“Tracking governance: advice to mothers about managing the behaviour of their children in a leading Canadian women’s magazine during two disease regimes”
Juanne N. Clarke
This paper explores how advice to mothers about raising healthy children differs in two distinct disease regimes as portrayed in articles in the pre-eminent Canadian women’s magazine Chatelaine about 50 years apart, 1928–1944 and 1990–2012. The paper compares intensive mothering, medicalization and the perception of risk. It suggests that both intensive mothering and medicalization are continuous from time period to time period (although the content of both mothering and medicalization differ in the two periods). Medicalization focused on the physical well-being and emphasized the importance of the routinized behaviours designed for conformity in the early period. In the latter period, there is a greater focus on individuality of children and their emotional well-being. This is linked to the rise of the discourses of the psy professions. With respect to risk, however, the paper documents an important change in the expansion of the degree to which life is considered risky. The substantive, theoretical and practical consequences of the findings are discussed.
“The contribution of qualitative research to the Healthy Foundations life-stage segmentation”
Vincent La Placa, Dominic McVey, Ewen MacGregor, Amy Smith and Malcolm Scott
This paper presents the results of the qualitative phase of Healthy Foundations, a study that groups people according to their motivations to live healthily or otherwise, their lifestyles, and the circumstances that affect this. These segments are ‘Health Conscious Realists’, ‘Balanced Compensators’, ‘Live for Todays’, ‘Unconfident Fatalists’ and ‘Hedonistic Immortals’. The aim was to explore people’s attitudes and motivations to live healthily or otherwise and the targeted healthcare interventions appropriate for each segment. The qualitative phase involved two strands: (i) focus groups and immersion in-depth interviews and (ii) video ethnographic ‘pen portraits’. It provides robust insight into the five segments’ motivations and behaviour and how these are constructed within and influenced by the wider environment. It also enabled the segments to give their views of and design appropriate interventions aligned to their individual requirements, lifestyles and structural environments. It demonstrates the usefulness of the qualitative approach to health segmentations and enhances the case for methodological pluralism, and a critical perspective, to enable development of health-related behaviour change interventions and policy more widely.
“Advancing population and public health ethics regarding HIV testing: a scoping review”
Rod Knight, Jean Shoveller, Devon Greyson, Thomas Kerr, Mark Gilbertand Kate Shannon
Recently, scholars have called for more robust population and public health ethical frameworks to inform how the health of populations and individuals ought to be improved through various approaches to HIV testing practices. Our objective is to examine the breadth, range and foci of a variety of ethical issues pertaining to HIV testing approaches within the peer-reviewed literature, and how these issues address population and/or individual interests. We identify potential tensions between individual and collective approaches as well as other concerns, including equity, justice and distribution of health and risk—hallmarks of the emergent field of population and public health ethics. Based on our review, we suggest that additional theoretical work and empirical research are required in order to inform more ethically robust debates related to population HIV testing practices. Specifically problematic were consequentialist arguments that deem testing approaches as either morally permissible or impermissible without sufficient robust empirical and/or theoretical underpinnings and about how a particular approach would unfold among individuals and populations. The current review underscores the need to continue to articulate an evidence- and theory-informed population and public health ethics pertaining to HIV testing.
“The spirit of the intervention: reflections on social effectiveness in public health intervention research”
Morten Hulvej Rod, Liselotte Ingholt, Betina Bang Sørensenand Tine Tjørnhøj-Thomsen
This paper suggests that public health intervention research would benefit from more thorough considerations of the social dynamics in which public health interventions are embedded. Rather than simply asking ‘What works?’, researchers should examine the social effectiveness of intervention programmes; i.e. (i) the creation of shared understandings among researchers and practitioners and (ii) the ways in which programmes reconfigure social relationships. Drawing on the theoretical work of philosopher Charles Taylor and sociologist Marcel Mauss, we suggest that the term ‘the spirit of the intervention’ may enable researchers to further articulate—and hence discuss—the source of an intervention’s social effectiveness. The empirical impetus of the paper lies in our experiences as an interdisciplinary team of researchers, trained in social science and public health and now working within intervention research. We describe our attempts at reconciling the methodological requirements of an effect evaluation, modelled on the randomised clinical trial, with a process of intervention development grounded in ethnographic methods. In particular, we discuss how we have grappled with the schism between fidelity and adaptation, which is a key methodological issue in intervention research. While public health intervention research tends to conceptualise programmes as fixed and bounded entities, we argue that ‘the spirit of the intervention’ offers a conceptual starting point for reflections on programmes as on-going social processes. In order to capture and explore this dimension of public health interventions, a great deal of potential lies in a further engagement between intervention research, ethnographic methods and social theory.
“Neoliberalism and the contract state: exploring innovation and resistance among New Zealand Health Promoters”
Sarah A. Lovell, Robin A. Kearnsand Russell Prince
Concern for the creep of surveillance and control into the everyday lives of citizens has revived contemporary debates over the politics of health promotion. We examined how political changes have impacted on the work of health promoters through qualitative research with individuals working in the health promotion sector. Interviews and focus groups were undertaken between January 2008 and March 2009. Caught in a neoliberally influenced drive to increase the efficiency of the health sector, health promotion in New Zealand has been subject to considerable changes in the funding and provision of services. Characterised by a growth in limited-term contracts with constrained budgets, health promoters have responded to fiscal limitations by pooling resources. We find that rather than being uncritical agents of the government’s health promotion agenda, health promoters often became advocates of the community’s agenda, occupying a ‘grey space’ where the demands of contracts create tension with their commitments to communities. Any portrayal of health promotion must acknowledge the contested nature of the spaces of governance health promoters occupy and resist reducing them to uncritical agents of the state.
“Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry”
Julia Brassolotto, Dennis Raphaeland Navindra Baldeo
To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard’s concept of epistemological barriers and Raphael’s seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized.
“Networks of knowledge or just old wives’ tales?: A diary-based analysis of women’s self-care practices and everyday lay expertise”
Alex Broom, Carla Meurk, Jon Adams and David Sibbritt
Complementary and alternative medicine is increasingly popular in Australia and particularly among women. While existing research provides some understanding of women’s engagement with complementary and alternative medicine and biomedicine, there has been comparatively little examination of the day-to-day character of their experiences. In this study, we utilise solicited diaries with women aged 60–65 years drawn from the 1946–1951 cohort of the Australian Longitudinal Study on Women’s Health to capture the temporal dimension of their therapeutic engagement. Focusing on 30 active complementary and alternative medicine users, we explore women’s experiences of managing their health, illness and well-being over a 1-month period. The themes that emerge from their diaries illustrate the day-to-day enactment of lay expertise through informal knowledge networks, practices of self-trialling and experimentation and the moralities underpinning self-care. The diaries provide unprecedented temporal insight into the (often problematic) enactment of lay expertise at the nexus of complementary and alternative medicine and biomedicine. They also point to the value of longitudinal techniques of data collection for augmenting more traditional sociological ways of exploring therapeutic pluralism.
“‘A post-transplant person’: Narratives of heart or lung transplantation and intensive care unit delirium”
Katy Flynn, Anna Daiches, Zoey Malpus, Nizar Yonan and Melissa Sanchez
Exploring patients’ narratives can lead to new understandings about perceived illness states. Intensive Care Unit delirium is when people experience transitory hallucinations, delusions or paranoia in the Intensive Care Unit and little is known about how this experience affects individuals who have had a heart or lung transplant. A total of 11 participants were recruited from two heart and lung transplant services and were invited to tell their story of transplant and Intensive Care Unit delirium. A narrative analysis was conducted and the findings were presented as a shared story. This shared story begins with death becoming prominent before the transplant: ‘you live all the time with Mr Death on your shoulder’. Following the operation, death permeates all aspects of dream worlds, as dreams in intensive care ‘tunes into the subconscious of your fears’. The next part of the shared story offers hope of restitution; however, this does not last as reality creeps in: ‘I thought it was going to be like a miracle cure’. Finally, the restitution narrative is found to be insufficient and individuals differ in the extent to which they can achieve resolution. The societal discourse of a transplant being a ‘gift’, which gives life, leads to internalised responsibility for the ‘success’ or ‘failure’ of the transplant. Participants describe how their experiences impact their sense of self: ‘a post-transplant person’. The clinical implications of these findings are discussed.
“Organ donation as transition work: Policy discourse and clinical practice in The Netherlands”
Katharina T Paul, Cees JJ Avezaat, Jan N Ijzermans, Roland D Friele and Roland A Bal
An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.
“‘It seemed churlish not to’: How living non-directed kidney donors construct their altruism”
Julianna Challenor and Jay Watts
Our objective was to explore how prospective altruistic kidney donors construct their decision to donate. Using a qualitative design and biographical-narrative semi-structured interviews, we aimed to produce text for analysis on two levels: the social implications for subjectivity and practice and a tentative psychodynamic explanation of the participants’ psychological investment in the discourses they used. A total of six prospective altruistic kidney donors were interviewed. A psychosocial approach to the analysis was taken. In-depth discourse analysis integrated Foucauldian with psycho-discursive approaches and psychodynamic theory was applied to sections of text in which participants seemed to have particular emotional investment. Analysis generated three major discursive themes: other-oriented, rational and self-oriented discourses. The desire to donate was experienced as compelling by participants. Participants used discourses to position themselves as concerned with the needs of the recipient, to resist questioning and criticism, and to manage difficult feelings around mortality. Participants tended to reject personal motivations for altruistic donation, positioning relatives’ disapproval as selfish and illogical. These results suggest that the term ‘altruistic’ for living non-directed organ donation constrains available discourses, severely limiting what can be said, felt, thought and done by donors, clinicians and the public. A more useful approach would acknowledge potential psychological motives and gains for the donor.
“‘There’s a lot of tasks that can be done by any’: Findings from an ethnographic study into work and organisation in UK community crisis resolution and home treatment services”
Across the United Kingdom, large numbers of crisis resolution and home treatment services have been established with the aim of providing intensive, short-term care to people who would otherwise be admitted to mental health hospital. Despite their widespread appearance, little is known about how crisis resolution and home treatment services are organised or how crisis work is done. This article arises from a larger ethnographic study (in which 34 interviews were conducted with practitioners, managers and service users) designed to generate data in these and related areas. Underpinned by systems thinking and sociological theories of the division of labour, the article examines the workplace contributions of mental health professionals and support staff. In a fast-moving environment, the work which was done, how and by whom, reflected wider professional jurisdictions and a recognisable patterning by organisational forces. System characteristics including variable shift-by-shift team composition and requirements to undertake assessments of new referrals while simultaneously providing home treatment shaped the work of some, but not all, professionals. Implications of these findings for larger systems of work are considered.
“The merit of sociological accounts of disorder: The Attention-Deficit Hyperactivity Disorder case”
This article argues in favor of a sociological perspective on health and illness, drawing on recognized positions from the philosophy of health and illness about how to demarcate disorder from non-disorder. The argument specifies that a normative context in which bodies or behaviors are disvalued is a necessary component for identifying what constitutes a disorder, as this normative context allows material differences to be understood as dysfunctional and pathological. Descriptions of material states in themselves are insufficient to distinguish what is legitimately a disorder; some evaluative stance toward those states is also required. This article applies the argument to disorders of inattention and hyperactivity, currently best known as Attention-Deficit Hyperactivity Disorder. These disorders have been controversial since their formalization in the 1970s, the same time that they began receiving sociological attention. Sociological analyses have consistently expressed ambivalence toward recognizing claims about the biological status of such disorders. This ambivalence has at times committed to a problematic relationship between sociological explanation and medical explanation, implicitly allocating sociological explanation to an auxiliary position. This article argues that this is not necessary, as sociological perspectives address disorders on a fundamental, rather than secondary, register. Disorders are only intelligible due to the normative and social context in which they are found, and so medical sociology can recognize the validity of biological claims about disorders, such as Attention-Deficit Hyperactivity Disorder, while still asserting the essential social nature of disorder.
“Green schoolyards as havens from stress and resources for resilience in childhood and adolescence”
Louise Chawla, Kelly Keena, Illène Pevec and Emily Stanley
This paper investigates how green schoolyards can reduce stress and promote protective factors for resilience in students. It documents student responses to green schoolyards in Maryland and Colorado in the United States under three conditions: young elementary school children׳s play in wooded areas during recess; older elementary school children׳s use of a naturalized habitat for science and writing lessons; and high school students׳ involvement in gardening. Drawing on ethnographic observations and interviews, it describes how the natural areas enabled students to escape stress, focus, build competence, and form supportive social groups. These findings have implications for theories of resilience and restoration and school interventions for stress management.
“How do people with learning disability experience the city centre? A Sheffield case study”
Alex McClimens, Nick Partridge and Ed Sexton
The use of city centre spaces by people with learning disability is not much debated in the literature. Here we include the thoughts and opinions of groups of people with learning disability as we undertook some guided walks through Sheffield city centre. We found that few of the participants had independent access to the city centre. Many cited concerns over personal safety and the most, on few occasions when they did visit, did so with family and/or paid staff for pre-planned purposes, usually linked to shopping. The need for appropriate support figured prominently. There is also a need to re-assess what we mean by social inclusion for this cohort.
“Social capital and the utilization of maternal and child health services in India: A multilevel analysis”
William T. Story
This study examines the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunizations using a multilevel analytic sample of 10,739 women who recently gave birth and 7403 children between one and five years of age in 2293 communities and 22 state-groups from the 2005 India Human Development Survey. Exploratory factor analysis was used to create and validate six social capital measures that were used in multilevel logistic regression models to examine whether each form of social capital had an independent, contextual effect on health care use. Results revealed that social capital operated at the community level in association with all three care-seeking behaviors; however, the results differed based on the type of health care utilized. Specifically, components of social capital that led to heterogeneous bridging ties were positively associated with all three types of health care use, whereas components of social capital that led to strong bonding ties were negatively associated with the use of preventive care, but positively associated with professional delivery care.
“Triple jeopardy: Adolescent experiences of sex work and migration in Zimbabwe”
Joanna Busza, Sibongile Mtetwa, Petronella Chirawu and Frances Cowan
Adolescence, migration and sex work are independent risk factors for HIV and other poor health outcomes. They are usually targeted separately with little consideration on how their intersection can enhance vulnerability. We interviewed ten women in Zimbabwe who experienced sex work and migration during adolescence, exploring implications for their health and for services to meet their needs. For most, mobility was routine throughout childhood due to family instability and political upheaval. The determinants of mobility, e.g. inability to pay school fees or desire for independence from difficult circumstances, also catalysed entry into sex work, which then led to further migration to maximise income. Respondents described their adolescence as a time of both vulnerability and opportunity, during which they developed survival skills. While these women did not fit neatly into separate risk profiles of “sex worker” “migrant” or “adolescent”, the overlap of these experiences shaped their health and access to services. To address the needs of marginalised populations we must understand the intersection of multiple risks, avoiding simplified assumptions about each category.
“An exploration of rural-urban differences in healthcare-seeking trajectories: Implications for measures of accessibility”
Jeannie L. Haggerty, Danièle Roberge, Jean-Frédéric Lévesque, Josée Gauthier and Christine Loignon
Comparing accessibility between urban and rural areas requires measurement instruments that are equally discriminating in each context. Through focus groups we explored and compared care-seeking trajectories to understand context-specific accessibility barriers and facilitators. Rural care-seekers rely more on telephone access and experience more organizational accommodation but have fewer care options. Urban care-seekers invoke the barrier of distance more frequently. Four consequences of accessibility problems emerged across settings which could be used for valid comparisons of access: having to restart the care-seeking process, abandoning it, using emergency services for primary care, and health deterioration due to delay.
“The Birth of the (Gay) Clinic”
Michael Brown and Larry Knopp
We apply and extend Philo’s (2000) arguments about Foucault’s Birth of the Clinic as an inspiration for health geography and the study of governance of gays. Philo identified three spaces through which he argued disease is framed: disease tabled, embodied, and institutionalized. These focus attention on the spatialities through which the medical gaze is power-laden. We adopt this framework empirically through an historical geography of an urban public health system engaged with sexually transmitted infections (STIs) in the “homosexual” population of Seattle, Washington in the 1970s. It reveals the interaction of homophobia, heteronormativity and resistances across places typically understudied in queer historical geography. Our findings also extend this framework, however, by revealing other spaces that were important in the urban politics of sexual health: the gay city, the gay doctor, and the gay community. We suggest, therefore, that these and other spaces may be helpful in other health geographies interested in the dynamics of sexuality, governmentality, and urban public health.
“‘At risk by fact of birth’: perceptions and concerns about medical male circumcision for HIV prevention in northern Malawi”
Paul Mkandawire, Jenna Dixon, Isaac Luginaah, Frederick Armah and Godwin Arku
In this article, we draw on critical approaches to risk to examine varied and interlaced perceptions of personal risk for HIV which young men in an area of traditionally low male circumcision have to Malawi government’s new policy of medical male circumcision for HIV prevention, locally known as mdulidwe. In this article, we draw on data from in-depth interviews (n = 29) and focus groups (n = 24) with young men aged 18–24 years undertaken in 2013 in an area with traditionally low rates of circumcision, Livingstonia in the northern region district of Malawi. Our findings show that the push for medical male circumcision in this region has given rise to a perception that the penile foreskin is an inborn anomaly that leads to excessive risk for HIV provoking anxiety, confusion, uncertainty, fatalistic views, and waning faith in national response to the epidemic. Our analysis of the data indicates that medical male circumcision has ushered in a layered and sometimes conflicting understanding of risk for HIV/AIDS where established ideas grounded in sexual propriety and risk-taking are being re-evaluated and reinterpreted within an emerging worldview coloured with sensibilities pertaining to notions of bodily normalcy. This indicates that the men in our study had a nuanced understanding of risk for HIV that incorporated notions of sexual risk-taking with corporeal impropriety, necessitating appropriate public risk communication about HIV/AIDS and policy responses for its prevention.
“Preparing for and communicating uncertainty in cancer genetic counselling sessions in Norway: an interpretative phenomenological analysis”
Tone Aasenand John-Arne Skolbekken
Risk communication is widely recognised as playing an important role in how individuals at risk of familial cancer understand and interpret their genetic status. To date, however, there has been little empirical investigation directed towards understanding how genetic counsellors themselves understand and actually deal with the challenges of communicating uncertainty of being identified with a gene fault in cancer genetic counselling sessions. In this article, we explore this relationship by using interpretative phenomenological analysis of semi-structured interviews with two genetic counsellors, prior to initial sessions with six patients in Norway, to examine whether the communication during consultations reflects what the genetic counsellors say they do. Analysis of the interviews demonstrates that the counsellors approach the patients’ experiences of their uncertain genetic status by drawing on past family history information and clinical experience as much as numerical risk information. Communicating the uncertainty in a manageable manner is described as a balancing act, involving being supportive while presenting realistic outcomes of the gene tests. Furthermore, our findings from the consultations show that although their clinical experience is emphasised, the counsellors do not explicitly invite patients to express how they themselves experience uncertainty in the context of their lives. While the counsellors provide the patients with balanced risk information, they do not explore how this uncertainty is experienced from the patient’s perspective. As such, our findings provide insight into an under-researched area within the field of genetic counselling.
“From Antipolitics to Post-Neoliberalism: A Conversation with James Ferguson”
This interview with James Ferguson traces his thinking from his groundbreaking The Antipolitics Machine to his newest work on neoliberalism. Ferguson explains how the process of development is above all about building justifications for why more money is needed to fund the next project, thus less about increasing state control or oversight over society than simply about creating more state. Conversely, rather than using the term “neoliberalism” as a political cudgel to condemn structural adjustment policies, Ferguson presses critics to linger over what is actually taking place under post-neoliberal forms of governance.
International Journal of Social Psychiatry
“Towards a treatment model for family therapy for schizophrenia in an urban African setting: Results from a qualitative study”
Laila Asmal, Sumaya Mall, Robin Emsley, Bonginkosi Chiliza and Leslie Swartz
Background: Family interventional programmes are effective adjuncts to pharmacotherapy in patients with schizophrenia. Modification in content of such programmes in response to local challenges is considered important, but has not been fully explored in Africa.
Aims: To assess the feasibility and acceptability of an interventional family study for people with schizophrenia and their families in a socially deprived urban community in South Africa and to explore the contextual factors that could influence implementation of the intervention.
Method: A psychiatric nurse facilitated semi-structured interviews with four multi-family groups, each comprising adult outpatients with schizophrenia and their caregivers. Six sessions were held per group. Thematic analysis was applied.
Results: Three themes emerged: stigma and abuse; substance abuse comorbidity and caregiver burden of multiple stressors. Many of these stressors relate to the challenges of an impoverished urban environment.
Conclusions: Multi-family groups with a psycho-educational and behaviour modification frame are acceptable. Negative symptoms are seen as protective in areas of community violence. Modification of traditional models of family therapy to include factors related to poverty, violence, caregiver burden, stigma and limited health care access should be considered in this setting.
“Experiences from the implementation of a comprehensive development plan for user involvement in a mental health hospital: A qualitative case study”
Marit B Rise, Marit Solbjør and Aslak Steinsbekk
Background: Few studies have investigated user involvement initiatives in whole organizations. The aim was to explore the experiences of professionals and user representatives taking part in the implementation of a user involvement plan.
Materials: A qualitative study in a mental health hospital included interviews and observational data.
Discussion: Three different stories emerged. The first described the implementation as a success. The second described the implementation as a success, but after overcoming several obstacles. The third described that the development plan had limited impact.
Conclusions: Close attention should be made to decision-making and resource allocation when implementing user involvement.
“The role of the psychologist in social change”
On 1 September 1967, the Nobel Prize-winning civil rights leader Martin Luther King Jr. delivered a speech entitled ‘The role of the behavioral scientist in the civil rights movement’ to the American Psychological Association (APA, 1999; King, 1968). With eloquence and passion, Martin Luther King championed the civil rights struggle and spoke to the interests of his audience. He stressed how behavioural scientists could and should support the civil rights movement. King’s eloquent and passionate speech is still relevant today—explaining how psychologists and other mental health professionals could help address today’s pressing social issues.
The British Journal of Psychiatry
“Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study”
T. M. Luhrmann, R. Padmavati, H. Tharoor and A. Osei
We still know little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries.
To compare auditory hallucinations across three different cultures, by means of an interview-based study.
An anthropologist and several psychiatrists interviewed participants from the USA, India and Ghana, each sample comprising 20 persons who heard voices and met the inclusion criteria of schizophrenia, about their experience of voices.
Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind.
These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.
Journal of the History of Medicine and Allied Sciences
“The AIDS Pandemic in Historic Perspective”
Potent antiretroviral drugs (ART) have changed the nature of AIDS, a once deadly disease, into a manageable illness and offer the promise of reducing the spread of HIV. But the pandemic continues to expand and cause significant morbidity and devastation to families and nations as ART cannot be distributed worldwide to all who need the drugs to treat their infections, prevent HIV transmission, or serve as prophylaxis. Furthermore, conventional behavioral prevention efforts based on theories that individuals can be taught to modify risky behaviors if they have the knowledge to do so have been ineffective. Noting behavioral strategies targeting individuals fail to address broader social and political structures that create environments vulnerable to HIV spread, social scientists and public health officials insist that HIV policies must be comprehensive and also target a variety of structures at the population and environmental level. Nineteenth-century public health programs that targeted environmental susceptibility are the historical analogues to today’s comprehensive biomedical and structural strategies to handle AIDS. Current AIDS policies underscore that those fighting HIV using scientific advances in virology and molecular biology cannot isolate HIV from its broader environment and social context any more than their nineteenth-century predecessors who were driven by the filth theory of disease.
“‘An Army of Reformed Drunkards and Clergymen’: The Medicalization of Habitual Drunkenness, 1857–1910”
Katherine A. Chavigny
Historians have recognized that men with drinking problems were not simply the passive subjects of medical reform and urban social control in Gilded Age and Progressive Era America but also actively shaped the partial medicalization of habitual drunkenness. The role played by evangelical religion in constituting their agency and in the historical process of medicalization has not been adequately explored, however. A post-Civil War evangelical reform culture supported institutions that treated inebriates along voluntary, religious lines and lionized former drunkards who publicly promoted a spiritual cure for habitual drunkenness. This article documents the historical development and characteristic practices of this reform culture, the voluntarist treatment institutions associated with it, and the hostile reaction that developed among medical reformers who sought to treat intemperance as a disease called inebriety. Those physicians’ attempts to promote therapeutic coercion for inebriates as medical orthodoxy and to deprive voluntarist institutions of public recognition failed, as did their efforts to characterize reformed drunkards who endorsed voluntary cures as suffering from delusions arising from their disease. Instead, evangelical traditions continued to empower reformed drunkards to publicize their own views on their malady which laid the groundwork for continued public interest in alcoholics’ personal narratives in the twentieth century. Meanwhile, institutions that accommodated inebriates’ voluntarist preferences proliferated after 1890, marginalizing the medical inebriety movement and its coercive therapeutics.
“Cadaver Brains and Excesses in Baccho and Venere: Dementia Paralytica in Dutch Psychiatry (1870–1920)”
Jessica Slijkhuis and Harry Oosterhuis
This article explores the approach of dementia paralytica by psychiatrists in the Netherlands between 1870 and 1920 against the background of international developments. The psychiatric interpretation of this mental and neurological disorder varied depending on the institutional and social context in which it was examined, treated, and discussed by physicians. Psychiatric diagnoses and understandings of this disease had in part a social–cultural basis and can be best explained against the backdrop of the establishment of psychiatry as a medical specialty and the specific efforts of Dutch psychiatrists to expand their professional domain. After addressing dementia paralytica as a disease and why it drew so much attention in the late nineteenth and early twentieth century, this essay discusses how psychiatrists understood dementia paralytica in asylum practice in terms of diagnosis, care, and treatment. Next we consider their pathological–anatomical study of the physical causes of the disease and the public debate on its prevalence and causes.
“‘Our Sickness Record Is a National Disgrace’: Adelle Davis, Nutritional Determinism, and the Anxious 1970s”
America’s most widely read nutritionist of the postwar decades, Adelle Davis, helped to shape Americans’ eating habits, their child-feeding practices, their views about the quality of their food supply, and their beliefs about the impact of nutrition on their emotional and physical health. This paper closely examines Davis’s writings and argues that even though she is often associated with countercultural food reformers like Alice Waters and Frances Moore Lappé, she had as much in common with the writings of interwar nutritionists and home economists. While she was alarmed about the impact of pesticides and food additives on the quality of the food supply, and concerned about the declining fertility of American soil, she commanded American women to feed their families better and promised that improved nutrition would produce stronger, healthier, more beautiful children who would ensure America’s future strength. She believed that nearly every health problem could be solved through nutrition, and urged her readers to manage their diets carefully and to take extensive supplementation to ensure optimum health. As such, she played an important role in creating the ideology of “nutritionism”—the idea that food should be valued more for its constituent parts than for its pleasures or cultural significance.
“When Bad Mothers Lose Good Babies: Understanding Fetal and Infant Mortality Case Reviews”
This article examines how the practices of the Fetal and Infant Mortality Review–Case Review Team (FIMR CRT) in “Florida City” constructs particular types of maternal and fetal subjects and how these narratives about fetal and infant death reflect particular discourses about “bad mothers” and “good babies.” I argue that the very methods of the Florida City FIMR committee structure the types of conversations and, in effect, judgments that can be made about women who experience a fetal or neonatal death. In addition, I examine how many of these ideas resonate with the discourses around fetal rights that pervade contemporary abortion politics in the United States.
“The Unfortunate Sufferer: Discursive Dynamics around Pregnancy Loss in Cameroon”
Erica van der Sijpta
Pregnancy losses are ambiguous affairs in East Cameroon. Childbearing is not always people’s primary aim within their fragile sexual and marital relationships, and it is often unclear to outsiders whether a pregnancy interruption is intended or unintended. Drawing on 15 months of fieldwork, I explore the discursive strategies Gbigbil women deploy while navigating such ambiguities around interrupted pregnancies. Suffering is central to their defensive discourses. Depending on the stakes in their relationships, women foreground the notion of suffering either to portray themselves as moral and innocent—and maintain social status or raise support—or to allude to or acknowledge their intention to terminate a pregnancy. This dynamic deployment of a suffering discourse reveals the interconnections of unintended and intended pregnancy losses, and of suffering (associated especially with the former) and agency (often associated with the latter).
“Silences and Moral Narratives: Infanticide as Reproductive Disruption”
Infanticide is a widespread practice, yet few ethnographic and theoretical works examine this. Drawing on ethnographic research conducted in the Indian Himalayas, I argue that infanticide is a form of reproductive disruption that elicits both public moral judgments and private silences. In this Himalayan context, the stigmas of abortion and premarital sex prevent community acknowledgement of infanticide and baby abandonment. Unmarried women hide their pregnancies, deliver and abandon their babies, and later are rushed to the hospital with postdelivery complications. While biomedical doctors deal with the debris of infanticide (postpartum hemorrhage), there is no formal accounting of the practice. I argue that by regarding infanticide as a form of reproductive disruption, we can open up women’s narratives of pain and suffering that are silenced because of moral repugnance.
“Living with Diabetes: Lay Narratives as Idioms of Distress among the Low-Caste Dalit of Nepal”
Tirtha B. Thapa
Among the Dalit community in Nepal, people consistently describe their diabetes in relation to stress caused by social inequality and social marginalization. Drawing on the illness narratives of 30 people from this community, I argue that through linking diabetes with stress as a result of caste-based discrimination, respondents use diabetes as an ‘idiom of distress.’ Respondents report that discrimination based on caste creates and aggravates their dire financial circumstances, resulting in the prolonged stress that causes and interacts with diabetes. Suffering with diabetes, and its ensuing financial struggles and accompanying stress, has for some led to suicidal thoughts and the preference of death to living with diabetes.
“Poisoned Blood, Ghaa, and the Infected Body: Lay Understandings of Arsenicosis in Rural Bangladesh”
M. Saiful Islam
This article draws on ethnographic data from rural Bangladesh to examine how community members affected by arsenicosis understand, explain, and experience this deadly illness. Biomedically, arsenicosis has been described as a disease caused by drinking arsenic-contaminated water, and it is manifested through physiological complications such as symmetric hyperkeratosis of the palms and soles, cancer of the skin, kidney and lungs, and diseases of the blood vessels. This article goes beyond such biomedical discourse and illustrates how arsenicosis has been vernacularized as ghaa in practice. It focuses on lay world views, logic, local knowledge systems, and sociocultural factors that shape popular understandings of the disease. This article is thus a contribution to our understanding of how arsenicosis, apart from its biomedical and clinical manifestations, is understood and experienced by affected individuals living within the particular sociocultural and ecological constraints of rural Bangladesh.
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