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6 Case Study – Complementary and Alternative Medicine (CAM) in the Medical Encounter
Health Consumers and the Clinical Encounter
his position immediately. Legitimation, or the denial of legitimation of his position,
is achieved interactionally, not cognitively. That is, what is deemed appropriate and
legitimate is not the outcome of rational debate but is achieved through the interaction of the participants. The second point is to show how quickly this occurs. Within
a phenomenally short time the patient is transformed from an inquiring subject
engaging in his own health care into a compliant patient aligning with the GPs position – a transformation that occurs in an instant of interaction.
01. GP: and um (.) now you had blood tests (.) they were all
02. PT: do you know wha- what my blood type is
03. GP: no [I haven’t] done a test for your blood type
[( ) no
05. PT: oh okay
06. GP: if you want me to do a test I will but there’ll be
small charge for that
08. PT: yeah yep okay (.) it’s just I was thinking maybe doing
a diet that um- and they need you know it’s good to
know what your blood type is and they tell you what
type of food to eat
((GP turns from computer and faces patient))
12. GP: ↑oh yeah ((inhales))
13. PT: yeah (.) or [not]
[well] if you want to it I mean it there’s
[none of these diets
16. PT: [nah (i don’t think so)]
17. GP: have any great basis I have to say
18. PT: nah oh you just got to eat healthy [that’s all]
just got to [eat ] a varied
22. GP: [die-] actually the mediterranean diet’s the one we’re
23. PT: [yep]
24. GP: [all] supposed to be eating
25. PT: [yep]
26. PT: yep
27. GP: and doing a bit of exercise
28. PT: yeah yeah yeah I know
29. GP: so if you’re doing [that] alan [you’re fine
[nah no problem]
31. GP: that okay
32. PT: yep yep
Case Study – Complementary and Alternative Medicine (CAM) in the Medical…
The “oh yeah” on line 12 signals that the GP has understood something that she
was not expecting, or that the inquiry being made by the patient is a problem in
some way (Heritage 2002). The “oh yeah” is immediately followed by a contrast
marker “well” (line 14) that suggests impending disagreement with the patient’s
line of talk (Maynard 2003).
But the patient has already understood the impending contrast – and so retracts
his request in overtalk with the contrast marker “or not” (line 13). What this alerts
us to is how incredibly sensitive we are to the smallest details in the health encounter. The patient has only heard “Oh yeah” but immediately knows that he has erred.
In the following turns of talk the GP elaborates on the disagreement and offers an
alternative to the patient’s position. In lines 15 and 17 the GP suggests that the
blood-type based diet does not have any “great basis” tacitly citing the evidence
base on the matter. The patient immediately aligns with the GP and himself offers
“nah you just got to eat healthy” (line 18). The GP then elaborates upon the inappropriateness of the alternative diet. The patient strongly afﬁliates with a series of
“yep-” and “yeah-” and a “nah no problem” to show that he is convinced. The GP
offers only vague alternatives, “the Mediterranean diet’s the one” and “doing a bit
of exercise” without any elaboration on exactly what these might mean. The unspoken reference to ‘the evidence’ has been the basis of her condemnation.
The socio-medical dilemma that can be seen here is that a patient is wanting to
explore an approach to health care that the GP does not agree with. There is no overt
conﬂict in the interaction. Both participants work to ensure that civility is maintained. We see in this transcript how legitimation is not a cognitive process, at least
in this instance, but is interactionally achieved. There is no need for an elaborate
explanation of the pros and cons of different diets calling upon different forms of
evidence. The instant response of the patient to the GP’s utterance of “oh yeah” is to
align with the GP in denying legitimacy to his attempts to pursue a particular diet.
The decision making process is very rapid. An ideal of shared decision making in
health care consultations would include a number of phases: deﬁning the problem;
discussing options; discussing risk and beneﬁts, understanding the patient’s values
and preferences, discussing the patient’s condition and making a recommendation,
checking patient understanding and providing an opportunity to defer the decision
(Stacey et al. 2010). In the transcript above we see something quite different where
the decision point is captured in lines 12 and 13:
12. GP: ↑oh yeah ((inhales))
13. PT: yeah (.) or [not]
We do not see the GP asking the patient why they think the usual ‘varied’ diet and
keeping your eye on fat intake is not sufﬁcient for him. Had he tried it before? What
does he think of it? Why is he exploring alternatives and so on?
Health Consumers and the Clinical Encounter
Self-Government and New Technologies
In the twenty-ﬁrst century, the shift towards chronic illnesses in an aging society has
led to great concern in relation to ballooning healthcare costs. For example in
England, over six times as much was spent on people over 85 in 2002–2003 by the
National Health Service, as on people below that age (Bury and Taylor 2008: 205).
As life expectancies increase, more people are living to very old ages, and doing so
in a more healthy manner, according to the ‘morbidity compression hypothesis’
(Bury and Taylor 2008). These social and economic pressures have led to a revitalisation of medical consumerism, in the form of a new ideal of ‘patient participation’
and ‘active care’.
New models of care such as the inﬂuential model produced by Kaiser Permanente
Health Maintenance Organization in California see 70–80 % of care as being selfcare, provided by patients and their families. Most of the complex cases will be
addressed through shared care between patients and professionals. Only the highest
risk cases will be primarily addressed through professional care (Bury and Taylor
2008). This leads to a new elaboration of shared decision-making that extends
beyond the face-to-face medical encounter; in everyday life as well as professionalised health care, the patient and practitioner are now expected to ‘co-produce’
good health (Bury and Taylor 2008). These new expectations of co-produced healthcare are being put into effect through the capacities offered by new health technologies. Personal health informatics and telemedicine are two such crucial
Personal health informatics involves the use of mobile health apps to monitor
blood pressure, heart rate, glucose, activity levels, sleep cycles, meals eaten and
other health related information (see Chap. 14). These surveillant technologies are
used to encourage people, particularly those from hard-to-reach groups such as
young adults, to engage in self-monitoring of their health behaviors, and to adjust
their lifestyles on the basis of this information (Lupton 2013a). They have been
lauded by health promoters as an exciting way to convey personalized health information that is much more interactive than that offered through social marketing
campaigns (Lupton 2013a). They are being used to create partnerships between
health providers and members of targeted ‘risk groups’ who now become responsible for managing their own health. There is a great deal of interest in new ways for
health policy-makers and informatics companies to use the vast data sets of information about health and bodily states that is thus being generated and uploaded to
the internet (Lupton 2013a, 2014).
Telemedicine involves the use of digital and other technologies to monitor
patients’ conditions and bodily states, thus reducing visits from and to healthcare
providers. It also involves communicating with healthcare providers digitally, rather
than face-to-face (Lupton 2013b). Telemedicine is thus creating a new form of ‘virtual clinical encounter’, which may greatly transform traditional modes of clinical
relationship. In practice, the highly optimistic expectations for the ‘empowerment’
and ‘activation’ of patients promised by these new technologies become more
nuanced. Many patients ﬁnd the practices of self-monitoring that are required to be
messy, highly intrusive, and difﬁcult to adhere to (Lupton 2013b). Being continually reminded by a bleep, for instance, to take one’s medication, check one’s glucose levels, or upload new information to the internet, can generate resistance,
unhappiness at the continual reminders that one is ill, and frustration with the experience of one’s home being transformed into a virtual medical clinic. On the other
hand, having access to greater amounts of information can provide security and
reassurance (Lupton 2013b). Patients, Lupton notes (2013b), respond emotionally
to the numerical data which is produced, feeling either anxious and depressed, or
reassured, depending on whether it is within expected parameters. Lupton concludes
that such technologies both empower and disempower patients, and that their contribution to better health outcomes along with reductions in expenditure will be
variable (Lupton 2013a, b).
We can see that there has indeed been a transformation in the social relations of the
clinical encounter. Patients are now expected to be more active and to take greater
responsibility for their own health, although we have seen that some patients resist
such expectations. However, such changes can to some degree be only superﬁcial.
We saw in the case study how the culture of clinical encounters can lead to interactional submission on the part of the patient, and thus to de-legitimation of elements
of patient concern that step outside a biomedical framework. Along with barriers
such as limited consultation times and the inﬂuence of third party funders in the
clinical encounter, these entrenched cultural patterns can act as hindrances to substantive change.
The inﬂuence of new technologies in the changing relations of the clinical
encounter should not be underestimated. With the development of self-help groups;
health related websites; online support groups; social media; mobile health surveillance apps; and virtual care through telemedicine, the context for the clinical
encounter is rapidly changing. It remains to be seen how these new technologies
will impact on the continuing transformation of the relationship between health
practitioners and their patients in the twenty-ﬁrst century.
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Material Conditions and Health Inequalities
Abstract There is a clear social gradient, where the poor, the less educated and
those living in more deprived neighbourhoods have a lower life expectancy and are
more likely to be sicker than their more fortunate neighbours. This chapter explores
various explanations for the causal pathways that explain this gradient, drawing on
a case study of AIDs in Zambia. The chapter argues that there is not one singular
explanation for disparities in health outcomes, but that political and economic systems, psychosocial effects of particular forms of work, the accumulation (or lack) of
social capital, and an individual’s life course, including their experiences as a child,
all play a role in perpetuating the inequalities that arise due to the relationship
between material conditions and health.
Keywords Health inequalities • Social determinants of health • Structural adjustment • Life course • AIDS • Zambia
There is a clear social gradient, where the poor, the less educated and those living in
more deprived neighbourhoods have a lower life expectancy and are more likely to
be sicker than their more fortunate neighbours. This disparity applies for just about
any illness or cause of death. On a global scale there are massive disparities in
health outcomes between countries. This chapter will provide a picture of these
disparities and consider different explanations for these unjust outcomes. It will be
argued that there is not one singular explanation for disparities in health outcomes,
but that material conditions, forms of social and political organization and psychosocial stresses all play a role.
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
Material Conditions and Health Inequalities
Material Conditions, Social Systems and Health
At a national level there are differences in life expectancy by occupation or social
class. In England and Wales, professional men have an 8-year advantage in life
expectancy over unskilled working men (Scambler and Scambler 2007). In the
United Kingdom the Black Report of 1980 reported on class gradients for almost all
causes of death, and the Acheson Report of 1998 reported that the inequalities had
further widened (Evans 2007). This sort of difference between income groups can
be seen around the world. Canadian statistics show a 5-year difference in life expectancy at birth between males in the lowest income quintile and males in the highest
income quintile (Statistics Canada 2014). In the United States, from 1998 to 2000
the least deprived 10 % of the population lived on average 4.5 years longer than the
most deprived 10 %. Furthermore this gap had increased from 2.8 years in the early
1980s (Singh and Siahpush 2006).
There has been a great deal of theorizing and research activity around the causal
pathways that explain these health inequalities. How much can be explained by
behavioral risk factors, how much by the psychological impact of inequality (the
psycho-social hypothesis) and how much as a result of material poverty (Evans
2007)? Or is it the case that when someone gets sick they also become poor?
The selective mobility hypothesis posits that people are on low incomes because
they are ill or have a disability. Sick people who are well off may become downwardly socially mobile as their earning capacity drops, and sick people who are
already poor have less ability to be upwardly socially mobile. However, the international literature based on longitudinal studies does not support the selective mobility
hypothesis as an explanation for the relationship between health and income. If
people are on persistently low incomes, this predicts the risk of death. Even when
initial health status is taken into account the relationship still holds (O’Dea and
Howden-Chapman 2000). In other words, people are not poor because they are sick;
they are sick because they are poor.
The Black Report of 1980 explained health disparities as arising from poverty
and material deprivation, the solution to which required a radical redistribution of
resources (Hardy 2001). With great improvements in health outcomes throughout
the last century, the health gap between the rich and poor has widened in some
countries like the U.K. (Evans 2007). This does not mean that the poor have become
sicker; in fact, the health status of the poor has improved but not as much as the rich,
therefore the gap between health outcomes has widened. But in other countries
inequalities are much smaller, as for example, in Sweden. Such differences between
nation-states are arguably the result of forms of social organization. Sweden has had
a long history of state involvement in the provision of health care and has strongly
emphasized the principle of equality (Blank and Burau 2010). This not only has an
impact on the provision of health services, where people have a right to access
health services regardless of income, but at a broader political level Sweden has
pursued policies of equality in the social and labour market spheres. The lower
levels of inequality in these spheres contributes to the reduction in inequalities in
health outcomes (Evans 2007).
Material Conditions, Social Systems and Health
Many countries have experienced an increase in income inequalities since the
1990s. For example, in the United States the top 1 % of households experienced a
17 % gain in real net worth between 1983 and 1995 whilst the poorest 40%t suffered
an 80 % decline in net worth (Whiteis 2008). There has also been an increase in
income inequalities between countries, widening the income gap between the rich
nations and the poor nations (Deaton 2004). The rich nations are getting richer and
the poor nations are getting poorer. A political economy perspective challenges current capitalist processes including those that foster uneven economic development
(Whiteis 2008). Less than 25 % of the planet’s population live in industrialized
countries but these countries have over 80 % of global Gross National Product
(GNP), which is the total value of goods and services produced in a country. To
exacerbate the inequalities many poor countries are in debt to the rich industrialized
nations and the interest payments alone on this debt amounts to billions of dollars a
month that flows from the poor to the rich countries (Larkin 2008). Positioned
between rich and poor countries are middle-income countries, which can be characterized in various ways. World-systems theory positions middle income countries as
semi-peripheral to the core rich countries, producing raw materials for them and
having a limited industrial capacity. Modernization theories position middle-income
countries as transitioning out of poverty and on a path to converge with the rich
industrialised countries (De Maio 2014).
Mortality rates are particularly high for children in low-income countries. They
are 16 times more likely to die before reaching the age of five than children in high
income countries (World Health Organization 2013: 10). The life expectancy of a
boy born in 2011 in Sierra Leone was 46 years of age, and a girl could expect to live
1 year longer. A boy born in Qatar could expect to live to 83, the longest male life
expectancy in the world, and a Qatari girl could expect to live to 81. This makes
Qatar one of the very few countries where men live longer than women. The best
life expectancy for women is 86 in Japan. For the Anglophone countries of the
United Kingdom, United States, Australia and Canada male life expectancy hovers
around the high 70s and female life expectancy around the low 80s (World Health
The magnitude of the injustice at play can be seen in Fig. 3.1 which shows that
even a relatively small redistribution of wealth internationally could have a dramatic
impact on the life expectancy of the poor and almost no negative health consequences for rich countries. It takes a very large increase in income to obtain even a
small increase in life expectancy in richer countries (Deaton 2007). The flattening
of the curve in Fig. 3.1 at around the $5000 mark is known as the epidemiological
transition, where deaths from infectious diseases are replaced by cancers and heart
disease (Deaton 2007).
The unequal access to resources and unequal exposure to health hazards points
to political processes as a root cause of health inequalities. These political processes
are developed and articulated at both a national level that foster free markets, and
internationally with policies imposing structural adjustment programmes on