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5 Case Study – Maternity Health Care Work
Case Study – Maternity Health Care Work
The place of midwifery in the health care system has varied over time and
between countries. Across North America midwifery has had a marginal role in
maternity care where physicians have been favored. In Canada, until the 1990s, the
performance of maternity services was almost exclusively restricted to licensed
physicians and surgeons (Benoit et al. 2005). Financial support for midwifery services started to develop as a result of a decline in the number of physicians available
to undertake maternity care due to its impact on the personal lives of physicians and
an increase in malpractice claims. Midwives were seen as a cost-effective solution
by provincial governments to fill this gap, and a consumer social movement demanding greater choice for women provided further support (Benoit et al. 2005).
In Finland too midwives have a minor role in the provision of maternity care. The
provision of free maternity and infant health care during the Second World War had
a long run impact of increasing the hospitalization of birth under the jurisdiction of
obstetricians. In Finland there has not been a strong consumer-driven push to provide women-centred maternity care. The feminist agenda in Finland has emphasized ‘sameness’ between men and women, and so the idea of choice has been
deemed elitist. Paternity leave to involve fathers more intensively in the childbearing process and childcare has been the social policy solution (Benoit et al. 2005).
The place of midwives in The Netherlands provides an insightful contrast. More
than 30 % of births occur in the home in The Netherlands, and most of these are
attended by midwives. The Dutch state has a history of providing strong legislative
support for midwives going back to the nineteenth century when legislation provided a specific sphere of practice for midwifery. Throughout the twentieth century
the profession of midwifery gained more strength and enhanced standards of training and recruitment. In contrast to Finland, the Dutch state has not introduced policies to involve fathers in child rearing, but a conservative family-centred approach
positions men and women as having complementary roles. Due to this more emphasis has been placed on financially supporting midwife assistants who, during and
after childbirth, provide social support for the woman allowing fathers to have less
of a role (Benoit et al. 2005).
The case of obstetricians in Chile provides other insights into the way in which
maternity care is shaped by political and institutional settings. According to the
World Health Organization a justifiable rate of caesarian sections is around 10 % of
births. Chile has one of the highest caesarian section rates in the world with a rate
of over 30 % of births in 2008 (Gibbons et al. 2010). Murray and Elston (2005)
highlight the particular working conditions of obstetricians that provide some explanation for this outcome. They argue that a high level of competition amongst obstetricians for clients in urban centres, like Santiago, and an expectation that private
clients will receive individualized care, places pressure on obstetricians to control
their work time. With maternity care that means having to control the ‘natural’ process of birth.
Prior to the CIA-backed military coup of 1973, Chile had a National Health
System and a government administered health insurance plan that covered 85 % of
the population. After the coup government spending on health care fell by 40 % and
the state-controlled system was increasingly replaced with a market model. By the
Health Care Work and Everyday Health Work
1990s one-third of obstetric deliveries were covered by private insurance. For most
obstetricians this resulted in a fragmented working life, with some clients attended
to in private maternity facilities where personal care from the obstetrician and their
team is expected, and other clients attended to in the public hospitals where continuity of care is not guaranteed. Obstetricians claimed that the low salaries offered in
the hospitals forced them into private work. But public hospital positions provided
some security in a situation where “a plentiful supply of obstetricians” made private
practice insecure for many practitioners (Murray and Elston 2005: 712). To be competitive many obstetricians in private practice would make themselves available at
any time of the day. This combination of working in different locations and requirements to be constantly available encouraged obstetricians to take control over time
schedules where they could, and one way to do this was by the use of elective caesarean sections. Obstetricians in private practice could plan these on days when they
did not have clinics and for the women it meant they could be sure of avoiding
surcharges for services that were provided outside of normal working hours.
Alternatively, women in the public hospital system, where obstetricians are not
placed under the same time constraints as they are working in rostered systems,
were more likely to start labour spontaneously.
What the case of the Chilean obstetricians alerts us to is the way in which political influences can have a major impact on the working circumstances of clinicians,
which in turn impacts on how and what health care is delivered. In this case the
medical profession was not able to successfully resist the political drive to diversify
the health care market (Murray and Elston 2005). The examples discussed so far,
including the case study of Chile, show us how the work of maternity care can vary
immensely in relation to the level of dominance of the medical profession in any
particular jurisdiction, particular ideologies about the role of mothers and fathers,
state concerns for efficiency, and health social movement concerns around women’s
rights and choice.
Everyday Health Work
A focus on the work of health professions can take attention away from the tremendous amount of health work that occurs outside of the organized health care system.
Although some argue that lay beliefs provide little in the way of a challenge to
medical dominance (Williams and Popay 1994) this perspective elides the extensive
amount of health work that occurs every day outside of the overview of health professionals. The health work undertaken in households is not usually overseen by
health professionals (there are of course exceptions, like health visitors and home
care workers in particular situations). In domestic spaces health care advice can be
worked and reworked as householders combine advice from different sources and
modify advice in response to their own observations and understandings. Lay people “adopt, mimic, critique, or rewrite expert positions” (McClean and Shaw 2005,
746). Householders instigate their own treatment interventions and procedures and
so homes are centres of health work in their own right (Dew et al. 2014).
An unremitting activity in households, and more so in those with children, is
diagnosis. Before a health professional is consulted about signs or symptoms the
householder has to determine that the signs and symptoms are appropriate for a
health care consultation. Is the headache just a result of tiredness, a late night, or has
it been going on a bit too long and should someone else try to make sense of it? The
parents and guardians of children get to know the ebb and flow of symptoms of illness and gauge how ordinary or extraordinary they are. Claire Williams (2000)
describes mothers of children with chronic illness as alert assistants as they identify
and anticipate the needs of their children. But the same can be said of partners
observing each other, or siblings or others who share the same domestic space.
Household observers make a determination of whether a child’s sickness, or their
own sickness, is one that requires the attention of a health professional or not. If it
is determined that a health professional should be consulted, then a decision is made
about which health professional to consult, maybe a pharmacist, a naturopath or a
If a practitioner is not consulted some therapy may be prescribed in the household. The therapy may be based on what has worked in the past for this sort of thing,
or what is believed could work, including over the counter purchases from pharmacists or modifications in diet. Advice may be taken from other householders or family members. Mothers and grandmothers may be more likely to pass on ideas for
therapeutic interventions where children are concerned. Research work may be
undertaken in the domestic sphere with libraries used, Internet searches undertaken
or work colleagues consulted. Patients may develop expertise in particular
approaches, maybe aromatherapy or homeopathy, and prescribe their own solutions
for themselves and those around them (Dew et al. 2014).
If a health professional is consulted, householders may engage in careful observation of the treatment and its effects. They may vary the advice given and experiment with medications, or stop taking them altogether if the advised medication
does not align with their own views of illness or if it is seen as causing more problems than it solves. In short, there is a great deal of health work and therapeutic
decision-making that occurs in domestic spaces, away from the oversight of anyone
else and we could usefully think of the home as a hybrid clinical practice (Dew et al.
Health work occurs in many spaces, such as the home and workplace, and not just
in health care centres and hospitals. But certain professional groups gain status
through their capacity to claim control over particular health work activities. For the
medical profession the claim to the right to diagnose is a particularly powerful form
of health work, but as noted in this chapter that claim is contested and blurred in
Health Care Work and Everyday Health Work
many different ways. Other professions, like nursing, have made inroads into claiming some rights to diagnose. In other situations diagnosis occurs even though it
cannot be given that name. In many situations diagnosis is a collective enterprise
and in everyday life diagnosis is a regular activity undertaken by lay people with
little or no health professional surveillance.
The case of maternity care demonstrates the variety of positions of maternity
care workers in different countries at different times, with midwives, physicians and
obstetricians having their working lives shaped by broader social and political
forces. The variety of ways in which maternity care is undertaken alerts us to the
fact that there is nothing inevitable about who undertakes health work and how it is
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Medicalization and Contested Illnesses
Abstract Medicalization is the process by which conditions, experiences, and situations, which were at one time not seen as medical in nature, come under medical
jurisdiction for treatment. This chapter explores the concept of medicalization historically, the different levels of medicalization, and the contemporary forces driving
medicalization. It draws on a range of examples of contested illnesses including
attention deficit hyperactivity syndrome, fibromyalgia, and pre-menstrual dysphoric
disorder, with a detailed case study of Gulf War related illnesses. Finally the chapter
addresses the recent phenomenon of biomedicalization, which is reorganizing
health care in a number of ways including a widening of the ambit of medicine to
incorporate enhancement processes applied to seemingly healthy bodies.
Keywords Biomedicalization • Gulf War related illnesses • Disease mongering •
Enhancement • Direct to consumer advertising • ADHD
Medicalization is the process by which conditions, experiences, and situations,
which were at one time not seen as medical in nature, come to be seen as medical.
They thus come under a medical jurisdiction for treatment (Ballard and Elston
2005; Conrad 2005). Some conditions which have been medicalized include alcoholism, menopause, baldness, and obesity. Conversely, conditions can be demedicalized, coming to be seen as not relevant to medicine, although this process is far
less common. These simple definitions conceal trends which are often emotionally
intense, and can occasion social movements aiming at deep social change. For
example, the movement to demedicalize homosexuality was central to the politics
of gay liberation in the 1970s in several Western countries (Conrad 2007). Marches,
demonstrations, disruptions of professional conferences, challenges to the proponents of the medical view, and negotiations in the revision committees of the
Diagnostic and Statistical Manual: Mental Disorders (DSM) eventually brought
about a shift from an understanding of homosexuality as sexual dysfunction and a
mental disorder, to an understanding of it as an embodied identity (Conrad 2007:
100). Similarly, the medicalization of conditions such as flatulence, anxiety,
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
8 Medicalization and Contested Illnesses
alcoholism and impotence bring about major changes in the stigmatization, the
treatment and the experience of these conditions. Medicalization and demedicalization are processes which entail major changes in our way of discursively organizing
our world, and thus have profound impacts on our experience of this world.
Although the concept ‘medicalization’ dates only to the early 1970s (Illich 1975;
Zola 1972), the process of medicalization extends back to the late seventeenth and
early eighteenth centuries in Western countries (Bell and Figert 2012). The
Enlightenment entailed a shift from understanding many processes in the human
and natural world through a religious lens to seeing them scientifically, and acting
on them through health systems (Bell and Figert 2012; Porter 1990). Utilitarian
philosophy encouraged medical reformers to advocate for social change which
would bring about happiness for the greatest number of people. This philosophy led
to the development of sewerage systems, water treatment, epidemiological surveys,
food regulation, working conditions legislation and social security. These changes
were largely motivated by medical advocacy and seen through a public health lens
(Bell and Figert 2012; Rose 2007a; and see chapter 15).
Foucault’s socio-historical studies (1967, 1973) detail the processes by which
medical expertise came to define appropriate ways of behaving in relation to life,
death, sickness and madness. In The Birth of the Clinic, Foucault argued that the
modern state was constructed alongside medicalization; he later termed this process
of using state power and surveillance to enhance the health and well-being of the
population, “biopower” (Foucault 1973, 1979, 1980; Bell and Figert 2012). These
changes had a massive impact on the ways we organize society, live in the world,
govern ourselves, and experience our embodied lives. More recently, Allan Brandt,
a medical historian, has argued that medicalization was a critical part of the transformation of society in the late twentieth century; medicine absorbs ever greater
amounts of economic resource, and frames increasingly large swathes of human
experience (Bell and Figert 2012). Differences in medicalization – whether a society is over or under medicalized – are thus critical to addressing global disparities
in human security and the human condition (Bell and Figert 2012).
In this chapter, we will explore processes of medicalization as they have taken
place since the 1970s. We will explore the medicalization of attention deficit hyperactivity syndrome (ADHD), and then will look at some other contemporary processes of medicalization, in relation to such conditions and processes as menstrual
suppression, cognitive enhancement, preventative medicine, and Gulf War related
illnesses. By focusing on contested conditions, we can see the many drivers of medicalization and also the barriers to a comprehensive shift in this direction. We can
also become aware of the multiple meanings, both positive and negative, that this
concept can have. Towards the end of the chapter, we will introduce the new concept
of biomedicalization, which looks at the forms medicalization is taking in the
twenty-first century. The concept of biomedicalization sensitises us to the profound
shifts currently taking place in the organization and experience of health care.
The Concept of Medicalization
The Concept of Medicalization
The concept of medicalization was developed at what was, arguably, the high point
of prestige and status for the profession of medicine; it thus may be unsurprising
that this concept arose as a critique of medical imperialism (Ehrenreich and English
1974; Illich 1975; Zola 1972). As Irving Zola put it in 1983, more and more of
everyday life was coming under medical supervision, influence and dominion
(Ballard and Elston 2005: 230). Thus, medicine was becoming a more important
locus for social control than the Church, or the criminal justice system (Zola 1972).
The medicalization thesis was put particularly strongly in relation to women and
childbirth, where it was seen as an instantiation of patriarchal dominance (Oakley
1984; Rothman 1989). It was also stated strongly in relation to mental illness (Bell
and Figert 2012; and see chapter 12). In the mid-to-late 1970s, Ivan Illich was arguing that this medical imperialism was leading to the degradation of people’s independence and self determination, and thus changing the very meaning of being
human (de Maio 2010; Illich 1975).
However, beliefs that medicine was inexorably increasing in cultural and social
authority, that the populace was simply passive in relation to it, and that medicine
played a negative role in relation to social control and health, were soon to be questioned by a number of sociologists (Ballard and Elston 2005; Riessman 1983). In a
key paper of the early 1980s, Catherine Kohler Riessman (1983) argued that women
have as much to gain as to lose from medicalization, and that female patients play
an active role in relation to it. This position has been borne out by subsequent studies which show that women often welcome medicalized childbirth and new reproductive technologies (Brubaker and Dillaway 2009; Fox and Worts 1999; Gunson
2010). Studies of a number of contested conditions have shown that patients often
advocate for greater medicalization. As Jessica Gunson (2010: 1326) notes, framing
medicalization as medical imperialism presumes that there is some true, original
way of being in the body, which is somehow altered for the worse through medicalization. However, a constructionist account of the body would say that there is no
authentic and essential way of being embodied (Grosz 1994).
According to Peter Conrad and Joseph Schneider (1980a) medicalization can
occur on at least three different levels: the conceptual level, the institutional level
and at the level of doctor-patient interaction. The conceptual level encompasses
medical discourse, medical research and medical definitions. The institutional level
can range from sick notes for employers, to sickness and disability benefits, to the
educational systems’ understandings of ‘special needs’. The level of doctor-patient,
or clinician-patient, interaction can encompass everyday clinical encounters with a
variety of practitioners from surgeons and general practitioners to physiotherapists
and complementary health therapists. These three levels of medicalization can
develop at different speeds and even in different directions. For example, while the
common cold is heavily medicalized conceptually, it is less medicalized institutionally – where people might be expected to come to work with a cold, for example –
8 Medicalization and Contested Illnesses
and it is not medicalized at the level of doctor patient interaction; people often treat
themselves rather than visit a doctor when they have one of these viruses.
Medicalization is now driven by a number of forces, including pharmaceutical
company marketing, patient advocacy and social insurance systems; as we shall see,
physicians are not generally the most important agents of greater medicalization
(Barker 2011; Conrad 2005 and 2007). Conrad and Schneider (1980b) described a
five stage process involved in medicalization. The first stage involves a behavior or
condition being defined as deviant and undesirable. The second stage involves a
discussion, in medical terms, of this condition in a medical journal or conference.
The third stage involves claims-making from a variety of agents; these can include
pharmaceutical companies, self-help groups, professional associations, medical
researchers, entrepreneurial clinicians, family support groups, and so forth. The
fourth stage involves the legitimation of the claim and the fifth stage its institutionalisation in social organization. They tested this process against historical case studies – including attention deficit hyperactivity syndrome (ADHD), alcoholism, and
opiate addiction – and found it provided a helpful framework for understanding the
process of medicalization (Conrad and Schneider 1980b; Conrad 1992).
Contested Illnesses and the Changing Face
The original thesis of medical imperialism, with its implicit assumption that medicalization was driven by doctors attempting to extend their professional standing,
has been superseded, as it becomes clear that the agents of medicalization can be
quite varied. For example, much of the pressure for the greater medicalization of
ADHD in children, at the institutional level and the level of doctor-patient interaction, has come from parents and teachers. Children who daydream in class, are
disruptive at school, are defiant towards teachers or violent towards other children
are, in some cultural contexts – particularly in North America – labelled as potentially having ADHD by teachers (Malacrida 2004; Rafalovich 2005). In Italy, where
the diagnosis of ADHD has been acceptable only since 2007, teachers may position
the hyperactive child as a threat to the successful management of the class, and a
risk to other children (Frigerio et al. 2013a). They often see medication as the only
way to accommodate such children within the school context (Frigerio et al. 2013a).
In North America, the Connors Rating Scale – which uses a Likert scale questionnaire to make an assessment of ADHD – is often used by school based teams;
schools may then pressure parents to take the child to a paediatrician for confirmation of the diagnosis (Rafalovich 2005). Parents can also be agents of medicalization. Mothers of hyperactive children may find that they face blame for their
children’s disruptive behavior, lessening their ability to take on a good mother identity (Brunton et al. 2014; Francis 2012; Frigerio et al. 2013b; Singh 2004). The
biological narrative of genetic causality partially removes this stigma in relation to
8.3 Contested Illnesses and the Changing Face of Medicalization
the quality of their parenting, repositioning them as the real experts in relation to
their child’s illness (Frigerio et al. 2013b). Such parents may thus take their children
to a number of paediatricians in search of a diagnosis of ADHD.
Another major agent of medicalization is the pharmaceutical industry (see Chap.
9). A particularly effective route by which the pharmaceutical industry sells medicalization at the conceptual level is direct to consumer advertising (DTCA) (Barker
2011; Ebeling 2011). This form of advertising is legal only in the United States and
New Zealand, although the internet provides a platform by which it can be diffused
more widely from these countries. As Kirsten Barker notes in relation to the contested illness of fibromyalgia, when DTCA encourages consumers to self diagnose,
and then to request a diagnosis from a physician, doctors may comply with such
requests, even if they are sceptical about the diagnosis (Barker 2011: 835). When
Pfizer received Food and Drug Administration (FDA) approval for its existing pain
medication, Lyrica, to treat fibromyalgia, it began to create a public awareness campaign around this disputed illness category. Central to its campaign was its intention
to legitimate fibromyalgia as a real disease, which is not psychosomatic in origin,
and for which a medical treatment exists. A biomedical explanation for the illness,
centering on ‘overactive nerves’ was provided in advertisements (Barker 2011).
This was welcomed by the largely female group of people living with the illness,
who struggle with delegitimation of their experience of chronic disablement.
However, the advertisements also trivialised fibromyalgia, presenting it as a minor
ailment that could be cured with a pill, something that is generally impossible to
accomplish (Barker 2011).
This process of selling a disease category, in order to generate a market for a new
treatment for it, has been termed “disease mongering” (Moynihan et al. 2002: 886).
As Ray Moynihan and his colleagues (2002) point out, disease mongering can
involve turning ordinary life conditions or minor ailments into medical problems,
seeing personal problems as being of a medical nature, treating risks as if they are
existing diseases, and framing prevalence estimates to maximise the potential market for a disorder’s treatment. An example can be seen in the way the pharmaceutical industry used symptom checklists within DTCA to sell pre-menstrual dysphoric
disorder, or what used to be known as premenstrual tension, as a major and treatable
disorder (Ebeling 2011). All of these strategies are designed to generate alarm
around a sometimes quite minor condition, in order to create the anxiety needed to
sell a potential treatment for it. In this respect, the disease mongering discussion
harks back to the critique, of medical over extension undermining self determination, made by Ivan Illich in 1975; thus, it may be seen as bringing the medicalization
debate full circle.
In addition to parents, teachers and pharmaceutical companies, patient advocacy
groups can be major agents of medicalization. When a condition is fully or partially
medicalized by patient action, in the face of medical or other institutional resistance,
it is called a contested illness. These illnesses are dismissed as illegitimate by
researchers, clinicians and policy makers operating within dominant paradigms
(Moss and Teghtsoonian 2008: 7), which means that patients carry the double burden of living with a disease, but without a legitimised sick role (Bϋlow 2008; Dumit
8 Medicalization and Contested Illnesses
2006; Oldfield 2013). Gulf War related illnesses (GWRI) are examples of conditions that have been deeply politicised by the contestation between a health social
movement and a very powerful government.
Case Study – Gulf War Related Illnesses
Gulf War related illnesses are an outcome of The Persian Gulf War of 1991, which
was triggered by Iraq’s invasion of Kuwait in 1990. In response, a coalition of 37
countries, led by the United States, initiated a massive air assault on Iraq in January
1991. This was followed by a land offensive in February, which involved approximately 697,000 troops from the United States, as well as some troops from coalition
countries (Cable and Shriver 2010; Shriver et al. 2002). A ceasefire was declared at
the end of February 1991. Many veterans of the war soon found themselves experiencing debilitating symptoms which included abdominal pain, chronic diarrhoea,
severe fatigue, loss of concentration, insomnia, short-term memory loss, mood
swings, rashes, migraine headaches, shortness of breath, blurred vision, aching
muscles and joints, bronchitis, sexual dysfunction, multiple chemical sensitivities,
and asthma (Cable and Shriver 2010; Shriver and Waskul 2006). Approximately
200,000 soldiers and former soldiers – or 30 % of the American veterans of the
war – signed a register set up to collect asserted cases of Gulf War syndrome (Cable
and Shriver 2010; Shriver and Waskul 2006; Shriver et al. 2002).
The veterans experiencing these symptoms had a number of explanations for
them. These included exposure to chemical and biological weapons used by the
Iraqis; although the US government argued that most soldiers weren’t exposed to
such weaponry, returning soldiers noted that chemical weapon alarms sounded on
various occasions, and that unusual animal deaths were common. Depleted uranium
weapons were used by some coalition governments with health effects that are contested intensely by the United States and other governments, but are argued to be
extensive (Green 2006). Powerful vaccines and preventative medicines – such as
Anthrax vaccine and Pyridostigmine Bromide (PB) pills were given to soldiers
leaving for the war; the PB pills were given repeatedly to almost all of the soldiers
to protect against nerve gasses such as sarin (Brown 2007; Shriver and Waskul
2006; Shriver et al. 2002). Organophosphate pesticides were extensively applied on
the body to deal with biting desert insects. The retreating Iraqi army set fire to
Kuwaiti oil wells, creating enormous clouds of thick black oily smoke. The assumption amongst returning veterans was that the synergistic effect of all of these toxins
led to the Gulf War related illnesses.
These suspected causes all fell under the general and highly contested category
of environmental illness (Brown 2007). By asserting an illness etiology which is
sociopolitical, economic and environmental rather than based in individual genetics, lifestyle and chance, environmental health activists challenge what Phil Brown
(2007: 1) calls “the dominant epidemiological paradigm”. This paradigm locates ill
health causation in individual behavioral factors rather than in social structure and