Health, Technology, and Society: A Sociological Critique

Andrew Webster

Health, Technology, and Society: A Sociological Critique

Palgrave MacMillan, 2007

ISBN:  9781403995254  

224 pages, £20.99 (pbk)

 

 

 

 

 

 

 

 

 

Reviewed by Kelly Joyce, College of William and Mary, Virginia, USA

Andrew Webster, a prolific sociologist of science and technology, outlines a sociological approach to the study of technological innovation and applies that approach to specific cases such as genetic diagnostic tests and tissue engineering. The sociological approach presented emphasises a co-construction framework. That is, Webster examines how various actors, institutions, scientific knowledge, and policies interact to produce health technology use and dissemination. For Webster, it is crucial to trace the traffic between groups, diagnostic categories, economic investments, and health care policies to better understand how and why some technologies are accepted as well as how patients, health care professionals, and caregivers simultaneously give meaning to and shape technological innovation. To build his theoretical approach, Webster synthesises an array of medical sociological literatures and ideas (e.g. sociology of bodies, illness narratives, the sick role). The amount of material covered is impressive, and Webster’s ability to build connections between various works is remarkable.

Technology, according to Webster, must be understood through social relationships and contexts or what he calls ‘the social matrix’. A sociological critique of innovation should trace the factors that contribute to a technology’s introduction. It should also examine the effects a technology has on our identities, relationships, and perceptions of health once it is used in health care. Webster pays particular attention to how private and public institutions invest, support, or control technological innovation. Charting transformations in medical practice over the last five decades, Webster argues that the state and the private sector have overtaken the importance of the clinicians ‘as drivers of new technology’ (49). Clinicians, however, still play an important role as gatekeepers; they help manage the way new techniques are integrated into clinical care.

      Central to Webster’s understanding of the social matrix of technological innovation is a reconsideration of the concept of the sick role. Developed by Talcott Parsons in the 1950s, sociologists have expanded, critiqued and refined the concept in subsequent decades. Webster develops what he calls ‘the new sick role,’ which extends the concept to include how individuals or groups mobilise, contest, and define the sick role in arenas (e.g., internet sites, media accounts) outside of or on the border of health care agencies. Webster outlines four ways individuals or groups actively contribute to the sick role.  They can: (1) collectively research and define an illness to marshal additional health care resources; (2) argue for an illness’s acknowledgement by mainstream health care professionals; (3) challenge the meaning of an illness; and/or (4) dispute a medicalised definition of an illness. Focusing on these processes emphasises the actions of patients, caregivers, and patient advocate groups. This move builds on scholarship by sociologists and science and technology studies scholars, and displaces the privileged status of health care professionals in sick role formulations.

Beyond emphasising how individuals reconfigure the sick role, Webster also begins to formulate a health role. Webster (95) writes, ‘It [health] is, like sickness, more than simply a reflection or expression of the biophysical state of the body… health in this sense is anchored in socio-psychological beliefs and emotions, thereby dependent, as is the sick role, for its affirmation and confirmation by others.’ Paying attention to the social definitions and expectations of ‘health’ is a productive new direction for scholarship. Although Webster briefly addresses this topic, the moral obligation to pursue health behaviours (e.g., exercise, eating plans, quit smoking); the relations between gender, race, class, nation, and changing definitions of health; and the linkages between interest groups and definitions of health require sustained sociological analysis. 

The cultural dimension of innovation and dissemination is another topic that could be more thoroughly discussed. Webster thoughtfully attends to the identity-body-technology nexus, but the relations between medical technology innovation and cultural values, beliefs, and practices are not highlighted. Such a perspective could ask, for example, why are some technologies (e.g. medical imaging machines) appealing while others (e.g. male contraception pills) are not? In The Male Pill: A Biography of a Technology in the Making, science and studies scholar Nelly Oudshoorn (2003) calls for analysis of the cultural construction of technology. A sociological critique that integrates analysis of cultural belief systems, contexts, and conventions will provide insight into why some technologies are adopted and why others are not.

Ultimately, Health, Technology and Society is a call for research. It presents a conceptual framework that can be taken up by social scientists. As such, the book will be useful in undergraduate and graduate courses; it will inspire new research on the technology, science, and innovation junction. Promoting sociological scepticism, Webster’s work challenges the celebration and fetishisation of technological innovation in popular culture and health care.

Reference

Oudshoorn, N. (2003) The Male Pill: A Biography of a Technology in the Making. Durham, NC: Duke University Press

 

 


Health Policy and Politics

Alison Hann (ed)

Health Policy and Politics

Ashgate, 2007

ISBN:  9780754670643

206 pages, £55.00 (hbk)

 

 

 

 

Reviewed by François Briatte,  University of Grenoble, France

The topic of health policy-making in Britain seems inextinguishable, constantly renewed by shifts in the balance of power between its main players – the state, the medical profession and civil society. In that context, the papers collected in Health Policy and Politics examine the political factors that currently shape the making of health policy in the National Health Service (NHS). Its fourteen chapters cover a wide array of overarching issues that affect virtually all forms of treatment within the health care sector, except for two more specific case studies (Chapter 10 on ‘protracted waiting for orthopaedic services’ and Chapter 12 on immunisation policy). Most chapters are drawn from conference papers given by members of the Health Politics Group between 2005 and 2006.

An important transversal theme of the book relates to the design and reform of structural, system-level aspects of the NHS, which Alison Hann introduces as the ‘macro’ level of British health policy-making. Chapter 2 explores the mechanisms that help to explain a characteristic paradox of the NHS, or as Rudolf Klein once put it, a paradox of famine among plenty: ‘how did a creditable record on NHS expenditure after 2002… come to co-exist with record deficits?’ (14). Chapters 3 and 4 address the parallel issues of decentralisation and modernisation within the institutional framework of health services, both observing that reform is driven by sets of dual dynamics which often contradict, between centralist and decentralist tendencies or between competing models of modernised policy-making. Such ambiguity and complexity affects all instances of NHS reform, as illustrated by the Quality Outcomes Framework recently introduced in primary care (Chapter 14).

Another common line of inquiry addresses legitimacy and accountability in health services, which forms the backbone of Chapter 6. The historically persistent trend towards a consumerist model of health care, as described in Chapter 5, emphasises responsiveness as an organisational imperative for the NHS, insisting on the need for ‘a more flexible mode of health provision’ (66) that considers the patient as an active figure in his/her care. For that reason, patient and public involvement in health services (PPI) has provided a recurrent motive for reform and a long history of unsolved issues, as presented in Chapter 8. In parallel to the forums dedicated to ‘expressing the patient’s voice,’ new institutions such as the National Institute for Health and Clinical Excellence (NICE) face a different challenge as they strive to establish themselves as legitimate decision-making bodies in the NHS, a task that blame-avoiding governments tend to avoid handling themselves because of, as shown in Chapter 7, ‘the high political profile enjoyed by the NHS, leading to the prospect of lost votes for any party seen to damage it’ (93).

The book inevitably leads the reader to look forward to the most important factors that might guide future developments in health policy. Alongside mentions of European regulatory convergence over particular aspects of health care, such as drug licensing (Chapter 13: 174), two chapters are particularly interesting in that respect. Chapter 1 provides a brief survey of the impact of European regulations, derived mostly from common market agreements, on public health policy—a trend, one may hint, which is set to increase in the coming years. A parallel source of influence over health policy-making stems from the rise of a ‘New Public Health’ ideology described in minute detail and through a careful examination of its historical lineage in Chapter 9. Both factors provide an institutional and ideational impetus that, when operating in conjunction with other social factors, may contribute to the introduction of important changes in the public health policies of European Member States, as already shown in the past with the adoption of new measures in tobacco control policy (115).

The texts collected in Health Policy and Politics provide an informative as well as critical vision of British health policy, which will prove especially useful to students of the NHS under New Labour. The only immediate regret that the reader might feel concerns some important aspects of health care that do not clearly appear in either the structure or the substance of the book, such as the evolution of clinical autonomy within clinical pathways built on networked models of care, the role of the third sector in supporting state-led treatment facilities and biomedical research, or the governance of the nursing profession in the NHS, all topics which become even more salient when observed in comparative settings.

 

 

 

Mental Health User Narratives: New Perspectives on Illness and Recovery

Bruce M.Z. Cohen

Mental Health User Narratives: New Perspectives on Illness and Recovery

Palgrave Macmillan 2008 

ISBN:  9781403945365

232 pages,  £53.00 (hbk)

 

 

 

 

Reviewed by Amy Chandler, University of Edinburgh, UK

In Mental Health User Narratives: New Perspectives on Illness and Recovery, Bruce Cohen has several related aims: to investigate the narratives of acute and severe mental health users; to compare those who have received in-patient psychiatric treatment with those who received a new home treatment service; and to demonstrate the usefulness of taking a ‘narrative approach’ in researching mental illnesses. Cohen also has a clear political project throughout the book: to expose and problematise the dominance of biomedical psychiatry in the treatment of people with mental illnesses. This project clearly informs his research methods, analyses and conclusions.

The research Cohen presents leads from his evaluation of a novel home based treatment approach to the care of people diagnosed with mental illnesses, which ran in Bradford, UK, between 1993 and 2003 (60-1). That the Bradford Home Treatment Service (BHTS) no longer exists in the form described by the participants of Cohen’s research makes the positive discussion of the service somewhat bittersweet, as the reader is aware that the service is now largely disbanded. This evidently informs the political sub-plot of the book, as Cohen seeks to demonstrate the ways in which psychiatric practice is mediated by politics and governance, as well as medical ‘knowledge’.

The book is useful on a number of levels, and thus will appeal to a variety of audiences. The early chapters provide interesting, concise and useful summaries which will aid students and readers new to either sociological perspectives on mental illnesses, or narrative research. Chapter 1 provides a review of the historical development of social scientific theories of mental illness, with a clear slant in favour of those critical to biomedical psychiatry. Chapter 2 summarises existing work in narrative research, focusing particularly on work on illness narratives and introducing Kleinman, Estroff and Palombo. Chapter 3 provides political and contextual information on the development, running of, and eventual disbanding of the BHTS.

The chapter on methods provides a fascinating discussion of the practicalities of actually ‘doing’ narrative research. Such reflexive and reflective discussions are often sorely lacking in existing narrative health research, and thus will prove interesting to both students and researchers alike. In particular, Cohen sets out solutions to some of the problems commonly faced by those of us attempting to ‘do’ narrative research – such as balancing ethical concerns about preserving narrative coherence with practical considerations regarding how best to present data.

Perhaps the most widely appealing sections of the book are the chapters of data, where Cohen presents the narratives of the people he spoke to in two distinct, but equally engaging, manners. Chapter 5 presents the narratives of 8 of the 49 interviewees in some detail. Large sections of transcribed text are presented, encouraging the reader to ‘contemplate new and alternative ‘readings’ of the accounts’ (91). Chapters 6 and 7, in contrast, give a more ‘traditional’ analysis of the whole data set, focusing on common themes from the cross-section of interviews. This two-pronged approach represents part of Cohen’s solution to a common problem in presenting narrative research – how to preserve the coherence of a narrative ‘as heard’, without ‘merely representing’. In attempting to do this, I would suggest Cohen has been largely successful. Chapter 5 gives the reader a good sense of the diversity of stories which Cohen heard, and also some idea of the variation in the ways in which these were told, whilst chapters 6 and 7 provide a broader view of some common narrative themes.

Chapter 6 focuses on the ways in which participants talked about their ‘descent’ into psychiatric illness and their experiences with services. Chapter 7 examines the different ways that participants talked about their recovery. Each of these chapters successfully illustrates the diverse ways in which these different aspects of being diagnosed with a psychiatric illness might be experienced. Supporting Cohen’s political project, these accounts are presented as correlating closely with the type of psychiatric intervention the patients experienced. Thus, those patients who had been cared for at home through the BHTS reported generally favourable experiences, and appeared to frame their illness as something they were now able to cope with, or had even recovered from. Conversely, patients who had only experienced in-patient psychiatric care were more likely to talk about negative experiences, and appeared more liable to view their illness as more permanent and debilitating. It is of course possible that these findings reflect the type of person more likely to be referred to BHTS (less ‘severe’ cases perhaps), or that Cohen’s political leanings led him to read more positive outcomes into the narratives of the BHTS patients. However, as no patients receive care from the BHTS now, this still leaves the discouraging possibility that whatever the reasons for the positive outcomes, they will be much less common now that the BHTS no longer exits.

The final chapter draws together Cohen’s arguments and data, making some challenging and sobering conclusions with regard to the state of mental health care in general, and psychiatric practice in particular. Here Cohen is clear about the limits of the BHTS approach, and the unlikelihood of this type of approach to mental health care successfully operating permanently in the current socio-political climate. Cohen argues cogently for the importance of taking into account ‘social and economic life factors’ (178) in the development and treatment of mental illnesses, a stance which clearly demonstrates the importance of sociological perspectives on this area of medicine. However, he also acknowledges that such an approach is greatly hampered by the continued preference for biological psychiatric approaches, not only in medical discourse, but also in the eyes of many patients (174). Overall, Cohen presents an engaging critical study of the development and treatments of mental illnesses, which successfully demonstrates both the importance and relevance of social scientific approaches to the study of this area of medicine.

 

 

 

 

The Health of Men and Women

Sarah Payne

The Health of Men and Women

Polity Press, 2006

ISBN:  9780745634548

240 pages, £16.99 (pbk)

 

 

 

 

Reviewed by Anna Gruszczynska, Aston University, Birmingham, UK

The strength of Sarah Payne’s book, ‘The Health of Men and Women’ lies in her inclusive approach to gender and health, which combines two previously usually separated areas of enquiry and health policy, that is, women’s health theory and the study of men’s health and gender, where the author adopts quite a strong and comparative international focus, both in industrialised and in developing countries.

The author starts by outlining her idea for a comprehensive model, which reviews similarities and differences in women’s and men’s physical and mental health as shaped by both gender and sex-linked biology, and also by outcome and by age, class, race/ethnicity, sexuality and global region. She starts by applying this model to health-related behaviours such as exercise, alcohol, smoking and drug use. She also provides a very timely discussion on the multi-factorial nature of obesity and related issues such as dieting and exercise. The main body of the book focuses on three themes, that is, mental health, reproduction and mortality where she illustrates the working of her theoretical framework on specific examples. The author’s choice to focus on case studies within each theme is a very good decision, which shows specificities and allows for a more in-depth understanding of complex factors connected with women’s and men’s health. Her discussion of mental health issues focuses on issues of eating disorders, depression and suicide. She then goes on to discuss issues connected with reproduction by focusing on sexual health, pregnancy and childbirths and HIV/ADIS. Finally, she examines issues of mortality, and looks at causes of both accidental and non-accidental death, and the factors behind healthy life expectancy. All of the case studies are examined in-depth in the context of her conceptual integrative framework – for instance, while looking at issues of mortality, she critiques gender differences in terms of healthy life expectancy and looks at the complex factors involved in the ‘gender paradox’ (i.e. the suggestion that women live longer in comparison with men but suffer poorer health). Finally, she returns to her model in the conclusion and argues for inclusivity in health-related research and the adoption of a framework that would include a critique of biological factors, material factors, gender discourses and gendered dimensions of treatment and research.

Paradoxically, the biggest strength of the book - the comprehensive model of sex and gender as elements of a larger theoretical framework in which class ethnicity and sexuality are also relevant - becomes the book’s weakness. Throughout the main body of the book the author quite often starts the analysis of case studies by focusing on women’s and men’s health in general, and only then goes on to mention specific issues concerning, for instance, sexual and ethnic minorities. This way, she effectively contributes to the othering of men and women who do not fall under the default option of a white, heterosexual and middle-class option. Furthermore, while the author’s attention to issues regarding gay and lesbian health is commendable, she chooses to omit transsexuality or intersexuality, which would provide a great opportunity to critique the normative notions of sex and the social construction of biology in relationship to health research.

Nevertheless, the book provides a thorough, quite exhaustive synthesis of research evidence on the relationship between gender and health that problematises a focus on women’s or men’s health alone. It should certainly be recommended as a reference book for both students and scholars of sociology of health and illness, and the publication will also be highly relevant for courses on gender, race and ethnicity as a good starting point for introducing the complex issues surrounding men’s and women’s health.

 

 

 

Infant Mortality: A Continuing Social Problem

Garrett, E., Galley, C., Shelton, N. & Woods, R. (Eds)

Infant Mortality: A Continuing Social Problem

Ashgate, 2007

ISBN: 9780754645931

312 pages, £65.00 (hbk)

 

 

 

Reviewed by Valerie M Sheach Leith, The Robert Gordon University, Aberdeen, UK

At the turn of the 20th Century, whilst health had improved for some sections of the population, infant mortality rates remained high, being over 150 (number of deaths under the age of one per 1,000 live births) in England and Wales. Through the publication of Infant Mortality: A Social Problem (1906) Sir George Newman, then Medical Officer of Health for the London Borough of Finsbury, increased awareness of this blight on the nation’s health and advocated a range of policies for reducing the loss of so many young lives. Crucially, Newman believed the causes of high infant mortality to lie in the realm of the social rather than the medical sphere.

Garrett et al.’s(2006) edited collection commemorates the publication of Infant Mortality: A Social Problem, which in retrospect can be understood as a landmark text in the struggle to reduce infant mortality rates.Bringing Newman’s work to a modern audience the editors’ aim is to ‘excite and inspire further research’ (14) in a topic which has been historically complex and, as their title notes, continues to be so.  Divided into three parts, the first section explores Newman’s life and the impact of his work. The second and most substantial section is comprised of historically based research which rigorously examines aspects of the different factors that Newman believed contributed to infant mortality, namely the mother, the child and the environment. The concluding chapters highlight the huge strides made in reducing infant mortality rates since the early 20th Century but also provide a sobering commentary on the inequalities that remain.

The text has a number of real strengths. It is an excellent resource for those undertaking or planning research into historical aspects of infant mortality. Reading the central chapters, I was struck by the specific challenges facing researchers in grappling with the intricacies of historical sources, e.g. parish registers (Smith and Oeppen, Chapter 4), as well as the difficulties in using data to make comparisons between different geographical areas, which could, for example, be influenced at the micro level by the individual preferences of doctors when certifying cause of death (Garrett, Chapter 7). The text also provides fascinating insights into the intricacies of teasing out the different factors which may have contributed to the high infant mortality rates. To take just one example, Sneddon in his study of the Lincolnshire Fens, 1870-1900 (Chapter 5) explores why the rural-agricultural region of the Fens ‘suffered from an infant mortality regime that was more akin to that of urban-industrial regions’ (86).  Revealing the need to rigorously interrogate data and to recognise its limitations, as well as emphasising the pitfalls of neglecting the nuances of class, ethnicity and geographic area, the text would also prove to be an excellent teaching resource not only in the public health arena but in the social sciences also.

To leave it there, however, would be to omit some of the most interesting aspects of the text. Newman (1906: 257-58 c/f Garrett et al2006: 42) was clear that the key to reducing infant mortality lay in improving the state of motherhood. He believed that, ‘the child...depends for its life in the first twelve months, not upon the State or the municipality, nor yet upon this or that system of crèche or milk-feeding, but upon the health, the intelligence, the devotion and maternal instinct of the mother’. Thus, mothers and the efficacy of their mothering were brought to the fore. Whilst this led to recommendations focused on the improvement of ante-natal and post-natal care, the education of mothers, particularly in relation to infant feeding, and consideration of the impact of maternal occupation (Reid, Chapter 10), it also meant that certain groups of mothers were identified as ‘ignorant and careless’. From Newman’s perspective some mothers were as much to blame for the death of their infants as was social and economic disadvantage. In the concluding chapter Shelton (257) considers the ways in which Newman’s concerns about mothering are reflected in contemporary policy initiatives (e.g. the ‘Healthy Start’ scheme) which it is argued still imply that ‘ignorance remains in the lower social classes’. Newman’s focus on infant feeding also resonates with contemporary concerns about the impact of social grouping on breastfeeding initiation and continuation rates (Kelly, Chapter 12). The final chapters also draw attention to current inequalities which still impact on infant mortality rates. To give a stark example, in the years 2002-2004 Birmingham experienced 449 infant deaths, whilst Eastleigh had 6 (Review of the Health Inequalities Infant Mortality PSA Target 2007: 14). This linking of past and present in an insightful and thought provoking manner is a notable feature of the text.

A small quibble is the presentation of some of the illustrations which challenged my eyesight. This, however, was a book which rewarded close reading and which it is hoped will indeed fulfil the hope of the editors in inspiring further research. Although Newman could in all likelihood not have envisaged infant mortality rates falling to single figures, inequalities remain and complacency is not an option.

Reference

Healthy Inequalities Unit, DH. (2007) Review of the Health Inequalities Infant Mortality PSA Target,Department of Health. Available online at: <http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065544> Accessed 1st September 2008.

 

 


A Constant Burden: The Reconstitution of Family Life

Margaret Voysey Paun

A Constant Burden: The Reconstitution of Family Life

Ashgate, 2006

ISBN: 9780754644705

254 pages, £60 (hbk)

 

 

 

 

Reviewed by Paul ten Have, University of Amsterdam, The Netherlands

This is a re-edition, or rather a reprint, of a book originally published in 1975 by Routledge. The original text is preceded by a short preface by the series editor Robert Dingwall, and a 'New Introduction' by the author. As far as I can see, the basic text has been re-set, but not revised. The book certainly deserves its status as a 'classic', not only in medical sociology, but also in qualitative research more generally. Its original impact, however, seems to be mostly limited to the U.K., where it was especially noted by authors like David Silverman who were, or became, rather sceptical of the conventional usage of interview-based research. Its significance, then, transcends its substantive topic of the study of the impact of having a disabled child on family life. The core data-base of the study consists of interviews with parents, mostly the mothers, of families with such a child, who were seen 4 times. Inspired by a wide reading of the then current literature on 'deviance' and related subjects, the author struggled to come to grips analytically with what the parents told her about their experiences. Rather than as 'reports', she came to see these expressions as 'performances' or 'accounts'. Talking to a stranger, vaguely associated with medical institutions, they presented a picture of their experiences in terms of a public morality of family life, relevant even in their exceptional circumstances.

Providing adequate care for one's child is one of strongest moral obligations one can have. One of its upshots is that one has to understand what a child needs. When 'something' seems to be 'wrong' with a child, this becomes especially difficult. In those cases, what one can observe is a complex and differentiated pattern of interaction between common sense knowledge derived from various sources and expert knowledge offered by, or sought from, professionals such as doctors. Differentiating aspects are onset (sudden or gradual), diagnosis (clear or not), and prognosis (certain or not). The author describes and illustrates some typical ways of, and developments in, seeing the child, depending on variations in these aspects.

Parenting a disabled child creates specific problems in contacts with the outside world. It makes the 'ordinary' task of demonstrating one's adequacy as a parent more difficult than it already is for 'normal' parents. One issue is whether and how to make the fact of the child's disability available to outsiders. One may try to hide it, tell it outright, or reveal it gradually, each of these alternatives having its problems of strategy and tactics, depending on various circumstances. Another set of difficulties has to do with the extent to which, and the ways in which, a parent may depart from how a normal child would be handled, because of the disability. Overall, parents do present their choices in these matters as accountably adequate, as 'normal' in the given circumstances. Two aspects of parental adequacy are especially relevant, their 'responsibility' for the child's condition and their 'power' to do something about it. By treating these components as dichotomous, the author distinguishes 4 combinations as typical conditions.

Raising a disabled child places an enormous burden on the parents' capacities to accept the child’s condition and all that it entails, and to present an image of parental adequacy and normality-in-the circumstances to the outside world. They do not have to face this hardship 'alone'. The author discusses various cultural resources, derived from religion, medicine, psychiatry and/or sociology, and institutional agents, such as medical ones, social workers, voluntary associations and/or press publications, that can be seen to 'assist' them in making sense of their unexpected burden. Taken together the parents are encouraged to accept their fate and make the best of it, and follow the assistance and advice of the relevant experts and agencies. In short, the parents are induced to 'accept and adjust' by a generally expressed or implied positive ideology. As the author writes: ‘[i]n general it can be seen that the ideology acts to define the situation of parents with a disabled child in such a way that it appears congruent with the normal order of child-rearing. Evident discrepancies between the parent's situation and that of normal parents are symbolically transformed so that, far from far from constituting a challenge to, they appear to affirm the validity of that order.’ (195)

Voysey's achievement was to use a wide range of theoretical insights, developed during the 1960s and early 70s, to carefully 'dissect' the actually used methods of making sense.  However, the analysis could have been brought 'up to date'. One could imagine, for instance, a parallel analysis along Foucaultian lines: would that be equally sensible and/or relevant? It may also be that aspects of the 'ideology' as expressed or implied by various professional bodies may have changed during the intervening 40 years. At least some of the terms used have, such as 'mongol'. But I do not hesitate to recommend the book, both as an exemplary methodological exercise and as deeply informative about sense-making practices regarding disability and parental accountability.

 

 

 

 

 

Madness in Buenos Aires: Patients, Psychiatrists, and the Argentine State, 1880-1983

Jonathan Ablard

Madness in Buenos Aires: Patients, Psychiatrists, and the Argentine State, 1880-1983

University of Calgary Press, 2008

ISBN: 9781552382332

300 pages, £23.50 (pbk)

 

 

 

Reviewed by Fernando De Maio, Simon Fraser University, Vancouver, Canada

Madness in Buenos Aires offers an excellent overview of the history of psychiatry in Argentina – a country well-known for its fascination with mental health, psychiatry, and psychoanalysis.  Jonathan Ablard’s book weaves together historical data gleaned from patient records, insanity proceedings, official hospital records (when available – there are, as may be expected, many gaps in these documents), medical publications, and popular media accounts with primary interviews with senior psychiatrists in the country and field observations at some of Buenos Aires’ psychiatric hospitals.  The result is a fascinating account of ‘the social, legal, medical, and ideological pathways that persons deemed insane followed in and out of hospitals’ (Ablard, 2008: 11; emphasis in the original).  Following the work of Allan Horwitz and Jonathan Sadowsky, Ablard’s concern is not so much with the validity of diagnoses (an area of debate that he labels ‘an intellectual minefield’) but with the social processes that lead to patients’ (often times involuntary) interaction with psychiatry. 

Whilst the bulk of the book is focused on the period 1880-1983 (the year Argentina returned to democratic rule), Ablard’s analysis also provides a brief overview of Argentina’s history, beginning with the colonial era.  A chapter on ‘Foundations, Myths, and Institutions’ outlines the country’s early psychiatric history, focusing on its ambitious attempts to develop a health system and its clear concern with the mental health of immigrants.  For Ablard, this centred on fear about who was entering the country: ‘…by the late nineteenth century, immigration was at the centre of almost all discussions of the country’s social ills.  The perceived relationship between immigration and insanity, which was confirmed by their numerical over-representation in the asylums, became one of the principal social themes of Argentine psychiatric discourse well into the 1940s’ (27).

Closely aligned with Italian criminology, Argentine psychiatry in the early 1900s brought ‘dangerous ideas’, particularly about anarchism, into the psychiatric gaze.  Ablard describes the consensus of the ‘reform period’ of 1880-1910: ‘[i]t was the duty of the state… to contain the threat of degeneration not only through progressive policies to foster the health of the population, but also to contain people who, because of inherent biological traits or of dangerous behaviours or ideas, threatened the national well-being’ (30-31).  Indeed, this fear clearly re-emerged in heightened and powerful forms during the military dictatorship of 1976-1983.

Ablard’s book frames the history of Argentine psychiatry within the country’s political history.  After reviewing efforts to establish and expand community-based care of the mentally ill in the late 1950s and 1960s, he notes that ‘[t]his fragile period of innovation came to a brutal end with the military coup of March 1976.  Military officers took over hospital administration; many progressive doctors were tortured, killed, or exiled.  In the vacuum created by their absence, more conservative psychiatrists regained their position of dominance.  Since the fall of the military in 1983 and the return from exile of many of Argentina’s ablest mental health professionals, some strides have been made in protecting and caring for the mentally ill.’ (7)  The strongest sections of the book are those where Ablard seeks to analyze the role of psychiatry and psychiatrists during the 1976-1983 dictatorship; he rightly points out that many psychiatrists and their families were the targets of repression, yet other parts of the profession participated in it.  Ablard writes: ‘…certain sectors of the profession updated the definition of social pathology to fit the ideological needs of the military’ (164), the result being an ever-expanding range of society under the gaze of professional psychiatry – including members of left-wing organisations, whether guerrillas, intellectuals, or sympathisers, and their relatives. 

This important historical period is described in a far-reaching chapter entitled ‘From Perón to the Proceso: Authoritarianism, Democracy, and Psychiatric Reform, 1943-83’.  Many readers will wish that this section of the book had been expanded; those forty years represent some of the most tumultuous in Argentina’s complex history, and perhaps the different eras within that period need to be considered as distinct stages.  Some readers will also be disappointed not to see analysis of Argentine psychiatry after the return to democratic rule – it is in this very period that the country has attempted to understand its experiences of military dictatorship and abuses of human rights.  But to be fair, the book’s analysis ends in 1983, and as Ablard notes, it is only in publications after that period that Argentine psychiatrists and social scientists offer reflections on those experiences and their relevance for the treatment of mental illness in the country today. 

The book will be of interest to medical sociologists interested in the history of psychiatry and ideas about mental illness as related to issues of immigration, poverty, and economic development. It will undoubtedly also be of interest to students in Latin American Studies programmes, both at the undergraduate and graduate levels.

  

 


 

Sarah Earle and Gayle Letherby (eds)

The Sociology of Healthcare: A Reader for Health Professionals

Palgrave Macmillan, 2008

ISBN: 9781403940803

336 pages, £21.99 (pbk)

 

 

 

 

Reviewed by Carrie Purcell, University of Edinburgh, UK

This edited collection from Earle and Letherby is intended to introduce sociological perspectives to healthcare professionals, and encourage critical thinking in this context, and succeeds as such an introduction by interweaving excerpts from classic texts such as Mills’ Sociological Imagination and Freidson’s Profession of Medicine with contemporary work from the field. The book is divided into five sections introduced by the editors, and each extract is both preceded by a commentary indicating its relevance or linking it to other readings in the volume, and followed by questions and activities to help the reader engage with the topic.

Part I, Sociological Perspectives on Health and Healthcare, begins with a look at the relevance of the political economy approach to contemporary healthcare, followed by a section on reproduction and women’s health. Given its vast significance as an issue, I was pleased to see the medicalisation of women around their reproductive function introduced at such an early stage in the text (most likely a reflection of the editors’ common interests). The excerpt from David Armstrong introduces Parsonian functionalism, and the idea of the ‘normal’ (Canguilhem’s The Normal and the Pathological is disappointingly absent from the suggested ‘further reading’), and the introduction of C. Wright Mills and the sociological imagination as a ‘tool’ in the final reading of this opening section should be particularly helpful to anyone new to the discipline.

Making Sense of Health and Healthcare is the driest of the five sections, although in turning its attention to epistemology, methodology and research methods – and with a distinction between the latter two made clear from the outset – it will be useful for those in the process of getting health research off the ground. Qualitative and quantitative data collection methods are outlined in an excerpt from Keith Punch’s introductory textbook, and secondary analysis in also touched on. Other readings in this part cover the politics and ethics of sociological research in general, including the power issues inherent in the researcher-respondent relationship, and the issue of ‘voice’ – to which the reading from Helen Roberts provides a useful introduction, alongside the recommended reading.

Of the five excerpts in Part III, which focus on Inequalities and Diversity, reading 12 stands out: Robert Crawford on ‘the politics of victim blaming’.  Although over thirty years have passed since it was written, Crawford makes several points regarding the culture of victim-blaming and the problem of rising healthcare costs which continue to be pertinent.  Other readings in this section touch not only on gender and ethnicity, as we would expect in such a reader, but also on the significance of geography as a factor in health, and on the benefits of listening to children’s perceptions of inequalities when studying healthcare in childhood. As with the volume as a whole, this section encourages practitioner reflexivity in terms of awareness of the multiple issues which shape an individual’s wellbeing.

It was the final two sections that attracted my attention most prior to reading the book, and I found them to be well selected and thought-provoking in their combinations of excerpts. Part IV, on Bodies, Minds and Emotions, reflects the upsurge in interest in the body in sociology over the last two decades or so. It begins with an extract from Deborah Lupton’s exploration of death – which seems appropriate since this is the state in which many healthcare trainees first encounter bodies. The reading on ‘dirty work’ from Ian Shaw provides another example based on empirical research (in this case on people with psychiatric problems) and highlights the division of labour in healthcare professions that perpetuates an order in which status is inversely proportional to proximity to bodies and their functions. Reading 22 introduces ‘emotion work’: concisely highlighting its central aspects as conceptualised by Hochschild and others, and again encouraging the reader to consider the theory in relation to their own practice.

The final part, Power, Professions and Practice in Health and Healthcare, begins with the excerpt from Freidson – an essential read for anyone interested in professionalism in healthcare – followed by Kellner et al’s take on professionalisation in the CAM sector (an inclusion I was relieved to find given the volume’s otherwise exclusively biomedical focus). Body modification and occupational boundaries are also touched upon in this final section, and it ends on a topic which can potentially be seen as both the best and worst thing ever to happen to healthcare: the internet. The argument about whether the latter facilitates the democratisation of healthcare knowledge or endangers lives by spreading inaccurate information is relevant to the work of all healthcare practitioners, conventional and complementary, and in a volume aimed at stimulating debate provides a most appropriate conclusion.

As with any reader of this sort, there is an enormous amount of fascinating material which could have been included, making the editors’ job all the more difficult. However, the selections here are well justified and thought provoking in a way which can be expected to promote reflexive practice and debate. The accessibility of the volume makes it relevant not only for practicing professionals, but also as an introductory text for students and trainees in the field, and anyone with an interest in the sociology of health, illness and healthcare.

 

 

 

 

Essays on Professions

Robert Dingwall

Essays on Professions

Ashgate, 2008

ISBN: 9780754646143

186 pages, £55 (hbk)

 

 

 

 

Reviewed by Stephen Timmons, University of Nottingham, UK

Alternatively,  Robert Dingwall ‘s Greatest Hits. This is a compilation of papers by Professor Dingwall, most of which have been published previously. Having said that, it does have a real value as a book, in so far as it shows how the sociology of professions has developed over Dingwall’s long career, in which he has been a major contributor to the field. 

Like a Greatest Hits album, there is a review of Dingwall’s career in the form of the Foreword. Chapter 1 is slightly out of the chronological order that organises the book. It is a reprint of the introduction to a book on the sociology of professions from 1983 which focuses on Parsons and Hughes. Chapters 2, 3, and 4 are based on Dingwall’s PhD research in the 1970s on health visiting. They continue to have a relevance both theoretical and practical. My own students (of nursing) are still told the same atrocity stories more than thirty years later. Chapter 5 ‘A Respectable Profession?’ reviews both economic and sociological perspectives on professions.  Despite the fact that professions have also been of interest to economists, going back as far as Adam Smith, there seems to have been little work that attempts to draw the two perspectives together, and Dingwall’s chapter is a clear, wide-ranging and interesting attempt to do so. It is perhaps surprising that Marxist sociologists and free-market economists reach approximately the same conclusions about the professions, that they are, in the words of George Bernard Shaw, ‘a conspiracy against the laity’.  Dingwall argues that adherence to a profession’s moral code is the price the profession pays for a state-sanctioned monopoly. This adherence is largely achieved through the experience of undergoing the training process, which may explain why the GMC is currently so exercised about the ‘character’ of doctors, and how to influence its formation, not least because of the shortcomings of medical ‘character’ displayed in some high-profile cases.

Chapter 6 has not appeared (in English) before. It is a short, but valuable history of the formation of pharmacy as a profession.  In chapter 7, Dingwall argues for a revival of interest in the British sociologist Herbert Spencer. He believes that Spencer has been unjustly neglected by sociology, largely because of Spencer’s unpalatable political beliefs. In the chapter Dingwall shows how Spencer’s  evolutionary, organic approach is a valid analysis of the formation of professions, prefiguring, in his view, the much better known work of Andrew Abbott in The System of the Professions.  Chapter 8 is more contemporary, considering the attack on the ‘market shelters’ of the professions by the neo-liberal state.  Dingwall speculates that the effect of globalisation may be to bring about the development of new, globalised forms of professions not linked to nation-states.

Chapter 9 is an analysis of the development of mediation as a profession, drawing on the insights of organisational studies as well as sociology, again bringing together disciplines which ought to inform each other perhaps more than they currently do. Dingwall ends this chapter with a rather engaging defence of the virtues of bureaucracy. Chapter 10 is an essay in memory of Eliot Freidson. It’s interesting to note that one of the enduring criticisms of medical sociology – that it is obsessed with the doctor-patient encounter at the expense of consideration of wider structures- was made by Freidson as long ago as 1970. One of Freidson’s great strengths is that he made concrete proposals for the reform of health care systems, again, something that medical sociology has sometimes been criticised for not doing enough. In this chapter, Dingwall reviews the last 30 years of threats to professional dominance, including increased accountability to both managers and patients, as well as competition. Freidson’s later work included an argument for professions being a defence against (neo-liberal) state power. I’m not sure I’m convinced by this, and neither is Dingwall.

One of the problems with works like this is that they are sometimes a bit repetitious. It would also have been nice to have an essay in conclusion. However, these do not detract from an interesting and valuable collection, by someone who has made a substantial contribution to the field in the period of time covered by this book.


Submitting a book review

Mso welcomes the submission of reviews of books that are of relevance to medical sociology.  A list of books available for review is published in each edition, but the editorial team will also be happy to consider reviews of books not listed, provided they are of relevance to the medical sociology community.  Please contact the editorial team if you would like a copy of a book for review.  There is no prescribed format for reviews, although reviewers should provide the full reference of the book, including the price, number of pages and the ISBN.  Reviews should be no longer than 1000 words.  Completed reviews should be submitted as a Word document via email to mso@liv.ac.uk.  Book reviews will not be subject to peer review, and the decision to publish them will be made by the editorial team.  The editorial team also reserve the right to edit articles prior to publication. 

 

Books available for review

Bergdolt, Klaus (2008). Wellbeing: A Cultural History of Healthy Living.  Cambridge: Polity Press

 

Berry, Bonnie (2008). The Power of Looks: Social Stratification of Physical Appearance.  Aldershot: Ashgate. 

 

Bird, Chloe E. and Rieker, Patricia P. (2008). Gender and Health: The Effects of Constrained Choices and Social Policies.  Cambridge: Cambridge University Press

 

Gabe, Jonathan and Calnan, Michael (Eds.) (2009). The New Sociology of the Health Service. London: Routledge

 

Green, Judith and Thorogood, Nicki (2009). Qualitative Methods for Health Research (2nd edition). London: Sage

 

Greener, Ian (2008). Healthcare in the UK: Understanding continuity and change. Bristol: Policy Press

 

Helman, Cecil (2008). Medical Anthropology. Aldershot: Ashgate.

 

Hunter, David J. (2008). The Health Debate: Policy & Politics in the Twenty-First Century.  Bristol: The Policy Press

 

Latimer, Joanna and Schillmeier, Michael (eds.) (2009). Un/knowing Bodies. Oxford: Blackwell/Sociological Review.

Shaw, Ian, Middleton, Hugh and Cohen, Jeffrey (2007). Understanding Treatment Without Consent. An Analysis of the Work of the Mental Health Act. Aldershot: Ashgate.

 

Vande Berg, Leah and Trujillo, Nick (2008). Cancer and Death: A Love Story in Two Voices. Cresskill, New Jersey: Hampton Press.

 

Victor, Christina, Scambler, Sasha and Bond, John (2009). The Social World of Older People: Understanding Loneliness and Social Isolation in Later Life. Maidenhead: McGraw Hill/Open University Press.

Williams, Simon J., Gabe, Jonathan and Davis, Peter (Eds.) (2009). Pharmaceuticals and Society: Critical Discourses and Debates. Oxford: Wiley-Blackwell.

 

 

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