In the Journals

In The Journals, March 2022, Part 2

Science as Culture

The Role of US Policymaking in the Emergence of a Digital Health Assemblage

Elisa Lievevrouw, L. Marelli, and I. Van Hoyweghen

Promising to improve the quality of care while decreasing healthcare costs, digital health technologies (DHT) are welcomed as a solution to the challenges increasingly faced by healthcare systems in the global north. In recent years, tech developers, consultants, policymakers, and researchers in the US have heralded Big Tech entrepreneurs as driving the emergence of these technologies. However, apart from Silicon Valley visions of DHT, there are a range of regulations, devices, institutions, and practices constituting the DHT assemblage in the US. These include US policies following the global financial crisis of 2008 – such as the US’ monetary policy, and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) – and the enactment of the Patient Protection and Affordable Care Act (ACA). Accordingly, a more granular approach is required to understand the rise of DHT beyond these stereotypical ‘Silicon Valley’ accounts of the emergence of disruptive digital technologies. Careful attention on various, seemingly unrelated, policymaking events reveals how the unintended alignment of these US policy visions, regulations, devices, institutions, and practices have played an instrumental role in the successful emergence of DHT, while also impacting ongoing global developments of these technologies.

It Takes Two to Techno-Tango: An Analysis of a Close Embrace Between Google/Apple and the EU in Fighting the Pandemic Through Contact Tracing Apps

Marjolein Lanzing, Elisa Lievevrouw, and Lotje Siffels

Science in Context 

A democratic program for healing: The Raspail domestic medicine method in 1840s France

Hervé Guillemain

Raspail’s domestic medicine method, popularized in 1840s France, has similarities with the practices of nineteenth century non-academic healers. His mass marketing of camphor as a universal treatment echoes the practices of “charlatans” and their circles. But Raspail is also very original in this history of popular care. As a scientist, a popularizer of encyclopedic knowledge and a political activist, he managed to blur traditional distinctions between science and politics and between popular and learned medicine. Raspail was a constant thorn in the side of academic institutions and professional organizations, which were struggling to gain legitimacy. His work took a political turn when he combined, within a single project, his approach to treatment and his call for democratizing medical care. Raspail’s method challenged institutional norms by acknowledging the importance of the patient’s contribution to the healing process, and recognizing the necessity of thwarting the occasionally deleterious effects of monopolistic medicalization.

Useful charlatans: Giovanni Succi and Stefano Merlatti’s fasting contest in Paris, 1886

Agustí Nieto-Galan

This paper analyzes the public fasts of two Italian “hunger artists,” Giovanni Succi and Stefano Merlatti, in Paris in 1886, and their ability to forego eating for a long period (thirty and fifty days respectively). Some contemporary witnesses described them as clever frauds, but others considered them to be interesting physiological anomalies. Controversies about their fasts entered academic circles, but they also spread throughout the urban public at different levels. First, Succi and Merlatti steered medical debates among physicians on the “scientific” explanations of the limits of human resistance to inanition, and acted as ideal mediators for doctors’ professional interests. Second, they became useful tools for science popularizers in their attempt to gain authority in drawing the boundaries between “orthodox” and “heterodox” knowledge. Finally, in the 1880s, Succi and Merlatti’s contest, the controversy around the liquids they ingested, and their scientific supervision by medical doctors, all reinforced their own professional status as itinerant fasters in a golden decade for that kind of endeavor. For all those reasons, Succi and Merlatti can be viewed as useful, epistemologically-active charlatans.

The “Controversial Cundurango Cure”: Medical professionalization and the global circulation of drugs

Elisa Sevilla, Ana Sevilla

This article examines the medical and political discussions regarding a controversial medicinal bark from Ecuador – cundurango – that was actively sponsored by the Ecuadorian government as a new botanical cure for cancer in the late nineteenth century United States and elsewhere. The article focuses on the commercial and diplomatic interests behind the public discussion and advertising techniques of this drug. It argues that diverse elements – including the struggle for positioning scientific societies and the disapproval of the capacities of Ecuadorian doctors, US abolitionist history, regional and local political struggles – played a role in the quackery accusations against cundurango and its promoters. The development and international trade of this remedy offer interesting insights into the global history of drugs, particularly how medical knowledge was challenged during a period when scientific medicine was struggling for hegemony. It explores how newspapers expanded “the public interest” in a possible cancer cure.

Science, Technology, and Human Values

Divided Attention, Divided Self: Race and Dual-mind Theories in the History of Experimental Psychology

C. J. Valasek

The duality of attention is explored by turning our focus to the political and cultural conceptions of automatic attention and deliberate attention, with the former being associated with animality and “uncivilized” behavior and the latter with intelligence and self-mastery. In this article, I trace this ongoing dualism of the mind from early race psychology in the late nineteenth century to twentieth century psychological models including those found in psychoanalysis, behaviorism, neo-behaviorism, and behavioral economics. These earlier studies explicitly or implicitly maintained a deficiency model of controlled attention and other mental processes that were thought to differ between racial groups. Such early models of attention included assumptions that Black and Indigenous peoples were less in control of their attention compared to whites. This racialized model of attention, as seen in the law of economy in the nineteenth century, with similar manifestations in psychoanalysis and neo-behaviorism in the twentieth century, can now be seen in present-day dual-process models as used in current psychological research and behavioral policy. These historical connections show that attention is not a value-neutral term and that attention studies do not stand outside of race and structural racism.

Listening Like a Computer: Attentional Tensions and Mechanized Care in Psychiatric Digital Phenotyping

Beth M. Semel

This article explores negotiations over the humanistic versus mechanized components of care through an ethnographic account of digital phenotyping research. I focus on a US-based team of psychiatric and engineering professionals assembling a smartphone application that they hope will analyze minute changes in the sounds of speech during phone calls to predict when a user with bipolar disorder will have a manic or depressive episode. Contrary to conventional depictions of psychiatry as essentially humanistic, the discourse surrounding digital phenotyping positions the machine as a necessary addition to mental health care precisely because of its more-than-human sensory, attentional capacities. The bipolar research team likewise portrays their app as capable of pinpointing sonic signs of mental illness that humans, too distracted by semantic meaning, otherwise ignore. Nevertheless, the team members tasked with processing the team’s data (audio recordings of human research subject speech) must craft and perform a selectively attentive machinic subject position, which they call “listening like a computer”: a paradoxical mode of attention (to speech sound) and inattention (to speech meaning). By tracing the team’s discursive and on-the-ground enactments of care and attention as both humanistic and machinic, I tune a critical ear to the posthuman promises of digital phenotyping.

The Algorithms of Mindfulness (open access)

Johannes Bruder

This paper analyzes notions and models of optimized cognition emerging at the intersections of psychology, neuroscience, and computing. What I somewhat polemically call the algorithms of mindfulness describes an ideal that determines algorithmic techniques of the self, geared at emotional resilience and creative cognition. A reframing of rest, exemplified in corporate mindfulness programs and the design of experimental artificial neural networks sits at the heart of this process. Mindfulness trainings provide cues as to this reframing, for they detail each in their own way how intermittent periods of rest are to be recruited to augment our cognitive capacities and combat the effects of stress and information overload. They typically rely on and co-opt neuroscience knowledge about what the brains of North Americans and Europeans do when we rest. Current designs for artificial neural networks draw on the same neuroscience research and incorporate coarse principles of cognition in brains to make machine learning systems more resilient and creative. These algorithmic techniques are primarily conceived to prevent psychopathologies where stress is considered the driving force of success. Against this backdrop, I ask how machine learning systems could be employed to unsettle the concept of pathological cognition itself.

Meditation Apps and the Promise of Attention by Design

Rebecca Jablonsky

This article demonstrates how meditation apps, such as Headspace and Calm, are imbricated within public discourse about technology addiction, exploring the consequences of this discourse on contemporary mental life. Based on ethnographic research with designers and users of meditation apps, I identify a promise put forth by meditation app companies that I call attention by design: a discursive strategy that frames attention as an antidote to technology addiction, which is ostensibly made possible when design is done right. I argue that attention by design is a promise unfulfilled. Meditation app companies construct attention as socially valuable by endlessly pointing out its purported opposite, technology addiction. Attention by design is promissory in that it keeps promising even when it doesn’t deliver what it promises, compelling the user to return to a practice that represents socially desirable traits that can never be fully acquired—and that often recede further from reach as the person becomes distracted by other obligations and communication mediated through the smartphone. Despite this broken promise, users believe they are becoming more attentive. The promissory attention designed into meditation apps reflects a new form of governmentality, in which users receive a mental nudge to reinterpret similarly designed experiences as different.

From Poacher to Protector of Attention: The Therapeutic Turn of Persuasive Technology and Ethics of a Smartphone Habit-breaking Application

Alex Beattie

This paper critically investigates the ethical perspectives and practices of individuals and organizations who make persuasive technologies (“persuasive technologists”). An organization that claims to be at the forefront of ethical persuasion is behavioral software company Boundless Mind. Yet Boundless Mind sells ostensibly oxymoronic software products: an Application Programming Interface for third-party applications that optimizes the capture of end user attention, and an application for end users on how to make third-party applications less persuasive. Drawing upon Foucault’s interpretation of ethics as an “aesthetics of existence” and the related concept of “therapeutic authority,” I argue Boundless Mind justify the “poaching” and “protecting” of user attention based on a view of the human subject as fixable and their capability to instrumentalize user subjectivity to socially desirable ends. I walkthrough Boundless Mind’s technology-habit-breaking application Space and highlight a behavioral technique administered by Space called stimulus devaluation, which enables the user to develop a transformative relationship with their technology habits and persuasive applications. I conclude the paper by arguing that a persuasive technology ethics based on fixing the user obfuscates the power of persuasive technologists by limiting the scope of ethical inquiry to the activities of the user.

Social Theory and Health

Bodies need yoga? No plastic surgery! Naturalistic versus instrumental bodies among professions in the Danish healthcare field

Kristian Larsen et al.

What characterises the similarities and differences in body investments among professions in the Danish healthcare field? This can be important when healthcare professionals relate to each other and to bodies of patients regarding differences in class, gender, age, and disease group. The study takes inspiration from Bourdieu’s sociology and the concept of health capital. We ask whether health capital can explain distinctions in the empirical data? We used the explorative–descriptive method multicorrespondence analysis (MCA) on data from 440 respondents gathered through an online survey. The respondents range from chief physicians to healthcare students. MCA makes it possible to condense frequency statistics and examine patterns of body investments through an examination of variables such as food intake, exercise, and medicine use that are then further related to supplementary variables such as social class and age. The analysis supports the concept of health capital and shows that some groups in the Danish healthcare field have a more instrumental body perception, such as the young age group (e.g. open to surgery, consume medicine, high exercise), while the upper-middle-class and older respondents have a more naturalistic perception of the body (e.g. read often, eat vegetables, practice yoga).

The changing governance of welfare: revisiting Jessop’s framework in the context of healthcare

Ian Greener

This paper revisits Jessop’s governance of welfare framework, suggesting that in the post-financial crisis era of austerity we need to look again at its analytical dimensions. The paper reformulates Jessop’s Schumpeterian Welfare Postnational Regime ideal-type framework through critique, and then applies its reformulated Galbrathian, Affluent Postnational Oligarchy ideal-type to the case of the English NHS to present a new political economy of health.

Assistive spectacles: A vision for the future

Steven Richardson and Thomas Abrams

Recent work in the intersections of feminist technoscience studies and critical disability studies provides a wealth of perspectives with which to challenge ableist and curative imaginaries that remain in the foreground of emerging accessible technologies (Hamraie in Hypatia 30(1):307–313, 2015; Kafer in Feminist, Queer, Crip. Indiana University Press, Bloomington, 2013; Shildrick 2015). These visions frequently cast such technologies as harbingers of a future where disability is all but eliminated. Perhaps no other device best exemplifies this trend than eSight, makers of a wearable headset, whose mission is “to make blindness history by 2020” (eSight in Make Blindness History by 2020, 2018e. https://web.archive.org/web/20190117025248/https://www.makeblindnesshistory.com/). The company uses viral marketing and crowdfunding campaigns with ‘tear-jerker’ (their words) videos of users regaining their sight or being able to see for the first time, inviting viewers to become donors and “see what happens when you give the gift of sight” (eSight in Moments. https://www.esighteyewear.com/moments, 2008b). In this paper, we explore the promises and perils of such visions of disabled lives and advocate for accessible futures (Kafer in Feminist, Queer, Crip. Indiana University Press, Bloomington, 2013), rather than just able-bodied ones. Crip technoscience offers a new way of thinking about disability and technology that crucially needs to be reflected in how these devices, narratives—and their users—are fashioned, reproduced and taken up; disability’s desirable future is more than just a marketing spectacle.

The healthy Indian child: a colonial construct

Abdullah Omar Saif and Amit Sundly

In the Indian Subcontinent, many commercial advertisements still use white children’s images to promote their products and push forward the idea that Indian children need to become better versions of themselves, both physically and mentally. Such views are neither encouraged nor accepted in the western world. We argue that these ideas are not new and that they were introduced during the British Raj. We further argue that the hegemonic culture promulgated by the British colonial rulers is still prevalent in this postcolonial era and is being used by international and local manufacturers, intentionally or unintentionally, as part of their promotional activities for Indian consumers. Drawing from historical and contemporary evidence, we offer arguments to this claim and analysis of the workings of the hegemonic culture in producing such advertisements.

Self-reported health and the social body

Mirza Balaj

Since the strong predictive power of self-reported health (SRH) for prospective health and social outcomes has been established, researchers have been in a quest to build a theoretical understanding of this widely used health measure. Current literature based predominantly in a biomedical perspective asserts a linear relationship between physical conditions and perception of health. Discrepancies from this expected relationship are considered an important weakness of SRH. Systematic discrepancies between physical conditions and reporting of SRH have been documented across different socio-economic groups. Evidence identified for educational groups shows that for the same level of health status, lower-educated groups report poorer levels of perceived health. This raised doubts whether it is useful to use SRH to measure social inequalities in health within and between countries. To date, sociologists of health have not engaged in the discussion of reporting heterogeneity in SRH. After reviewing existing evidence, we contend that the discrepancy in SRH reporting across social groups argued to be a weakness of SRH as a health measure is a strength from a sociological perspective. SRH as a social measure of health is a better predictor than objective measures of health precisely because it captures the lived experience of the embodied agent.

Medical hybridity and beyond: professional transitions in Italian outpatient settings

Federico Sofritti

The marketization of public healthcare has brought about organizational transformations, affecting health professionals’ ways of working in hospitals and outpatient organizations. As a result of the reforms in the 1990s, the principle of business-like healthcare has been introduced in the Italian health system. This paper presents the main findings of a study of specialist doctors working in two local health organizations in the Tuscany region. Drawing on semi-structured interviews with specialist doctors working in an outpatient setting, the article examines the manifold reactions to changes of the medical profession within outpatient settings. In particular, the combination of professional and organizational dimensions has been taken into consideration. The results show that a change is involving outpatient specialist doctors’ identity: organizational change affects several dimensions of the medical professional ethos. The change has been understood by categorizing three major types of approaches to medical professionalism, which are aimed to understand the complexity of the domain and to summarize professionals’ reactions: the first is linked to a traditional model of professionalism; the second accepts partially business-like organizational issues, while trying to create individual spaces of autonomy in daily tasks; the third co-opts new organizational issues, which become part of the medical professional ethos.

Social Science & Medicine

Re-imagining ‘the patient’: Linked lives and lessons from genomic medicine
Susie Weller et al.

How ‘the patient’ is imagined has implications for ethical decision-making in clinical practice. Patients are predominantly conceived in an individualised manner as autonomous and independent decision-makers. Fields such as genomic medicine highlight the inadequacies of this conceptualisation as patients are likely to have family members who may be directly affected by the outcome of tests in others. Indeed, professional guidance has increasingly taken a view that genetic information should, at times, be regarded as of relevance to families, rather than individuals. What remains absent from discussions is an understanding of how those living through/with genomic testing articulate, construct, and represent patienthood, and what such understandings might mean for practice, particularly ethical decision-making.

“Dirty looks”: A critical phenomenology of motorized mobility scooter use
Alfiya Battalova et al.

The use of motorized mobility scooters has become increasingly prevalent. Drawing on the critical-phenomenology and disability-studies literature, this study explored the embodied nature of scooter use among 20 new scooter users. The analysis revealed four themes: 1) Navigating the social environment and being (un)seen presented a paradox of how hypervisibility and invisibility can both exist; 2) Transitioning to scooter use revealed the affective component of becoming a scooter user despite the underlying desire to avoid unwanted attention; 3) Experiencing accessibility challenges en route and at destinations demonstrated that the inconsistency in accessibility along different routes unavoidably makes disability more visible; 4) Strategic and personalized use of devices for mobility illustrated how reliance on other mobility devices (e.g. canes and walkers) can be used as a strategy to circumvent the barriers and lessen the visibility of disability. The lifeworlds of “lived relation”, “lived body”, “lived space”, and “lived things” encapsulated the multi-faceted experiences of new scooter users. The critical phenomenology of scooter use emphasized the need for creative strategies to address the physical and attitudinal barriers as well as scooter design-related concerns.

“There is no standard vulva”: Sanitized vs. contextualized instruction of hands-on medical skills

Bex MacFife

Medical education overlooks bodily variation by presenting a de-contextualized patient. This standardization perpetuates inequality and stigma. Initially a feminist project in the US, Gynecological Teaching Associates (GTAs), or specially trained educators who teach while receiving vaginal/pelvic and breast/chest examinations, are understudied despite how common they are in MD programs. GTAs have been subject to standardization when incorporated into medical school training, but opportunities to challenge the status quo remain. I conducted interviews with 25 GTAs across the United States. Thematic, iterative coding reveals two overlapping genres of GTA engagement. Through sanitized instruction, GTAs stick to 1.) professionally distanced, 2.) (supposedly) politically neutral, and 3.) student-protective methods. Alternatively, through contextualized instruction, GTAs 1.) are open to personal disclosure, 2.) present a wide range of normal and bring in sticky topics, and 3.) try to prepare students for a messy reality. Contextualizing instructors describe tactics for centering physiological and social diversity, such as framing non-normative factors (identity, sexual practices, underrepresented bodies, etc.) as clinically relevant.

“The kind of doctor who doesn’t believe doctor knows best”: Doctors for Choice and the medical voice in Irish abortion politics, 2002–2018

This article examines how the physician advocacy organization Doctors for Choice articulated a collective pro-choice “medical voice” over the course of sixteen years. This voice was central to the successful 2018 campaign to repeal Ireland’s Eighth Amendment, which had imposed a virtual ban on abortion in the Republic of Ireland since 1983. I examine how DfC set itself in opposition to the powerful cadre of anti-abortion Catholic physicians who had dominated Irish public discourse on abortion for decades. DfC not only had to provide a strong alternative argument, but also had to distance itself from a legacy of physicians as gatekeepers to abortion. Based on oral histories and documentary sources, I argue that DfC developed a collective pro-choice “medical voice” and a politics of physician advocacy by leveraging the cultural authority of physicians and using discourses of medical expertise and patient autonomy. Doctors have been called upon to use their social position to fight health-related social inequality. By providing a detailed case study based on individual experiences of and perspectives on physician advocacy, this article examines the framework of “physician advocacy” in practice. It identifies affective and structural barriers to physician engagement in abortion politics across medical specialties. Finally, it considers how, in the face of these barriers, a small group of physicians helped to set the terms of a movement for accessible and equitable abortion care in Ireland.

Affordances of home drinking in accounts from light and heavy drinkers
Sarah MacLean et al.

Home drinking contributes substantially to health harms associated with alcohol consumption. Drawing on practice theory and new materialism, we argue that drinking is a social practice that allows particular sets of effects, or affordances, when it takes place in a person’s home. Qualitative interviews were conducted by telephone with 40 Australian adult home drinkers, of whom 20 drank at a level designated as low risk and 20 at a level which exposed them to a higher likelihood of harm. Our analyses identified four substantive affordances of home drinking practice. The first two concern transformations of home life. Home drinking allowed both celebration and smoothing of dissatisfaction with domestic relationships. Through producing subtly different affective states at home compared to in other locations, drinking practice rendered domestic settings home-like: as places of comfort and respite. The second two affordances of home drinking concern how home as a place acts in the co-constitution of drinking patterns. This entailed routinising alcohol consumption alongside other home-based practices and loosening constraints on intoxication. Importantly for our argument, each of these operated with greater intensity for participants who drank at a heavier level than for those who drank more moderately. For example, heavy drinkers expressed a greater imperative to alter relationships and affective states at home and emphasised how being at home produced opportunities for, and removed obstacles to, heavy drinking. We show that home drinking is patterned with other activities and entwined in domestic wellbeing and the emergence of home as a space of privacy, autonomy and relaxation for Australians in our study sample. Understanding home drinking as deeply embedded in the constitution of contemporary western domestic life helps to explain heavy alcohol consumption in these settings. It also supports the need for targeted public health responses such as restrictions on home delivery of alcohol.

Effects of ‘doctor shopping’ behaviour on prescription of addictive drugs in Sweden
Yana V. Zykova et al.

Free choice of health care providers is aimed to improve the quality of health care by increasing both access to it and the competition between providers. However, it may also give patients possibilities for doctor shopping (DS) behaviour, i.e., visiting different providers to receive illicit drug prescriptions. Abuse of prescribed addictive drugs is a growing problem worldwide and is associated with increased mortality, lower quality of life and other problems on both the individual and societal level. We study DS behaviour for three categories of addictive drugs – opioid painkillers, benzodiazepine anxiolytics, and z-hypnotic sleeping drugs, in the outpatient care sector in Västerbotten County, Sweden. Our dataset contains all drug prescriptions purchased by the residents of Västerbotten in the period from January 2014 to April 2016 (approximately 160,000 observations). To identify signs of addictive prescription drugs abuse by DS, we analyse overlapping prescriptions. We use ‘Defined Daily Doses’ (DDDs), which is the average treatment dose of a specific drug per day for adults, as a proxy for the treatment duration. To control for medically legitimate overlaps, we compare overlapping prescriptions within a clinic with overlapping prescriptions between different clinics. Our empirical results suggest that there is a significant and positive relationship between the number of overlapping doses and the number of unique providers in the overlap. More specifically, we find that visiting different providers on average gives patients up to three additional DDDs per day. This is three times higher than the standard treatment dose. We discuss policy implications in the concluding discussion.

Cutting Women: Unnecessary cesareans as iatrogenesis and obstetric violence
Vania Smith-Oka

This article deepens the current understanding of the sources of obstetric violence and iatrogenesis through an analysis of cesareans. The data are drawn from ethnographic research in 2018 at a public maternity hospital in Mexico. Data collection methods included observation, semi-structured interviews, and free lists with 12 senior obstetrics residents. Analysis of the data revealed that: (1) doctors used perceptions of high risk to justify their use of cesareans even when not clearly medically indicated; (2) doctors responded to scarcities of time and resources in the system by viewing cesareans as a less than ideal but acceptable solution; and (3) doctors practiced medicine defensively as a way to control their fear of risk and to pre-empt legal consequences from patients’ demands. The discussion suggests that the relative ease of cesareans and the benefit they provided the doctor and medical system rather than the patient constituted forms of obstetric violence and iatrogenesis. These often arise as a consequence of either too much intervention or not enough in situations in which providers seized on unclear or presumed indications as pretexts to perform cesareans that were not clearly medically indicated.

The interplay between time spent gaming and disordered gaming: A large-scale world-wide study
Halley M. Pontes et al.

‘Gaming Disorder’ (GD) is now an officially recognized mental health disorder according to the World Health Organization (WHO) framework while ‘Internet Gaming Disorder (IGD) remains as a tentative disorder as per the American Psychiatric Association (APA) framework. Although both GD and IGD reflect disordered gaming tendencies marked by excessive time spent gaming, little is known about the extent to which too much time spent gaming becomes particularly problematic. Moreover, emerging research has highlighted the need to further explore how both disordered gaming frameworks perform in the assessment and estimation of disordered gaming symptoms and related behaviors.

Racial discrimination and health among two generations of African American couples
Ashley B. Barr et al.

The current study extends research on the detrimental health implications of racial discrimination by examining how these implications reverberate across romantic relationships. Using two generations of different-gender romantic couples from the Family and Community Health Study, we examined how racial discrimination experienced by a romantic partner was associated with poor health among Black adults, independent of one’s own level of racial discrimination. Results from the actor-partner interdependence model showed that beyond the effects of socioeconomic status, health behavior, relationship satisfaction, and own experiences of racial discrimination, a romantic partner’s experiences of discrimination were associated with increased psychological distress for both the middle/older-age generation and the young-adult generation. Further, in the middle/older-age generation, partners’ experiences of racial discrimination were associated with increased cardiovascular disease risk, particularly for men. These results reiterate recent findings that researchers may underestimate the impact of racial discrimination on health when we fail to consider linked lives. Further, they indicate that there may be gender and generational differences in the individual and relational implications of racial discrimination on health.

Land loss and the intergenerational transmission of wellbeing: The experience of iwi in Aotearoa New Zealand
Rowan Ropata Macgregor Thom, Arthur Grimes

We analyse the impact of land loss, through colonisation, on contemporary cultural wellbeing and health outcomes of Māori, the Indigenous population of Aotearoa New Zealand. In 1840, Māori legally owned all land in the country; by 2017, Māori owned just 5% of land. Ties to the land (whenua) have been identified as being critical to spirituality (wairua) and health (hauora). All tribes (iwi) experienced major land loss, but the timing, extent and nature of land loss differed across iwi. In some cases, land was confiscated following the New Zealand wars of the nineteenth century. We draw on recently derived data for historical landholdings of 70 (North Island) iwi to link the extent of historical landholdings, and whether land was confiscated, to contemporary outcomes for five cultural wellbeing and health outcomes for each iwi: te reo Māori (Māori language) proficiency, importance of involvement in Māori culture, visiting an ancestral marae (meeting place), difficulty in finding support for Māori cultural practices, and rates of regular smoking. We find that higher land retention within an iwi’s rohe at the end of the nineteenth century is supportive of contemporary cultural wellbeing outcomes, while confiscation is linked to higher contemporary rates of smoking. The evidence is consistent with historical trauma having significant effects on the cultural wellbeing and health outcomes of Aotearoa New Zealand’s Indigenous population over a century later.

Society and Mental Health 

Mental Health Treatment Histories, Recovery, and Well-being

Peggy A. Thoits

Epidemiological and sociological research on recovery from mental disorder is based on three rarely tested medical model assumptions: (1) recovery without treatment is the result of less severe illness, (2) treatment predicts recovery, and (3) recovery and well–being do not depend on individuals’ treatment histories. I challenge these assumptions using National Comorbidity Survey-Replication data for individuals with any disorder occurring prior to the current year (N = 2,305). Results indicated that (1) untreated remissions were fully explained by less serious prior illness, (2) treated individuals were less likely to recover due to more serious illness, and (3) people who had past–only treatment were more likely to recover than the never–treated, while those in recurring and recently initiated care were less likely to recover. Treatment histories predicted greater well–being only if recovery had been attained. Histories of care help to explain recovery rates and suggest new directions for treatment–seeking theory and research.

Treatment Network Typologies and the Working Alliance of Clients with Serious Mental Illness

George S. Usmanov, Eric R. Wright, Raeda K. Anderson

The climate and culture of treatment for clients with serious mental illness (SMI) are complex. In this study, we aim to cultivate a deeper understanding of the treatment environment using a network typological approach to measure the local treatment context and assess its implications on the perceived quality of clients’ relationships with their care providers. We use in-depth egocentric network data from clients with SMI in community mental health centers and state psychiatric hospitals from the Indiana Mental Health Services and HIV Risk Study (N = 417). Clustering analysis identifies five unique and distinct network types: supportive, sparse, diverse, clinical, and treatment-focused. Weighted least squares regressions reveal clients in networks with high amounts of support predict a more trusting working alliance, whereas care-oriented networks predict a less trusting alliance. Our findings underscore the need to consider the local network context in studies of the quality of care provided to people with SMI.

The Disjuncture between Medication Adherence and Recovery-centered Principles in Early Psychosis Intervention: An Institutional Ethnography (open access)

Elaine Stasiulis et al.

To examine how recovery principles are enacted in an early psychosis intervention (EPI) clinic, we used an institutional ethnographic approach focused on how the ideology of medication adherence organizes young people’s experiences of EPI services. Methods included ethnographic observation, in-depth interviews with 27 participants (18 clinic staff, four young people, and five family members), and textual analysis of clinic documents (e.g., case files, administrative forms, policy reports). The disjuncture between service providers’ intent to provide recovery-principled care and the actual experiences of young people is actualized in institutionalized practices of informal coercion around medication adherence, which we identify as “enticing,”“negotiating,” and “taking responsibility.” We link these practices to institutional accountability, risk, and efficiencies, and discuss the need for a shift in medication management approaches in EPI settings.

Mental Health Stigma and Social Contact Revisited: The Role of Network Closeness and Negativity

Elizabeth Felix, Freda Lynn

Researchers and policymakers are increasingly interested in the extent to which mental health stigma can be mitigated through social contact with people who disclose mental health issues. Empirical research on contact and stigma, however, largely focuses on the presence of contact without fully examining the nature of relationships. Interpersonal ties, for example, can be enduring and supportive, enduring and stressful, or weak yet cooperative. Using a novel egocentric network survey, this study contributes by measuring contact with respect to both the presence of alters with perceived mental health issues and the nature of those connections. Results show that, compared to respondents without any contact, naming more mental health contacts is associated with a reduction in stigma only when those relations are characterized by closeness and a lack of negativity. Among individuals with contact, a higher proportion of relationships perceived as negative or “difficult”exacerbates stigma. Implications of these findings for stigma reduction are discussed.

Aspiring to Do All Things Through Him Who Strengthens? Quixotic Hope, Religiosity, and Mental Health in Emerging Adulthood

Laura Upenieks

Beliefs about the probability of educational success tend to be very optimistic in the United States. However, scholars are beginning to uncover mental health consequences associated with quixotic hope—the unrealistic outstripping of expectation by aspiration. Using longitudinal data from Waves 1 and 3 of the National Study of Youth and Religion, this study asks, (1) does religiosity promote or diminish the likelihood of quixotic hope? and (2) does religious attendance and closeness to God mitigate long-term mental health consequences of quixotic hope? Results show that weekly religious attendance had a modest negative relationship with the likelihood of experiencing quixotic hope, while increasing religious attendance over time attenuated the negative mental health consequences of quixotic hope on increases in depression. Closeness to God neither predicted quixotic hope nor played a moderating role for depression. As educational expectations rise, regular religious practice may help protect the emotional well-being of youth.

Sociology of Health & Illness

Disaggregating inequalities in the career outcomes of international medical graduates in the United States

Rebecca Anna Schut

Although research finds that international medical graduates (IMGs) fill gaps in US health care left by US medical graduates (USMGs), the extent to which IMGs’ career outcomes are stratified along the lines of their country of medical education remains understudied. Using data from the 2019 American Medical Association Physician Masterfile (n = 19,985), I find IMGs from developed countries chart less marginalised paths in their US careers relative to IMGs from developing countries; they are more likely to practise in more competitive and popular medical specialities; to attend prestigious residency programmes; and to practise in less disadvantaged counties that employ more USMGs relative to IMGs. These findings suggest IMGs experience divergent outcomes in the United States based on their place of medical education, with IMGs from developing countries experiencing more constraints in their careers relative to IMGs from developed countries. This understudied axis of stratification in medicine has important implications for our understanding of how nativism and racism may intersect to generate inequalities in the medical profession and in US health care more broadly.

Attending to child agency in paediatric palliative care consultations: Adults’ use of tag questions directed to the child (open access)

Katie Ekberg et al. 

Children’s agency in their own lives is increasingly recognised as important, including within paediatric health care. The issue of acknowledging child agency is complex in the context of paediatric palliative care, where children have serious and complex conditions that often impact their ability to verbally communicate with others. This study explores how clinicians and parents/guardians direct talk towards a child patient when they are present in a consultation. Conversation analysis methods were used to examine 74 video-recorded paediatric palliative care consultations. Detailed turn-by-turn examination of the recorded consultations identified the recurrent use of a practice described by linguists as a ‘tag question’, which follows some statement (e.g. ‘he loves that, don’t ya’). Both clinicians and parents/guardians often directed these tag questions towards the child patient. Analysis demonstrated how these tag questions: (1) validated the child’s epistemic authority over what was being said and (2) made a child’s response a possible, but not necessary, next action. The findings are discussed in relation to the sociology of child agency and how this agency is acknowledged and displayed within and through social interaction. This research provides direct evidence of children’s competence as informants about their own symptoms.

Encapsulation: Governing actual uncertainty in the coronavirus pandemic

Michael Rabi, Limor Samimian-Darash, Eva Hilberg

The coronavirus pandemic has revived scholarly engagement with the concept of biopolitics, with interpretations diagnosing either the widespread adoption of a classic biopolitical regime or the full-blown emergence of totalitarian repression (or both of these simultaneously). Relying on a close analysis of different interventions taken by Israeli authorities in response to the pandemic, this article argues that, rather than classic biopolitical strategies, such governmental interventions are better understood in relation to a problem of actual uncertainty. The case of Israel demonstrates how state apparatuses responded to actual uncertainty with technologies that are linked to different rationalities and how these technologies enabled the creation and management of a new milieu. The article further argues that, in making and intervening upon this milieu, state apparatuses employed a particular normalisation strategy that is tied to a form of power that we term encapsulation.

Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis

Meredith Bergey, Giuseppina Chiri, Nikki L. B. Freeman, Thomas I. Mackie

While the effects of social stratification by gender, race, class, and ethnicity on health inequalities are well-documented, our understanding of the intersecting consequences of these social dimensions on diagnosis remains limited. This is particularly the case in studies of mental health, where “paradoxical” patterns of stratification have been identified. Using a Bayesian multi-level random-effects Poisson model and a nationally representative random sample of 138,009 households from the National Survey of Children’s Health, this study updates and extends the literature on mental health inequalities through an intersectional investigation of one of the most commonly diagnosed psychiatric conditions of childhood/adolescence: attention-deficit hyperactivity disorder (ADHD). Findings indicate that gender, race, class, and ethnicity combine in mutually constitutive ways to explain between-group variation in ADHD diagnosis. Observed effects underscore the importance and feasibility of an intersectional, multi-level modelling approach and data mapping technique to advance our understanding of social subgroups more/less likely to be diagnosed with mental health conditions.

Personalising clinical pathways in a London breast cancer service (open access)

William Viney et al. 

Using interview and observational data from a busy and research-intensive breast cancer service in the United Kingdom, we discuss recent developments in personalised medicine. Specifically, we show how clinical and research practices meet in clinical pathways that are reconfigured in response to changing approaches of diagnosing, monitoring, treating and understanding cancers. Clinical pathways are increasingly sensitive to changes in evidence deduced through new technologies and therapies as well as decisions based on intensive, iterative analysis of data collected across a range of platforms. We contribute to existing research by showing how the organisation of clinical pathways both maintains established clinical practices and responds to new research evidence, managing a threshold between evidence-based and experimental medicine. Finally, we invite comparisons with other forms of personalisation to understand how they depend on the ‘real time’ collection, analysis and application of data.

Gender roles and selection mechanisms across contexts: a comparative analysis of the relationship between unemployment, self-perceived health and gender (open access) 

Giulia Tattarini, Raffaele Grotti

Health literature shows that unemployment has a gendered effect on health. However, whether men or women are more affected and why remains unclear. We assume that unemployment harms women less than men because of two mechanisms: social roles theories and health selection. First, the availability and centrality in individuals’ lives of roles other than employment may reduce the detrimental effect of unemployment for women. Second, the gendered impact of unemployment on health results from the different ways selection mechanisms operate across genders. Moreover, these two mechanisms may operate differently in different contexts – for example, across different gender regimes. We investigate this by pursuing a three-step comparative approach. The analysis relies on EU-SILC data covering Italy and Sweden for 2004 to 2015 and SOEP data for Germany (1995–2017) and applies correlated dynamic random-effects probit models. While we find weak support for the role of health selection in shaping the relations between unemployment, health, and gender, our empirical results are in line with the hypothesis of a larger gendered effect in older (vs younger) cohorts, western (vs eastern) Germany and Italy (vs. Sweden). Future empirical research needs to directly address the role of gender regimes in moderating such complex relationships.

Are stress-related pathways of social status differentiation more important determinants of health inequities in countries with higher levels of income inequality?

Dana Lee Olstad et al. 

We explored socioeconomic gradients in self-rated overall health (SROH) using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial perspectives (subjective social status (SSS)) among adults living in countries with varying levels of income inequality, and the importance of psychosocial stress in mediating these associations. If psychosocial processes at the individual and societal levels correspond, associations between SSS and SROH should be higher among adults in countries with higher income inequality, and psychosocial stress should be a more important mediator of these associations. We used multigroup structural equation models to analyse cross-sectional data from the International Food Policy Study of adults (n = 22,824) in Australia, Canada, Mexico, the UK and the United States. Associations between SSS and SROH were not higher in more unequal countries, nor was psychosocial stress a more important mediator of these associations. Inequities in SROH in more unequal countries may not predominantly reflect stress-related pathways of social status differentiation.

Vaccine hesitancy and emerging parental norms: A qualitative study in Taiwan

Chen-I Kuan

This article reports a qualitative study on vaccine hesitancy in Taiwan. Based on its findings, this research illuminates the close relationships between expanding vaccine hesitancy and current parental norms. It answers the following questions: how do parents understand their roles and responsibilities regarding childhood vaccination under new parental norms? How do new parental norms interweave with other social contexts to shape parental practices of childhood vaccination? This research collected data from March 2018 to July 2020. This research observed lectures and activities concerning childhood vaccination organised by parental groups and interviewed 24 parents and three CDC professionals. Results show that ‘uniqueness of every child’, ‘informed decision-making’ and ‘intensive parenthood’ are three essential elements in contemporary parental norms that significantly influence parents’ experiences regarding childhood vaccination. Under the norms, parents perceive their responsibility to inform themselves and make decisions most suitable for their children. Results also highlight the tension when health authorities failed to recognise new parental roles in childhood vaccination. The current lack of communication on childhood vaccination causes parents’ anxiety even among those who comply with vaccination policy. Health authorities and professionals should pay attention to new parental norms affecting people’s childhood vaccination practices and develop suitable communication strategies.

Theory, Culture, & Society

China’s Post-Socialist Governmentality and the Garlic Chives Meme: Economic Sovereignty and Biopolitical Subjects

Pang Laikwan

This article analyzes a popular meme that has spread rapidly among Chinese internet users in the last few years, ‘garlic chives’ (jiucai), as a self-mockery of the bio-economic subject in contemporary China. This metaphor refers to those ordinary Chinese people who are constantly lured to participate in all kinds of economic activities, but whose investments are destined to be consumed by the establishment. Through a close study of this popular meme and the social conditions from which it arises, this article demonstrates two main features of the Chinese economic subject that supports the state’s economic sovereignty: the thriving of self-sufficient and rule-abiding individuals, and the quality of these individuals as hard working and capable of producing wealth on their own. This article offers a critique of PRC’s post-socialist governmentality, and it provides insights about the relation between the biological and the political in our complicated world order.


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