[Proposals for social class classification based on the Spanish National Classification of Occupations 2011 using neo-Weberian and neo-Marxist approaches]

In Spain, the new National Classification of Occupations (Clasificación Nacional de Ocupaciones [CNO-2011]) is substantially different to the 1994 edition, and requires adaptation of occupational social classes for use in studies of health inequalities. This article presents two proposals to measure social class: the new classification of occupational social class (CSO-SEE12), based on the CNO-2011 and a neo-Weberian perspective, and a social class classification based on a neo-Marxist approach. The CSO-SEE12 is the result of a detailed review of the CNO-2011 codes. In contrast, the neo-Marxist classification is derived from variables related to capital and organizational and skill assets. The proposed CSO-SEE12 consists of seven classes that can be grouped into a smaller number of categories according to study needs. The neo-Marxist classification consists of 12 categories in which home owners are divided into three categories based on capital goods and employed persons are grouped into nine categories composed of organizational and skill assets. These proposals are complemented by a proposed classification of educational level that integrates the various curricula in Spain and provides correspondences with the International Standard Classification of Education.

The end of the golden age of doctoring

Eight interrelated reasons for the decline of the golden age of doctoring are discussed in this article. Major extrinsicfactors (generally outside the control of the profession) include (1) the changing nature of the state and loss of its partisan support for doctoring, (2) the bureaucratization (corporatization) of doctoring; (3) the emerging competitive threat from other health care workers; (4) the consequences of globalization and the information revolution; (5) the epidemiologic transition and changes in the public conception of the body; and (6) changes in the doctor-patient relationship and the erosion of patient trust. Major intrinsic factors are (7) the weakening of physicians' labor market position through oversupply; and (8) the fragmentation or weakening of the physicians, union (AMA). Despite the recent sociopolitical transformation of modern U.S. medicine, our thinking remains wedded to a now inadequate theoretical approach. A future sociology of the professions can no longer overlook now pervasive macrostructural influences on provider behavior (corporate dominance). Until these influences are appropriately recognized and incorporated in social analyses, most policies designed to restore the professional ideal have little chance of success.

Health reform in central and eastern Europe and the former Soviet Union

In the two decades since the fall of the Berlin Wall, former communist countries in Europe have pursued wide-ranging changes to their health systems. We describe three key aspects of these changes-an almost universal switch to health insurance systems, a growing reliance on out-of-pocket payments (both formal and informal), and efforts to strengthen primary health care, often with a model of family medicine delivered by general practitioners. Many decisions about health policy, such as the introduction of health insurance systems or general practice, took into account political issues more than they did evidence. Evidence for whether health reforms have achieved their intended results is sparse. Of crucial importance is that lessons are learnt from experiences of countries to enable development of health systems that meet present and future health needs of populations.

Successful eradication of sexually transmitted diseases in the People's Republic of China: implications for the 21st century

The global control of sexually transmitted diseases (STDs) represents a daunting task, and there have been very few examples of success. The scope of the STD problem in China before the formation of the People's Republic and the effects of a governmental STD control program were reviewed. In major cities, 10% of the population had syphilis, reaching 50% prevalence in some rural minorities. By 1964, STDs in China were virtually eliminated through a program that destigmatized STDs, provided an infrastructure for case finding and therapy, and eliminated prostitution. The People's Republic of China demonstrated the possibility of eliminating STDs, at least for some period of time. Although the Chinese approach may not be ideal for Western democracies, understanding some features of the Chinese program may help in designing a strategy for the eradication of human immunodeficiency virus when or if treatment becomes available.

Development and quality of life: a critique of Amartya Sen's Development as freedom

Presented here is a critical analysis of some of the major theses of Amartya Sen, as presented in his seminal work Development As Freedom. The author suggests that Sen's work, while representing a major break with the dominant neoliberal position reproduced in most national and international development agencies, is insufficient to explain the key relationship between freedom and development. The absence of an analysis of the power relations that cause and reproduce underdevelopment through national and international political institutions leaves Sen's work wanting. The author shows how Sen's interpretation of events and the conclusions derived from them, such as an explanation of famine in Bangladesh, are insufficient--when not faulty. The author also critically analyzes the United Nations Development Program reports, which, while documenting the nature and consequences of underdevelopment, barely touch on the political context in which underdevelopment occurs.

Toward a political-economy of alcoholism: the missing link in the anthropology of drinking

This paper addresses a shortcoming in the existing anthropological and related social science literature on alcohol use and abuse, namely the general inattention to global political-economic forces that have in the past and continue to reshape social relations and drinking practices cross-culturally. Following a critical review of the dominant approaches adopted in the varying explanations of heavy drinking and alcoholism, several alternative concepts are presented and developed in order to lay the ground for the emergence of a political-economy of alcoholism. The paper urges transcendence of the existing narrow boundaries of inquiry and perspective characteristic of most anthropological study of drinking and drinking problems.

Health in China. From Mao to market reform

After the Liberation by Mao Ze Dong's Communist army in 1949, China experienced massive social and economic change. The dramatic reductions in mortality and morbidity of the next two decades were brought about through improvements in socioeconomic conditions, an emphasis on prevention, and almost universal access to basic health care. The economic mismanagement of the Great Leap Forward brought about a temporary reversal in these positive trends. During the Cultural Revolution there was a sustained attack on the privileged position of the medical profession. Most city doctors were sent to work in the countryside, where they trained over a million barefoot doctors. Deng Xiao Ping's radical economic reforms of the late 1970s replaced the socialist system with a market economy. Although average incomes have increased, the gap between rich and poor has widened.

Cardiovascular risk factors in the former communist countries. Analysis of 40 European MONICA populations

MONICA Project findings provide a unique opportunity to compare cardiovascular disease (CVD) risk factor levels in a large number of populations living in different political systems. 15 European communist populations had significantly higher age-standardized mortality for age groups 35-64 years from all causes, from CVD and stroke than 25 democratic MONICA populations. The prevalence of systolic and diastolic hypertension in males and females, prevalence of smoking in males and prevalence of overweight in females were significantly higher in communist MONICA populations. In these populations there was tendency to lower prevalence of hypercholesterolemia. In simple and multiple regression analysis hypertension and smoking prevalence had the highest relation with CVD mortality in men; hypertension and overweight prevalence had the highest relation with CVD mortality in women. The combination of 'classical' CVD risk factors could explain only part of differences observed. In communist Europe there was high consumption of spirits, low consumption of fruits and extremely low intake of citrus fruits. Instead of exaggerated anti-cholesterol propaganda emphasis should be given to the prevention of antioxidant deficiencies by the increase of fruit and vegetable consumption and to the decrease in salt, spirit and cigarette consumption in former communist countries.

A Marxist view of medical care

Marxist studies of medical care emphasize political power and economic dominance in capitalist society. Although historically the Marxist paradigm went into eclipse during the early twentieth century, the field has developed rapidly during recent years. The health system mirrors the society's class structure through control over health institutions, stratification of health workers, and limited occupational mobility into health professions. Monopoly capital is manifest in the growth of medical centers, financial penetration by large corporations, and the "medical-industrial complex." Health policy recommendations reflect different interest groups' political and economic goals. The state's intervention in health care generally protects the capitalist economic system and the private sector. Medical ideology helps maintain class structure and patterns of domination. Comparative international research analyzes the effects of imperialism, changes under socialism, and contradictions of health reform in capitalist societies. Historical materialist epidemiology focuses on economic cycles, social stress, illness-generating conditions of work, and sexism. Health praxis, the disciplined uniting of study and action, involves advocacy of "nonreformist reforms" and concrete types of political struggle.

International Monetary Fund programs and tuberculosis outcomes in post-communist countries

BACKGROUND

Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries.

METHODS AND FINDINGS

We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval, -1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables.

CONCLUSIONS

IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis-related health outcomes.

Health, health services, and health planning in Cuba

The profound changes which have occurred in the Cuban health services since 1958 are described and appraised in this article. The first part treats the main socioeconomic policies, particularly the urban and agrarian reforms, that have had an equalizing effect on the distribution of resources (including health resources) between regions and social classes. These socioeconomic developments have determined changes in mortality and morbidity patterns, particularly in the control of waterborne diseases, in the reduction of the level of malnutrition, and in the increasing prevalence of chronic conditions. The second part describes the main characteristics of the health services development in the last decade: centralization of inpatient facilities; decentralization of ambulatory ones; and the training of large numbers of physicians, paramedical personnel, and, especially, auxiliary personnel. The health services are structured according to a regional model that aims at the integration of preventive with curative services, personal with environmental, and medical with social services. Within this model, great priority is given to primary care, especially in the rural areas, where the greatest benefits of the restructuring of the system have been realized. The education and training of human resources, particularly of physicians, in response to the requirements of the system and the flight of nearly half the medical manpower after the Revolution, are also discussed in this section. The third part of the article describes the process of decision—making and planning in Cuba today, with special emphasis on the health sector. This process is highly centralized in plan preparation but highly decentralized in plan implementation. The medical profession has a definitive and decisive influence in the preparation of the plans, through the very powerful advisory planning task forces. The advantages and disadvantages of this active participation are discussed. Plan implementation is accomplished with massive participation by the population and its organs, the mass organizations, which partly explains the great achievements of the public health programs. The relationship between decision—makers and planners, not always an easy one, is also analyzed.

Health lifestyles and political ideology in Belarus, Russia, and Ukraine

This paper examines the association of political ideology with health lifestyle practices and self-rated health in Belarus, Russia, and Ukraine. The political trajectory of post-Soviet societies has taken two divergent paths, either toward democracy or autocracy. The health trajectory has followed the same pattern with the more autocratic states continuing to experience a mortality crisis, while those former socialist countries that have embraced democracy and moved closer to the West have escaped this crisis. This paper investigates whether political ideology in three post-Soviet countries that are firmly (Belarus), increasingly (Russia), or recently (Ukraine) autocratic is related to health lifestyles and health self-ratings. Data were collected by face-to-face interviews (N = 8406) with a representative national sample of the adult population. The results show that respondents who are against restoring communism have healthier lifestyles and rate their health better than respondents who wish to see communism return.

Nutrition transition and dietary energy availability in Eastern Europe after the collapse of communism

After the economic transition of the late 1980s and early 1990s there was a rapid increase in overweight and obesity in many countries of Eastern Europe. This article describes changing availability of dietary energy from major dietary components since the transition to free-market economic systems among Eastern European nations, using food balance data obtained at national level for the years 1990-92 and 2005 from the FAOSTAT-Nutrition database. Dietary energy available to the East European nations satellite to the former Soviet Union (henceforth, Eastern Europe) was greater than in the nations of the former Soviet Union. Among the latter, the Western nations of the former Soviet Union had greater dietary energy availability than the Eastern and Southern nations of the former Soviet Union. The higher energy availability in Eastern Europe relative to the nations of the former Soviet Union consists mostly of high-protein foods. There has been no significant change in overall dietary energy availability to any category of East European nation between 1990-1992 and 2005, indicating that, at the macro-level, increasing rates of obesity in Eastern European countries cannot be attributed to increased dietary energy availability. The most plausible macro-level explanations for the obesity patterns observed in East European nations are declines in physical activity, increased real income, and increased consumption of goods that contribute to physical activity decline: cars, televisions and computers.

The micropolitics of medicine: a contextual analysis

Certain features of the doctor-patient encounter "medicalize," and thereby depoliticize, the social structural roots of personal suffering. The critique of medicalization holds that medicine has become an institution of social control, that the health care system helps promulgate the dominant ideologies of a society, and that the doctor-patient relationship is a major site where these developments occur. This paper presents a contextual analysis of medical encounters, drawn from a sample of tape-recorded doctor-patient interaction in medical practice. The doctor-patient relationship manifests problems that arise despite the best conscious intents of well-motivated participants. Conveying the symbolism of scientific medicine, messages of ideology and social control reinforce current relations of economic production and reproduction in work, the family, leisure, pleasure, sexuality, and other areas of social life. Ambiguities within the doctor-patient relationship both reflect and help reproduce broader social contradictions and structures of oppression. The medical encounter is one arena where the dominant ideologies of a society are reinforced and where individuals' acquiescence is sought. A vision of a progressive doctor-patient relationship must include a conception of how that relationship contributes to fundamental social change.

China's "market economics in command": footwear workers' health in jeopardy

This study of occupational safety and health (OSH) problems in the footwear industry in China, the world's largest shoemaker, is based on four years of research in China supplemented by research in Taiwan, Australia, and the United States. With the advent of the economic reforms of the early 1980s, the Chinese state is being driven by an economic imperative under which the profit motive overrides other concerns, causing a deterioration in OSH conditions. Footwear workers are being exposed to high levels of benzene, toluene, and other toxic solvents contained in the adhesives used in the shoe-making process. Many workers have been afflicted with aplastic anemia, leukemia, and other health problems. Most of China's current permissible exposure limits to toxins are either outdated or underenforced. As a result, the Chinese state's protection of footwear workers' health is inadequate. The article aims to draw the attention of the international OSH community to the importance of setting specific exposure standards for the footwear industry worldwide.

Commensal communism and the oral cavity

The world we live in contains unimaginable numbers of bacteria, and these and other single-celled creatures represent the major diversity of life on our planet. During the last decade or so, the complexity and intimacy of the interactions which occur between bacteria and host eukaryotic cells during the process of infection have begun to emerge. The study of such interactions is the subject of the new discipline of cellular microbiology. This intimacy of bacteria/host interactions creates a major paradox. The average human being is 90% bacteria in terms of cell numbers. These bacteria constitute the commensal or normal microflora and populate the mucosal surfaces of the oral cavity, gastrointestinal tract, urogenital tract, and the surface of the skin. In bacterial infections, much of the pathology is due to the release of a range of bacterial components (e.g., modulins such as lipopolysaccharide, peptidoglycan, DNA, molecular chaperones), which induce the synthesis of the local hormone-like molecules known as pro-inflammatory cytokines. However, such components must also be constantly released by the vast numbers of bacteria constituting the normal microflora and, as a consequence, our mucosae should constantly be in a state of inflammation. This is patently not the case, and a hypothesis is forwarded to account for this "commensal paradox", namely, that our commensal bacteria and mucosal surfaces exist in a state of bio-communism, forming a unified "tissue" in which interactions between bacteria and epithelia are finely balanced to ensure bacterial survival and prevent the induction of damaging inflammation. Evidence is emerging that bacteria can produce a variety of proteins which can inhibit the synthesis/release of inflammatory cytokines. The authors predict that such proteins are simply one part of an extensive signaling system which occurs between bacteria and epithelial cells at mucosal surfaces such as those found in the oral cavity.

Social science. Stress: the invisible hand in Eastern Europe's death rates

The end of communism opened up a life of economic uncertainty in the Eastern Bloc. And that, say some social scientists, may be exerting a deadly effect on residents, whose high expectations that their lives would improve were quickly dashed by the bumpy transition to a market economy. Disillusionment led to stress and depression, and depression was a harbinger of death.

Europe and central Asia's great post-communist social health insurance experiment: Aggregate impacts on health sector outcomes

The post-Communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs regression-based generalizations of the difference-in-differences method on panel data from 28 countries for the period 1990-2004. We find that, controlling for any concurrent provider payment reforms, adoption of social health insurance increased national health spending and hospital activity rates, but did not lead to better health outcomes.

Freidson then and now: an "internalist" critique of Freidson's past and present views of the medical profession

Freidson is a foremost analyst of the medical profession. Most recently Freidson attacks those who claim that medicine is declining in power. He insists that medicine has not lost the core elements that make it a powerful, indeed, the dominant, health profession. The author compares Freidson's early writings on medicine with his most recent ones, and shows that there are critical confusions in Freidson's central concepts of professional autonomy and dominance. This difficulty is illuminated by viewing dominance, autonomy, and subordination as on a continuum of control. Using this continuum, the author argues that Freidson implicitly admits what he set out to deny (that medicine has not declined in power) by shifting his focus from medical dominance to that of autonomy. Freidson also now rejects valid parts of his earlier work (that which emphasizes social structural determinants of behavior over socialization). In equating medicine in the United States with teaching in that country, Freidson's contention of "little change in medical power" meets its own refutation. Finally, despite his derogation of others, Freidson's lack of an adequate framework to explain the dynamics and not simply the structure of health care produces purely normative, utopian (and unhelpful) policy recommendations.