Marisa de Andrade, Kathryn Angus, Gerard Hastings, Nikolina Angelova
The tobacco market has been transformed by the arrival of e-cigarettes and array of alternative nicotine delivery systems (ANDS). Public health has struggled to cope with these changes and clear divisions are apparent, but less is known about the tobacco industry (TI) response. This first empirical study to examine TI and independent ANDS companies’ business strategies fills this gap. Primary data were collected through 28 elite interviews with senior/influential TI and independent stakeholders, triangulated with a documentary analysis of company reports, investor analyses, market research, and consultation responses (1022 documents). A deliberately emic analysis shows that tobacco multinationals were initially disconcerted by ANDS, but logic provided by the fiduciary imperative is enabling them to turn a potential threat into profitable opportunities. Interviewees argue market changes played to their strengths: customer links, expertise in nicotine, and enormous financial resources. This enabled portfolio diversification in which combustible and ANDS coexist; providing potential to develop robust scientific and regulatory positions and hope of retrieving corporate reputations. The principal threat for major tobacco players comes from the independent sector, which is prepared and able to satisfy bespoke consumer needs. Multinationals by contrast need to turn ANDS into a genuinely mass-market product appealing to its global customers. They are making progress. Given the continued buoyancy of the combustibles market, they have extensive resources to continue their efforts. Disruptive innovations are not unique to tobacco control. Equivalent technological solutions – with concomitant business opportunities − are emerging in obesity and alcohol fields with implications for public health.
In this article, I argue that citizens’ relations with, and uses of, dietary health campaigns may be more heterogeneous than just pragmatic adaptation or tactics of resistance. The article takes a practice theoretical approach in order to focus on the links between the existing food practices and the socially expectable and normatively acceptable ways of performing healthier shopping, cooking, and eating. The empirical study, on which the article is based, is a qualitative study of Danish citizens, and the analysis shows three different, but related, kinds of mundane negotiations of the official Danish dietary advice, according to connection, expert knowledge, and everyday agency.
WK Tim Wong, Alex Broom, Emma Kirby, Zarnie Lwin
Medical encounters – while often viewed as centred on conveying clinical knowledge – are also sites of emotion and for exerting emotional labour by healthcare professionals. The temptation to view these encounters as largely ‘technical’ – an exchange of knowledge or information – can marginalise the complex emotions often experienced by healthcare professionals, and negates the critical work done in these encounters. Drawing on in-depth interviews with 22 Australian medical oncologists, this article explores the experience and meaning of (their) emotions in medical encounters, and the manner in which emotional labour is performed by medical oncologists. Emotions, as it emerges, are central to the ‘management’ of encounters, ensuring professional sustainability and in ‘achieving’ clinical outcomes. Here, we broaden understandings of emotionality in oncological work, focusing on emotions as central to the production and enactment of professionalism, relationships and identities across professional careers. We illustrate how the performance of emotional labour reflects a dialectic between notions of ‘professionalism’ and ‘feelings’ – which in practice are co-existing and intermingling dimensions of oncology relations – manifested in the practice of ‘bounded caring’.
Maria Orphanidou, Irini Kadianaki
Media offer people ways of understanding mental health and illness, shaping their attitudes and behaviour towards it. Yet, the literature on media representations of depression is limited and fails to illuminate sufficiently the content of representations. In times of financial crisis, the prevalence of depression is increased and the particular meanings associated with depression are widely diffused. To unpack these meanings, we focused on the Greek-Cypriot press during the financial crisis of 2013. Two-hundred and three articles from seven widely circulating newspapers were thematically analysed. Two antithetical themes of representations of depression were identified: Biomedical Depression, which constructed depression as a biologically grounded illness treated through medical/pharmaceutical means, and Everyday Depression, which portrayed depression as something normal, encountered in anyone, attributed to psychosocial factors (e.g. the financial crisis), and treated through self-management. Biomedical Depression reflects a widespread medical and deterministic understanding of depression. Nevertheless, this understanding has not overridden, as the literature suggests, references to individual agency, which are present in the Everyday Depression and the more normalising understanding of depression it expresses. We argue, however, that both themes promote an individualistic understanding of depression, placing individuals in a tense position of being responsible for a condition perceived to be outside their control.
Discourse on the highly sensitive child as a mode of individual coming-into-being is transforming notions of good motherhood. Mothering a child is weighted with practical challenges, normative expectations, and moral implications, all of which can be accentuated when parenting a child that appears to differ from the average. How mothers address themselves to a highly sensitive child can reveal much about contemporary currents in family life. Through analysis of the online discussions in a Swedish forum, I examine mothers’ discourse regarding categorization of highly sensitive children, elaboration on the behaviors that constitute this category of protean individuality, and the negotiation of motherhood norms. Three themes are identified: the way in which participants established entitlement to the application of the highly sensitive child label through a process of “enlightenment” based on observing their children and scrutinizing their own childrearing practices; discourse on the “allure” of the highly sensitive child since it depicts the children as super-normal and themselves as mothers called to the custodianship of a “different child”; and finally, how the highly sensitive child label deflects the guilt and frustration linked with handling challenging behaviors, in tension with permitting the sensitive child’s self-determined development. The article suggests that the mothers’ discourse reflects the intensive mothering norms of child-centered parenting that prevail in Western countries such as Sweden. Through the lens of the highly sensitive child, however, motherhood acquires new anticipatory, considerate and susceptible norms, and strategies that constitute a highly sensitive parenting style.
Michele Statz, Kylie Everz
Policy attention to growing rural “health care deserts” tends to identify rural distance as a primary spatial barrier to accessing care. This paper brings together geography, health policy, and ethnographic methods to instead theorize distance as an expansive and illuminating concept that highlights place-based expertise. It specifically engages rural women’s interpretations of rural distance as a multifaceted dimension of accessing health care, which includes but is not limited to women’s health services and maternity care. Presenting qualitative research with 51 women in a rural region of the U.S., thematic findings reveal an interpretation of barriers to rural health care as moral failings rather than as purely spatial or operational challenges, along with wide communication of negative health care experiences owing to spatially-disparate but trusted social networks. Amid or owing to the rural crisis context, medical mistrust here emerges as a meaningful but largely unrecognized barrier to rural women’s ability—and willingness—to obtain health care. This underscores how a novel interpretation of distance may inform policy efforts to address rural medical deserts.
Jennifer Dean, Samantha Biglieri, Michael Drescher, Anna Garnett, Troy Glover, Jeff Casello
The majority of research on built form and walking has been approached from a deterministic perspective and does not address the theoretical underpinnings of individual walking behaviour. This paper interrogates the relationship between individual walkers and their local environment in order to illuminate how and why people walk through/with space. Specifically, the paper reports on findings from 20 adult participants in Waterloo, Canada who took part in a participatory walking interview accompanied by a member of the research team. A relational interpretation of the data revealed that the relationship between built form and walking extends beyond the correlates of residential density, mix of land uses and street networks. Our findings reveal that there are blurred boundaries between utilitarian and recreational walking behavior, and that walking decisions were influenced by desires to avoid discomfort, seek pleasure, foster social connection and more-than-human encounters. We conclude with the argument that a relational perspective better captures the dynamics between people and place, and ultimately guides practitioners to design built environments that accommodate the realities of human activity in general and walking behavior in particular.
Jill Owczarzak, Noelle Weicker, Glenna Urquhart, Miles Morris, Ju Nyeong Park, Susan G.Sherman
This paper explores how a peer-and street-based naloxone distribution program (Bmore POWER) reshapes narratives and practices around drug use and harm reduction in an urban context with an enduring opioid epidemic. Data collection included observations of Bmore POWER outreach events and interviews with peers. Bmore POWER members create a sense of community responsibility around overdose prevention and reconfigure overdose hotspots from places of ambivalence to places of grassroots action. It expands a harm reduction approach to Black communities that have not traditionally embraced it and that have been underserved by drug treatment programs. Policy makers should consider ways to use peers grounded in specific communities to expand other aspects of harm reduction, such as syringe and support services.
Shukru Esmene, Catherine Leyshon, Michael Leyshon
Social prescribing (SP) is an increasingly popular means of enabling medical professionals to refer people to social activities. However, how individuals accommodate activity groups into their routines has been neglected by studies exploring SP. This paper uses qualitative approaches to explore how place and sociability influence the experiences of individuals with type-2 diabetes in a social prescription walking group. Using in-situ conversations and in-depth interviews, we demonstrate how place and sociability extends beyond a group via storytelling, and allows individuals to become part of a group. Understanding place, sociability and storytelling is critical in characterising the benefits of social prescription.
Mike Prescott, William C. Miller, Francois Routhier, W. Ben Mortenson
The ability to move about the community safely and easily plays a key role in the lives of people who use mobility devices. This study explored how personal characteristics, mobility device use, transportation, and environmental factors affected the size of their activity spaces (i.e., daily path area). Seventy-eight people who used manual wheelchairs, power wheelchairs, scooters, walkers, canes, and/or crutches tracked their movements in the community using a geographical positioning system device over a 7-day period. Participating in productive activities, walkability, the interaction between access to a vehicle and walkability, seasonality, and location helped to explain 43% of the variability in daily path area. The type of mobility device used and years using a device were associated with activity space size in bivariate analysis but not significantly significant in the regression model. The findings underscore the complex challenges that people who use mobility devices face moving about the community. Implications for researchers and transportation planners are discussed.
James Lowe, Geoffrey DeVerteuil
This paper presents the lived experiences of individuals with mental illness as they navigate the benefits landscape in an age of welfare reform in the UK. We focus on the impacts upon their well-being and daily geographies. We articulate the relationship between welfare reform and mental health using the concept of poverty management and its ‘missing geographies’, in which everyday well-being and routines are dismissed by the restructuring welfare system. We liken this dismissal to a shift towards a narrower and more unforgiving mode of poverty management, where even the smallest misstep can unravel the entire edifice of everyday survival and well-being.
Framed both as a solution to and as an additional part of the tobacco problem, e-cigarettes have been the subject of risk controversies since they were launched in 2006, followed by massive divergence in media, public health approaches and regulations across the world. This study explores vapers’ risk perceptions and accounts of the public risk communication and regulation of e-cigarettes in a Norwegian context were nicotine-containing e-liquids are prohibited from being sold by domestic retailers. Based on analyses of semi-structured qualitative interviews (n = 30, 17 males) with adult vapers, I find that the participants emphasised three important dimensions related to risk. First, they perceived vaping as harm reduction by substituting for smoking. Second, they devalued much of the risk communication about e-cigarettes from Norwegian health authorities and media. Interlinked with their harm-reduction approach, they perceived the present regulation of nicotine e-liquid and vaporisers as increasing risk by decreasing their availability to smokers. Third, in general they preferred the lay expertise available online to the health authorities’ information on e-cigarettes. The analysis displays a lack of trust among the participants in what can be labelled as top-down information. Based on these dimensions, I conclude that the dissonance between vapers risk perceptions and the regulation and mixed messages in risk communication of e-cigarettes has contributed to their preference for bottom-up expertise. From the vapers’ point of view, e-cigarettes represent harm reduction, and the vaper community symbolises a bottom-up health movement where peer assistance compensates for a perceived lack of assistance from health authorities.
Allyson Ion, Saara Greene, Christina Sinding, Daniel Grace
This paper presents an institutional ethnography that explored how risk discourse organised the experiences of pregnant women living with HIV and was reproduced in the work of healthcare providers operating in a ‘high risk’ prenatal clinic in Ontario, Canada. This inquiry began from the standpoint of pregnant women living with HIV, and made connections between women’s experiences, the work of healthcare providers delivering prenatal care, and the ruling relations that organised women’s experiences and healthcare providers’ activities. The study revealed how risk was an omnipresent discourse in women’s lives and became visible through the treatments women were prescribed, the prenatal clinic appointment schedule women were expected to follow, and the application of medical interventions. The discourse of risk coordinated the work of healthcare providers and was inextricably linked to practices that prioritised foetal health. Women’s daily realities and experiences were overshadowed by the healthcare providers’ focus on the foetus and mitigating perinatal risks. As a result, the work women did to organise their lives to participate in care, and the physical and emotional costs they experienced when attending their appointments, taking their medicines, and following clinical procedures were overshadowed within an institutional context where the primary goal was to reduce risks to their babies – even if women shared concerns and aspirations about preventing perinatal HIV transmission. Women’s experiences reveal some important consequences regarding the current organisation of prenatal care that emphasises risk and possible ways to enhance prenatal care policies and practices.
This article argues that key points in the female life-course – specifically, the transition into independent adulthood and motherhood – have come to be characterised by risk. The discussion is anchored in two case studies: the first concerns female undergraduate students’ strategies for managing the risks associated with socialising, and the second deals with the depiction of pregnancy-related health issues in British newspapers. Across both, discussion focuses on the protective and self-limiting routines that have become a distinctive feature of women’s lives. This article approaches these as ‘risk rituals’ and works towards a refinement of this concept. First, by suggesting that this concept should pay greater attention to the critical question of who is being asked to take responsibility for a risk. Secondly, by suggesting that ‘risk rituals’ might on occasion serve to mark and manage life-course transitions. The article’s conclusion seeks to explain why risk rituals might serve this function. Developing out of conditions of detraditionalisation and individualisation, risk rituals are nonetheless socially-patterned, rather than universal. They are, for example, a particular feature of the female life-course, and in making this argument the article points out the connections between practices of risk-avoidance on the one hand, and social constraints associated with gender on the other. In making this case, the article seeks to provide a fresh perspective on risk and the life-course, as well as contribute to the emerging ‘risk rituals’ literature and work on gender and risk.
Although uncertainty is a key characteristic of epilepsy, and despite the close relationship between uncertainty and risk, our understanding of individuals’ experiences of childhood epilepsy in relation to risk is limited. In this paper I explore family members’ perceptions of the risks associated with the condition by drawing on qualitative data collected during 2013 and 2014 from 24 families with a child with epilepsy (including data from 28 parents, 13 children with epilepsy and 14 siblings). The diagnosis of childhood epilepsy provided parents and children with a new framework that they used to evaluate risks posed by the physical environment. Indeed, roads, water and heights were reconceptualised when viewed through an ‘epilepsy lens’ and were seen to present more risk to the child with epilepsy in comparison to the level of risk the same hazards posed to their siblings or peers. Furthermore, while parents described prioritising new and reconceptualised physical risks to their child, the children with epilepsy were more concerned about being stigmatised by their peers. The children’s discussions surrounding stigma suggest that this results from interactions with their peers, rather than stigma being learnt within the family, as previous studies have suggested. Overall, I demonstrate that risk is a central feature of contemporary experiences of epilepsy for children with the condition and their parents, but that parents and children perceive and prioritise risks differently.
Sylvia Becerra, Marie Belland, Alain Bonnassieux, Catherine Liousse
Ambient air pollution is currently a major environmental health hazard in many urban areas across the African continent. Driven by the increased concentration of human activities in cities, occupational exposure represents one of the main risk factors to disease burden. Consequently, ‘living with’ air pollution is a significant daily life public health issue. In this study, we focus on three specific occupational sites in Abidjan, Côte d’Ivoire, representing different major pollution sources – road traffic, wood fires and waste-burning fires. We explore in particular the social experiences of people exposed to chronic air pollution as well as the distribution of health risks across different occupational sources. We assessed the characterization of the ‘risk culture’ of workers, studying if it varies according to participants’ occupations and how it influenced their exposure. Our analysis combines a qualitative assessment of the ‘risk culture’ of air pollution with the development of a Risk Culture Indicator (RCI). We show firstly that the working conditions and occupational practices in each group shape specific representations of air pollution, varying levels and emphasis within understandings of risk as represented within the RCI scores. We also demonstrate that occupational status in each group plays a role in reducing exposure to air pollution, with those most vulnerable socio-economically remaining the most exposed. Finally, the findings suggest that risk culture is the combination of a tangible experience of air pollution and other risks encountered in daily life, technical mediations shaping that experience (objects and equipment), as well as existing power relationships. These considerations of risk culture should be considered as an integral part in assessment of health risks.
This paper presents the development of a Newtonian approach to medicine in the eighteenth century by studying the case of its appropriation in the Viceroyalty of New Granada by the Spanish botanist and savant José Celestino Mutis (1732-1808). First, I briefly depict the academic milieu in which Mutis presented his ideas on modern medicine in his General Plan for the Medical Studies in 1804, claiming that they were greatly influenced by Boerhaave’s appropriation of Newtonian medicine. Next, I explain in detail the emergence of this approach to medicine by considering the works of Archibald Pitcairne, George Cheyne and James Keill. Afterwards, I characterise Boerhaave’s use of Newtonian physical principles for explaining both physiological and chemical phenomena. Lastly, I lay the foundations for explaining that Mutis’s introduction of Newton’s ideas was a complex enterprise, encompassing Newton’s mathematics and physics not only as strict theoretical elements related to natural philosophy but also as they were related to the medical and chemical fields.
David P Helm
Britain’s mid-nineteenth-century healthcare economy has often been described as a “medical marketplace” in which struggling doctors faced intense competition from a range of unqualified rivals. Chemists and druggists, who proliferated in industrial cities and supposedly prospered by exploiting the poor and the gullible, are widely regarded as having presented a serious threat to medical livelihoods. However, the activities of four Gloucester chemists show how the dispensing of medical prescriptions brought individual chemists and doctors closer together. Competition between chemists and druggists for this trade was intense and it was instrumental in establishing them as trusted community pharmacists and giving impetus to the process of professionalization. Prescription books, an under-represented source in the literature, also show that customers for prescription medicines were surprisingly socially diverse and that most prescriptions were collected by women, with significant variation in dispensing activity through the week. This, and the volume of prescriptions being dispensed, suggest prescription medicines were regularly being used to treat chronic and less serious ailments, where collection could await normal shopping days. Significantly, prescriptions were the property of the patients and could be re-presented whenever they thought fit. For some patients, it thus effectively became an instrument of self-medication.
Igor J Polianski
This study examines how medical discourse and culture were affected by the denazification policies of the Soviet occupation authorities in East Germany. Examining medical textbooks in particular, it reveals how the production and dissemination of medical knowledge was subject to a complex process of negotiation among authors, publishers, and censorship officials. Drawing on primary-source material produced by censorship authorities that has not been rigorously examined to date, it reveals how knowledge production processes were structured by broader ideological and political imperatives. It thus sheds new light on a unique chapter in the history of censorship.
Agnes R Howard
In the early to mid-twentieth-century United States, prenatal care helped reshape pregnancy by extending medical directives into the everyday life of pregnant women. What began with minimal strategies for a few women at high risk grew into a “lifestyle” for all expecting babies. Maternity manuals helped popularize this process. Studying revisions of a widely circulated and publicly funded manual, Prenatal Care, from the U.S. Children’s Bureau between 1913 and 1983, shows that prenatal-care standards offered women healthy pregnancies on condition that they abandon older ways of understanding pregnancy and become maternity patients. Prenatal Caretaught women to take positive steps to enhance outcomes, but a woman’s active role in her own pregnancy was complicated by the fact that the guides made obedience to her doctor her primary responsibility.
Christopher T. Dole
A massive earthquake that struck Turkey in 1999 generated an unprecedented mobilization of Turkish psychiatrists and psychologists to address the mental and emotional aftermath of the disaster. In this article I examine how these mental health professionals, swept up in a wave of humanitarian compassion, confronted the limits of their own expertise and struggled to improvise a therapeutic response that could match the scale of psychological suffering precipitated by the earthquake. Framing humanitarian and global health interventions as inescapably scalar projects, I explore the pragmatic and imaginative labor involved in making psychiatric expertise scalable, what I characterize as their “work of therapeutic scalability.” In doing so, I raise a series of questions about the psychological subject of disaster, the transnational mobility of technoscientific expertise, and the politics of both life and scale at play in psychiatric humanitarian intervention.
Chronic Living in a Communicable World (open access)
Lenore Manderson, Ayo Wahlberg
By April 2020, COVID-19 lockdowns had restricted the movements of over half the world’s population. As health authorities advise people living with chronic conditions to self-isolate because they are at particular risk of serious complications and death, the epidemiological split between communicable and noncommunicable disease is tenuous. We argue that much more is at stake for people living with (multiple) medical conditions than being “at risk” of infection of coronavirus. We emphasize the need to attend to the long-term effects of COVID-19, but also the importance of the continued care of people living with other lifelong medical conditions.
Abigail A. Dumes
In the US, disagreement over the biological basis of “chronic Lyme disease” has resulted in the institutionalization of two standards of care: “mainstream” and “Lyme-literate.” For mainstream physicians, chronic Lyme disease is a “medically unexplained illness” that presents with an abundance of “symptoms” in the absence of diagnostic “signs.” For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.
Jennifer J. Palmer
Programs for neglected tropical diseases (NTDs) such as sleeping sickness increasingly involve patients and community workers in syndromic case detection with little exploration of patient understandings of symptoms. Drawing on concepts from sensorial anthropology, I investigate peoples’ experiences of sleeping sickness in South Sudan. People here sense the disease through discourses about four symptoms (pain, sleepiness, confusion and hunger) using biomedical and ethnophysiological concepts and sensations of risk in the post-conflict environment. When identified together, the symptoms interlock as a complete disease, prompting people to seek hospital-based care. Such local forms of sense-making enable diagnosis and help control programs function.
Much has been written about how structural (e.g. colonialism) and social (e.g. gender) determinants shape embodied health outcomes. However, little attention has been paid to the ways that marginalized populations become complicit in their own oppression. Ethnographic data collected over two years at a rural public hospital in Malawi show that the tobacco political economy produces significant intra-rural inequalities that result in the exclusion of migrant farm workers, called “tenants,” from HIV care. Using an analytical framework informed by Bourdieu’s concepts of social field and habitus, I illustrate how social inequalities persist unchallenged, even by the most disadvantaged people.
Lydia Z. Dixon
I examine midwives’ interpretation of – and efforts to reimagine – the contemporary Mexican birth narrative. Throughout my research, midwives argued that, for birth outcomes to improve, women need to become “the protagonists of their own births”. I analyze midwives’ creative representations of how birth is and could be, and argue that the counter narrative they promote reveals the conditions within which they believe women can become empowered. By centering women’s choice as the measure of success, this counter narrative stands in contrast to development initiatives and contemporary biomedical approaches to care. It also emphasizes the continued need for midwifery in Mexico. Examino los esfuerzos de parteras mexicanas para reinventar la narrativa mexicana sobre el nacimiento. Las parteras dijeron que, para que los resultados del parto mejoren, las mujeres deben convertirse en “las protagonistas de sus propios partos”. Analizo las representaciones creativas de las parteras acerca del nacimiento, y sostengo que la contra-narrativa que promueven revela las condiciones dentro de las cuales creen que las mujeres pueden empoderarse. Al centrar el poder de las mujeres como la medida del éxito, esta contra-narrativa contrasta con las iniciativas de desarrollo y los enfoques biomédicos contemporáneos. También enfatiza la necesidad continuada de partería en México.