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6 Case Study – Complementary and Alternative Medicine (CAM) in the Medical Encounter

6 Case Study – Complementary and Alternative Medicine (CAM) in the Medical Encounter

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2



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.

Extract 2.1

GP06-03

01. GP: and um (.) now you had blood tests (.) they were all

last year

02. PT: do you know wha- what my blood type is

03. GP: no [I haven’t] done a test for your blood type

04. PT:

[( ) no

]

05. PT: oh okay

06. GP: if you want me to do a test I will but there’ll be

07.

small charge for that

08. PT: yeah yep okay (.) it’s just I was thinking maybe doing

09.

a diet that um- and they need you know it’s good to

10.

know what your blood type is and they tell you what

11.

type of food to eat

((GP turns from computer and faces patient))

12. GP: ↑oh yeah ((inhales))

13. PT: yeah (.) or [not]

14. GP:

[well] if you want to it I mean it there’s

15.

[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]

19. GP:

[I think

] you’ve

20.

just got to [eat ] a varied

21. PT:

[yep ]

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

] is

30. PT:

[yeah]

[nah no problem]

31. GP: that okay

32. PT: yep yep



2.6



Case Study – Complementary and Alternative Medicine (CAM) in the Medical…



17



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?



18



2.7



2



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

innovations.

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



References



19



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).



2.8



Conclusion



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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Chapter 3



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



3.1



Introduction



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,

DOI 10.1007/978-3-319-31508-9_3



23



24



3.2



3



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).



3.2



Material Conditions, Social Systems and Health



25



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

Organization 2013).

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

nation-states.



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