in which these "moral agents" must be situated within their social and cultural universe. Together, these insights challenge the view that medicine can remain neutral in the mediation of tradition.

Behavioral science at the crossroads in public health: extending horizons, envisioning the future

The social and behavioral sciences are at a crossroads in public health. In this paper, we attempt to describe a path toward the further integration of the natural and behavioral sciences with respect to the study of behavior and health. Three innovations are proposed. First, we extend and modify the "stream of causation" metaphor along two axes: time, and levels of nested systems of social and biological organization. Second, we address the question of whether 'upstream' features of social context are causes of disease, fundamental or otherwise. Finally, we propose the concept of a risk regulator to advance the study of behavior and health in populations. To illustrate the potential of these innovations, we develop a multilevel framework for the study of health behaviors and obesity in social and biological context.

The medicalisation of shyness: from social misfits to social fitness

Shyness has become an 'unhealthy' state of mind for individuals living in contemporary Western societies. Insofar as its behavioural 'symptoms' imply a failure to achieve certain cultural values, such as assertiveness, self-expression and loquacious vocality, shyness is increasingly defined as a problem for which people can, and should, be treated. This paper first critically discusses the idea that we are witnessing a new 'cultural epidemic' of shyness, as evidenced by increasing rates of diagnosis for Social Phobia, Social Anxiety Disorder and Avoidant Personality Disorder. It then examines three main dimensions of the medicalisation of shyness: biomedical and genetic approaches, the therapeutic interventions of cognitive-behaviour therapy and 'shyness clinics', and the disciplinary regimes imposed by self-help books and websites. Within a cultural climate of pervasive anxiety and privatised risk, the medicalisation of shyness suggests a powerful new way of defining and managing certain kinds of deviant identities, but we can also find some evidence of resistance to this approach.

Introduction: Patient organization movements and new metamorphoses in patienthood

In this introduction, we examine health activism as one expression of an emergent 'politics of vitality' or flurry of activity around health matters that includes: advances in technoscientific medicine, healthcare restructurings, and a re-thinking of science-society contracts. In querying politicized mobilizations around 'health matters and the mattering of health,' we provocatively entitle our discussion 'patient organization movements'. This marks an invitation to interrogate (in reverse order) each term along the way, pausing in our concluding discussion to turn our attentions to the patient. The figure of the patient is thematized as an historical inscription and a formidable dimension of personhood under modernity/late modernity. Moreover, we argue that conventional categorizations of the patient are undergoing accelerated processes of change at the present time. We characterize three transformational trends: moves to author and authorize patienthood, mutiny from patienthood, and mutations in the category of the patient. Such metamorphoses in patienthood represent both reflections and repercussions--at once consequences and catalysts--of the proposed politics of vitality. We explore the pluralization of the patient's persona via a closer look at the 11 empirical studies of health activism that comprise this collection.

Pregnancy and infant loss support: A new, feminist, American, patient movement?

Using as examples three of the earliest pregnancy and infant loss organizations and multiple recent initiatives, I argue this is a unique patient movement, in part due to the particularities of pregnant patienthood. Although during the first 20 years of this distinctively US movement, pregnancy and infant loss support was hospital-based, there was remarkably little attention to the "medical" dimensions of these losses, e.g. etiology, diagnosis, prevention, and treatment. The thrust was instead on changing ideas and feelings. It is only since the turn of the century that bereaved parents have started to forge collaborations with physicians to work toward prevention. During the first phase (mid-1970s to mid-1990s), it was a women's movement, though it did not present itself as such, and although it was indebted to the feminist movement and included some feminist initiatives, the movement was dominated by a traditionally feminine ethos and included pro-life elements. During the second phase, as physicians and researchers have become more involved, leadership has become somewhat less female-centric while at the same time, more initiatives are explicitly feminist.

Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients'heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new 'technological' solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices--technogovernance--in which the heterogeneous narratives of the patient-centred encounter can be resituated and guided.

Contesting contraceptive innovation—Reinventing the script

The article describes how the merging of Southern and Northern women's health groups resulted in a powerful transnational movement, with a collective oppositional identity based on shared solidarity in campaigns for reproductive rights and against state coercion in reproductive matters. It focuses on the ways in which the movement framed issues of rights and safety and pointed to the possible abuse potential of two new longer-acting contraceptive technologies, Norplant and the anti-fertility vaccines. The contestations by women's health advocates resulted in the emergence of a strong commitment among scientists to involve women's health advocates in the development and introduction of new contraceptive technologies. By engaging in the construction of safety and efficacy claims, and by outlining conditions for the introduction of the new technologies (so-called introduction scripts) women's health advocates were able to reinscribe the technologies with representations of bodily integrity and reproductive rights, rather than population control. I argue that a split within the women's health movement on the need to ban the new technologies did not weaken its impact, but, in fact, enhanced this success. I describe, in detailed case studies on the Norplant and Anti-fertility vaccine controversies, how both strands of women's health advocacy claim to be able to represent the interest of users, but that their representations of users differ. The 'no-to-Norplant' and 'no-to-anti-fertility' vaccines strands see users as victims of a state-led medical establishment enabled power, which is inscribed in the technology. The more moderate strand of activism argue that women's interests and needs differ from one setting to another, and that they are best met by making available to women a range of contraceptive options which allow for a free and informed choice.

Anti-aging medicine: A patient/practitioner movement to redefine aging

Having enjoyed tremendous growth for the past 5 years, the anti-aging medicine movement is redefining aging so that it becomes a target for biomedical intervention. Targeting aging for intervention dislodges popular understandings of aging: for anti-aging practitioners it no longer matters if aging is natural since it can be itself the target of therapy. So-called "age-associated" diseases like cancer are, in this framework, conceived of as symptoms of aging. Anti-aging medicine is a broad term that may comprise groups selling remedies over the Internet, companies touting the "anti-aging"ness of their products, practitioners who work outside of scientific medicine, and practitioners of anti-aging medicine in clinics who believe that their work is strictly scientific. This article, drawing from more than 3 years of ethnographic interviews, participant observation in clinics and conferences, and a review of the literature, considers the last group. It examines the involvement stories of anti-aging medicine practitioners in two Western United States metropolitan cities. These stories reflect the practices of anti-aging medicine practitioners and the accompanying rationale for involvement. Often originally patients themselves, practitioners frame their involvement with the anti-aging movement in three ways. First, they describe aging as it is currently experienced as a time of decline, suffering, and weakness. This anguish is not inevitable, they argue, and their work toward treating aging biomedically is situated as clearly moral. Secondly, intense frustration with the current biomedical environment has motivated practitioners to look for other ways in which to practice: anti-aging medicine is their chosen alternative. Finally, with dramatic expectations of future biotechnologies and disdain for current medical treatments of old age, anti-aging practitioners embrace a scientific revolutionary identity. These stories of migrations from patient to practitioner reveal the values upon which this movement is grounded and how coming to be a part of it is as much about the movement's mission as it is the origins of the migrations.

The incubation of a social movement? Preterm babies, parent activists, and neonatal productions in the US context

This article explores health-based activism on the part of the US 'parents of preemies' movement, a mutual-help network mobilized around babies born precariously early and acutely dependent upon life-support incubators. The movement articulates two meta-agendas for parental empowerment: (1) the quest to access/exercise greater participatory inclusivity vis-à-vis the preterm baby within the biomedical domain; and, (2) the quest to secure/command greater representational authority over the preterm baby within the public domain. Seen in terms of the erosion of the status quo, it can be argued that the movement's tangible and intangible aims to chip away at these traditions have been softly revolutionary: heralding new working partnerships between medical practitioners and patients' families; radical shifts in the technological consciousness and competences of preemie parents; and cyborg changes in conventional categories of the person. Yet, seen in terms of a normative order of things, it can be argued that the movement has largely and willingly been "co/operated": meaning that it has been "cooperative," but equally "co-opted" and "operated into" the disciplinary trajectory of neonatal medicine as well as the historical march of biopolitics with its governance of the collective body populous. From this critical perspective, the movement qua social movement thus itself might be considered incubated--cocooned, gestated, disciplined--and brought into existence by the very powers and hegemonic (patriarchal) machinery that viable resistance might struggle to govern instead of serve.

The field of psychiatric contention in the UK, 1960–2000

In this paper I discuss the question of how we should understand the concept of "social movements", particularly as applied to health related movements. My argument is that movements should be understood as "fields of contention". This concept, as I develop it, emphasizes two key aspects of social movement mobilization. Firstly, departing from traditional models of movements, which tend to view them as unified "things", it draws our attention to the numerous groups and agents who interact within the internal space of a "movement" and to the relations, alliances and conflicts between those various groups/agents as they unfold through time. Secondly, it draws our attention to the embedding of social movement struggles within multiple differentiated contexts of struggle, each of which affords different opportunities for struggle but each of which makes different demands upon activists if struggle is to prove effective. The model of fields of contention is explored within the paper using empirical data on a variety of "social movement organizations" (SMOs) which have formed around the mental health system in the UK over the last forty years.

Uncharted ground: Patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings

The development of "integrative health care" (IHC) settings combining various aspects of Western biomedicine and complementary/alternative medicine (CAM) is a relatively recent phenomenon among biomedical and CAM professions. While IHC is recognised internationally and occurs in many different contexts (e.g. clinic or hospital), patterns of interaction between biomedical and CAM practitioners, and the nature of IHC settings, are largely unknown. This paper presents findings from a research study of two newly established IHC settings in Canada. The main research question was: how are biomedical and CAM practitioners integrating or not integrating with each other at the level of professional interaction in IHC settings? Using a case study design, in-depth interviews were conducted with 13 biomedical and eight CAM practitioners during 2002-2003, and ethnographic observation and document analysis was conducted at each site. Drawing from closure theory of the professions, comparative analysis of the sites revealed that biomedical practitioners enact patterns of exclusionary and demarcationary closure, in addition to the use of "esoteric knowledge", by: (a) dominating patient charting, referrals and diagnostic tests; (b) regulating CAM practitioners to a specific "sphere of competence"; (c) appropriating certain CAM techniques from less powerful CAM professions; and (d) using biomedical language as the primary mode of communication. CAM practitioners, in turn, perform usurpationary closure strategies, by: (a) employing their own "esoteric knowledge" in relation to biomedicine and other CAM professions; (b) appropriating biomedical language and terminology; (c) increasing their professional status by working with biomedicine; and (d) referring among CAM practitioners to increase patient flow. The findings suggest that when attempts are made to integrate biomedicine and CAM, dominant biomedical patterns of professional interaction continue to exist. Despite continued patterns of social closure, biomedical and CAM practitioners continue to provide a certain form of integrative care that may be of benefit to patients, albeit not as integrative as current models of integration would prefer.

How to build an “active” patient? The work of AIDS associations in France

"What is an "active" patient?" is a question that arises in most medicine and illness-related social science research. This article examines the normative work carried out by AIDS associations in France to define an "active" patient in healthcare and research. While the fight against AIDS is often presented as being homogenous, we look at the diversity of opinion between different associations (Aides, Act Up-Paris, Actions Traitements and Positifs). We find four different cases: the patient as manager of his illness, the empowerment of patients, the science-wise patient and the experimenter. Systematic comparison of these cases shows that these perceptions of the "active" patient, in terms of the same pathology, are based upon different ways of seeing: the nature of the relationships between the different types of knowledge of the illness (scientific knowledge, clinical knowledge, experience of the illness) and the distribution of roles and powers among the various actors in the healthcare system (the government, pharmaceutical companies, the medical profession, the patients). This article highlights the historical dynamics which allow us to have a better understanding of these differences, especially the major distinction between two generations of associations, which adopted different positions with regard to their public identity.

Anti-vaccination movements and their interpretations

Over the last two or three decades, growing numbers of parents in the industrialized world are choosing not to have their children vaccinated. In trying to explain why this is occurring, public health commentators refer to the activities of an anti-vaccination 'movement'. In the light of three decades of research on (new) social movements, what sense does it make to attribute decline in vaccination rates to the actions of an influential anti-vaccination movement? Two sorts of empirical data, drawn largely from UK and The Netherlands, are reviewed. These relate to the claims, actions and discourse of anti-vaccination groups on the one hand, and to the way parents of young children think about vaccines and vaccination on the other. How much theoretical sense it makes to view anti-vaccination groups as (new) social movement organizations (as distinct from pressure groups or self-help organizations) is as yet unclear. In any event there is no simple and unambiguous demarcation criterion. From a public health perspective, however, to focus attention on organized opponents of vaccination is appealing because it unites health professionals behind a banner of reason. At the same time it diverts attention from a potentially disruptive critique of vaccination practices; the critique in fact articulated by many parents. In the light of current theoretical discussion of 'scientific citizenship' this paper argues that identifying anti-vaccination groups with other social movements may ultimately have the opposite effect to that intended.

The shifting locus of risk-reduction: the critical role of HIV infected individuals

This article discusses the shifting locus of control over risk-reduction and examines its implications for the care and support of HIV-positive individuals. We begin by presenting a brief history of the continuum of HIV related risk, illustrating the ways in which advances in risk-assessment and intervention have led to this important shift. Second, we discuss the current state of risk assessment and intervention as it relates to three factors: (a) the point along the continuum of risk at which risk assessment and intervention occurs; (b) the locus of control over risk reduction; and (c) the distinction between primary and secondary risk reduction efforts. Finally, we discuss the meaning of HIV risk and the role of HIV-positive individuals in the new geometry of care that integrates treatment and prevention. How is HIV-risk defined and understood? Who is of risk to whom&#63 Who is responsible for reducing risk&#63.

[The XXI century patient]

We are experiencing a social change in health that is unprecedented in the history of humanity. Modern sociology attempts to explain this change using concepts of reflexive modernisation, liquid life or society, or the end of history. This social change results in a new model of patient who is better informed and has greater expectations with respect to healthcare and health. More information does not mean better understanding and more responsibility with respect to health. For this to occur, it is necessary to increase the social and individual conscience of people as health agents and as responsible users. The University of the Patients emerges as a project directed towards increasing the health and civic literacy of the population and from the need to adapt the health systems to the new needs generated by a new model of user.