Final Flashcards
Reading: Elliot
Pertains to the pharma industry;
Pharma don’t point out the flaws in their drugs;
Overly involved in continuing medical education;
High numbers of ghostwritten articles that are well read;
Writers need to keep the favour of the people paying them;
Science is becoming commercialized, for profit;
Reading: Lextin
Pertains to pharma industry in Canada;
Primary motivation for making drugs is profit and they have larger profit margins than any other industry;
Trips agreement gives 20 year patent and patents mean large costs;
State can’t afforts to control pharma so private pharma is allowed;
Few new drugs offer significant improvement;
Only make drugs for profit, not for poor or uncommon diseases;
Promotion to doctors becomes the doctor source of info on drugs, this is where the money is spent;
Reading: Carpenter
Asses impact of the WHO goal of health for everyone;
Goals of Alma Mata not reached, emergence of AIDS, health disparities due to capitalism;
WHO and unicef have neoliberal ideas with selective care;
Opening up trade had negative impact on poorest 40% of population;
One of the most important conditions for health is a state that is legitimate and democratically accountable;
Exportation of hazardous jobs;
There have been real gains in health but poverty and health inequality have increased since globalization due to negative activities of multinationals and ineffective govs;
Reading: Knowles
The responsibility of the individual / health and morality;
Improvement in health due to better sanitary conditions, and only in small part medicine and surgery;
Simple paradigm of medicine;
Ill health due to individual responsibility;
Cost of bad habits is born by the state;
Cost going into medicine doesn’t correlate with increased health of population;
We live in a culture that has eroded individual responsibility while maintaining individual rights - credit societ (do now, pay later);
Unhealthy lifestyles (food, stress, smoking, alcohol);
Research stresses bio and not epidemiological roots;
Reading: Leichter
Lifestyle correctness and secular morality;
Being healthy is the new secular state of grace;
Social class issue;
Good health might be conditional for employment so there is an economic punishment for being unhealthy/sinning;
Political/economic turmoil so people turn to controlling their health since it is one of the few things they can control;
Growth of gov and importance of health, decline of importance of family and religion;
People constantly surrounded by health risk warnings;
American conservatism promotes self-help so obsession with health is consistent with American values;
Elitist because it doesn’t recognize the economic and env factors that shape healthy behaviour;
Overlap bt lifestyle correctness and middle/upper class status;
Reading: Solomon and Green
The history of non-medical opiate use and control policies in canada;
First laws against opium directed at chinese and posed no risk to white middle class users;
Not until 1950s was treating addicts instead of punishing them proposed;
1908 opium act created the black market
Biomedical model assumes (about normality)
Assumes that being healthy is normal;
Quantitative - statistically normal;
Qualitative - what is functional, working properly, not deviant;
Foucault on normality
If you are not like everyone else you are abnormal
If you are abnormal you are sick. These three things are different, but have been reduced to the same thing.
Historical shifts in power
Public executions - a lot of work
Incarceration
Panopticon - you watch yourself. We bring this to the rest of society. You judge yourself while you eat french fries on behalf of your doctor.
Alan Hunt
Moral Regulation: efforts to change conduct and ethical subjectivity of individuals
Responsibilisation: process of making people responsible
Foucault inspired.
Introduced using morality in health regulation through moral projects. If you moralize something you also say someone is responsible for it (possibility that one may be blamed).
Cross cultural studies on the health-morality link
Different cultures all use moral explanations for people getting sick. Even in Western culture, people ask “what did I do to deserve this?”
Children studies on the health-morality link
Western children explain illness with morality. See it as a form of justice. “You went outside and got sick”
US christiain fundamentalism in health-morality link
Getting sick is moral retribution. AIDS was seen as god’s punishment for sexual perversion
College student food and morality study
Rated images of people eating healthily and doing health activities as more moral than people eating fast
Factors the contribute the morality of health
- The rise of secular morality
- The rise of protestantism
- Fear of harm to children
- Association with a stigmatized, marginalized or minority group
- Favourable short-term cost-benefit ratio
- Confusion about cause.
Pros of the health-morality link
Saves lives by encouraging people to have healthy lifestyles;
Force action, hold government/business accountable.
Cons of the health-morality link
Victim-Blaming - overemphasis of the factors that are under the control of people who become ill;
Focus on individual vs. structural factors;
Knowles (briefly)
Individuals need to take responsibility for their health. It is a choice not to and if you don’t, you are being a burden
Leichter (briefly)
The movement of health-morality erodes the support for community-based medicine. Excludes the poor yet again from the privileges and practices of the rich
Deterministic means
One factor determines something else
Reductive means
reducing the group to one aspect
Essentialist means
thins have an essence that is intrinsic to them and this is used to define the group
Define Race
The idea that there are human subspecies; biologically distinct groups that have distinct sets of traits.
Discuss Race
- Developed and justification for 18th century colonialism;
- Criteria used to define race often inconsistent;
- Biological foundations of race contested by social scientists and geneticists;
- Focus on racial health disparities obscures/naturalizes the effects of racism;
- Race is a social construct that has real effects through structural racism
Racialization
The social process of assigning people to racial categories. Whiteness treated as the standard and yields privileges, not disadvantages (being white doesn’t become a signif. part of one’s identity)
Structural racism
the way that society is organized in such a way to systemically discriminate against racialized groups
Define ethnicity
A system of categorization based upon presumed cultural characteristics such as culture, history, language, religion or regional affiliation
Discuss Ethnicity
- Thought to challenge biological reductionism of race by focusing on cultural/social aspects of disease and ways of dealing with disease
- Can be self-identified and empowering, but can also be ascribed by others
- Often conflated with race, immigration and visibile minority in health research
Healthy Immigrant Effect
New immigrants in Canada have an overall higher level of health than the average in Canada because the standards for immigration are so high. Over time spent in Canada this levels out with the rest of the population.
Inclusion-and-difference paradigm
Epstein. Has 2 main aims:
1) Inclusion of women and children and
2) Inclusion of people of colour
who are underrepresented in clinical studies
National Institutes and Health Revitalization Act
- Came with the inclusion-and-difference paradigm.
Meant well but…
-Encouraged biological reductionism
- Overestimates biological incommensurability between races.
-Encourages racial profiling in clinical settings (assumptions on race are used to choose treatment)
- Obscured differences within racialized groups
- Diverts attention from structural/social disparities
- Rise of recruitmentology/contract research organizations and more overseas research
Recruitmentology
A new field of study about gaining access to research participants by finding the best ways to convince them to join trials.
Researchers compete for a scarce number of racialized groups to participate in their studies.
Lot’s of studies in foreign countries where participants are ‘pharmacologically naive’, research is cheaper to conduct and there is a comparative absence of highly demanding research participants.
The 3 major outcomes of the inclusion-and-difference paradigm and the National Institute of Health Revitalization Act
- ALready marginalized groups come to bear more of the brunt of research and its risks
- Their supposedly biological differences from the ‘standard’ (white) male human are reified
- The social causes of inequality still aren’t much addressed
How is culture thought about in health care:
Fixed, homogeneous cultural ‘traits/, values and beliefs that strongly influence or determine clinically relevant behaviour.
How is culture thought about in contemporary anthro?
Flexible, ongoing process of transmitting and using knowledge conditioned by dynamics both within communities and between communities and social institutions
Problems with the way culture is thought of in health care.
- Culture seen as determining behaviour
- Emphasizes difference from the dominant group
- Emphasizes differences in the minority group
- Diverts attention from structural inequality and racism
- Justifies discrimination on basis of supposedly rational/progressive values, but it is essentially racism. People belong or don’t belong to the dominant group.
- Victim-blaming: minorities dangerous to their own health
- Pathologization of minority culture
Cultural Competence
Arose out of recognition that cultural differences between care providers and users affect immigrant health care
Having the knowledge, understanding and skills about a diverse cultural group that allows the health-care-provider to provide acceptable care.
Assumptions in Cultural Competence
- Culture is a matter of ethnicity and race
- Culture is possessed by the other; the other is/has the problem.
- The problem of cultural incompetence lies in the practitioners’ lack of familiarity with the Other
- The problem of cultural incompetence lies in the practitioner’s discriminatory attitudes toward the Other
- Cross-cultural health care involves white practitioners working with ethnic or racialized minority groups
- Cultural competence is about being confident in oneself and comfortable with others
Cultural Safety
Tries to address the role of racism and the power dynamics of interactions between users and the system.
- Requires doctor to view everyone, including themself, as bearers of culture that can affect care and responses to it.
- Service provider is responsible for addressing power relat bt user and provider;
Service user must be a part in the decision making. They determine if the care is culturally safe or not and their way of knowing must be seen as valid.
Epidemiology
statistical study of patterns of disease in the population
Four Historical Regims
Armstrong:
- Quarantine Regime
- Sanitary Regime
- Social Medicine Regime
- New Public Health Regime
Quarantine Regime
14th to mid-19th century
Threat to health: Sick places
Response: Quarantine - prevent traffic bt sick and healthy places (pest houses)
Responsibility: State (police power) - police and military enforcement. Force used where necessary
Sanitary Science Regime
- Mid 19th to early 20th century
- Modern epidemiology and public health are born
- Chadwick’s Sanitary Idea - charting disease and poverty
- Class Ideology - poor in a ‘troubling’ state. Poor just don’t know how to be sanitary. Still a problem today.
- Ill health is connected to the interaction bt bodies and environments. The contaminate each other.
Threat: Squalor
Response: Sanitation
Responsibility: State (with help from the individual) - Beginning of disciplinary power. Surveillance builds/cajoling people to help/Responsibilization
Social Medicine Regime
- Early to late 20th century
- personal hygiene and self-discipline
- Ill health is due to interaction bt bodies (Germ Theory, Children)
Threat: Germs - human to human contact
Response: Good Hygience - moral responsibility, target children and educate using established public education. Gendered.
Responsibility: Individual (with advice from the state) - disciplinary power apex. Responsibility of the ind to learn the rules and stop the spread of disease by following them.
New Public Health Regime
-1970s to present
- New focus on Risk (Ill health due to lifestyle, identity, industrialization, technology)
-Skepticism - growing dependence on and mistrust of expert authority. Too much conflict in opinions, too much info.
Epidemiology has conservative and radical potential (can contribute to individual risk and social foundations of risk)
Threat: Human Action - but individual or collective?
Response: Lifestyle changes or political action?
Responsibility: Individual? State? Corporation?
Armstrong opinion on the New Public Health Regime
Move to surveillance medicine.
Focus on risk and entire population. So many risks to everyone, even healthy people.
You can always be healthier, so keep working at it.
Caster opinion on New Public Health Regime
Transition from dangerousness to risk.
Dangers beyond control, but risks give us impression that we you can insure yourself against risk by regulating your behaviour)
Beck opinion on New Public Health Regime
The Risk Society.
Risk conversation is ironic because modern society has created the risks that we are also trying to protect ourselves from (industrialization, environment pollution)
Goffman
Framing.
Symbolic Interactionism - how people make meaning of social like and use that to decide what to do.
Dramaturgic Model - social life is like a play. People behave differently when they are onstage.
Frames
Culturally share, socially specific schemata.
Organize experience
Provide context and meaning
Multiple frames for the same action.
How do social movements use frames
To mobilize support.
Rhetoric used contributes to the way we perceive the cause.
Frame as unjust, worth or sympathy, something that affects us all;
Frame of the breast cancer movement
- Promotes a fight, strength ec
- Reinforce traditional femininity, status quo (makes it feel less threatening)
- Framing of the ideal breast cancer patient: positive, volunteer, feminine. Those who don’t conform are ostracized.
Define a social problem
An alleged situation that is incompatible with the values of a significant number of people who agree that action is needed to alter the situation.
Framing and social problems
Framing is used to decide what is and isn’t a social problem.
For there to be a problem, there has to be a moral judgement. Has to be seen as a problem by a number of people who social power.
Problematization
The process we go through that decided that something is a problem
Agenda Setting
Pain journals were covering OxyContin as an addicting substance before addictions journals were. Addictions journals picked up coverage following high profile media coverage of the drug with addiction of crime, so the media set the AGENDA for the addictions journal.
Who did the news blame for the OxyContin crisis?
Criminals Addicts/Dealers Overprescribing physicians Purdue Users Youth
Who sis experts and advocates blame for the OxyContin Crisis?
Newspaper/media Law Enforcement Government Criminals Medical Colleges Prescribers/doctors Set-Up of Health Care Culture of opiphobia Anti-Oxy activists Purdue
Effects of the OxyContin Crisis on pain medicine
- Greater threat of regulation from colleges (Physicians fear criminal prosecution)
- Fewer willing prescribers who then face more demand
- More research for alternative drugs
- More press
- More self-regulation, standardization, risk management and patient monitoring.
Effects of OxyContin Crisis on pain patients
- Consistently negative
- Less access to one major line of treatment
- Longer waits
- Increasing health insurance costs
- Fear of Crine
- Fear of labeling
OxyNEO
The replacement for OxyContin made by purdue that is tamper resistant and patent protected, but very expensive
Pharma industry impact on health care costs
Expenditure on drugs in Canada are rising and this lines up with increase in medical spending (now on par with cost of doctors)
How does the pharma industry control information about drugs? (4)
- Funding Medical Research (Ghostwriting, bias, ties to major medical and research organizations, who else will fund)
- Funding conferences and continuing medical education
- Educational materials for doctors and patients (Direct mailing, detailing, CPS)
- Advertising (medical journals, direct-to-consumer advertising)
Regulation of the drug industry in canada
By the Health Protection Branch - responsible for approving drugs for prescription. Troubling relat with pharma
Globalization
The fact and/or perception that nations, businesses and people are becoming more connected and interdependent across the globe.
Affects health by enhancing spread of disease.
Effects of globalization, trade and inequality on health (3)
- Increased spread of disease
- Reduced public health funding
- Reduced ability of governments to enforce public health measures or resist corporate actions.
NAFTA
Agreement for patent protection on brand name drugs.
Give monopoly;
Generic power drops and health care costs rise;
What is evidence based medicine?
Integrating individual clinical expertise with the best available external clinical evidence from research.
Types of evidence strongest to weakest
Randomized controlled trial
systematic review
observational studies
unsystematic clinical observation
What are observational studies?
Effects of treatment therapies are studied between groups of patients where the clinician has not randomly selected them
Criticisms of EBM (3)
Our experiments in treatment are accepted but wouldn’t be accepted by science standards - scientism.
Questioning medical authority - moral judgement, do different things
Reform of medical education
Questioning medical authority
Sudnow showed that pronouncing dead depended entirely on the doctor’s moral perception of the patient;
Wennberg and Gittelsohn showed regional variations;
Fletcher, Fletcher, Wagner published first text for med students questioning the knowledge of their teachers;
Reforming medical education
We need to fuse traditional methodologies of clinical medicine and epidemiology so we need to teach epidemiology and biostatistics in med student training.
Reorganization of the hospital.
Clinical Practice Guidelines
Weisz said that they changed the method of regulating the quality of medical care;
Changes in governance and professional norms as well as in the conventions of medical practice;
Different colleges endorse different guidelines;
Deresponsibilization
Judgments of individual clinicians must be externalized through guidelines that can be successfully regulated;
Physicians need not assess evidence, just guidelines;
Colleges use guidelines to make judgements when complaints are made;
Undermines EBM;
What led to the reform of medical education
Prolematization of various medical uncertainties in clinical practice led tot he reform of medical education, rendering medical judgements amenable to intervention;
What is social control
Means for the preservation of social order;
Customs, mores, values; Use shame, guilt, exclusion, criticism to regulate people;
How people respond to unacceptable behaviour;
How people try to manage, prevent or reduce unacceptable behaviour;
Surveillance;
What is a drug?
Two common definitions in the West:
1) A medical agent
2) Substance that exerts physiological and psychological effects;
Why do we control drug use? (6)
- Gov revenue
- Ensure purity
- Symbolic control - class distinction
- Cultural/religious virtues
- Protection of public order (there are rules)
- Improve public health (minimize harm)
Means of regulation of drug (4)
- The product (eg size)
- The seller
- The condition of sale (opening hours)
Of the consumer (age)
Drug control phase 1
1850 - early 1900s
Lead up to prohibition;
Many substances illicit today were widely consumed;
Drug use predominantly by white, middle-class early settlers;
Drug control phase 2
1900-1950: Legislation of the morality of health
Start putting out acts to control the consumption of narcotics in USA and opium in Canada;
Forces shaping drug control come in;
Anti-immigration sentiment and reefer madness;
Forces shaping drug control (5)
Second phase of drug control (1900-1950)
- Moral Reform Movement - pure society due to wars
- Child saving - keep them pure and good
- International Pressures (Britain)
- Anti-immigration sentiment
- Drug Ideology - Reefer Madness
Emily Murphy
Write the Black Candle.
Strong political campaigner and moral crusader;
First female judge in British empire;
Linked minority populations with demeaning cartoons;
Themes of degradation of women;
Phase three of drug control
1960s and 1970s
Drug law reform because;
Rise of middle class and youth consumption / white hippies;
LeDain Commission (1972)
Convictions go down, but use goes up and heroine convictions go up;
LeDain Commission
1972
Politicians get together to change drug laws. Agree to decriminalize drugs because it’s costing too much money and not working.
Focus on harm instead.
Very progressive but nothing happened.
Phase 4 of Drug control
1980s - War on Drugs
Indruduction of Crack Cocaine pushed the war
War rhetoric used. Us vs Them.
Ronald Regan in power. Affected Mulroney.
8:1 crack to cocaine possession law.
Elliot
Pharma Industry
White coats, black hats. Ghostwriting, masking flaws, ghostwritten articles that have led to drug crises;
Lextin
Pharma is Profit First.
State handed over the right to say drugs are okay for the market to the pharma companies because it was too expensive, so now we don’t know what drugs are safe.
New drugs not made for rare diseases
Carpenter
Global health and social development of Alma Malta.
WHO and Unicef use neo liberal ideals;
There have been some gains but the health of the poor has gone down since globalization;
KNOWLES
Health is an individual responsibility and if you aren’t taking responsibility for your health you are a burden on the rest of the community and the state;
Credit society;
LEICHTER
Health is a community responsibility. We are making it so only the rich have access to services and yet again excluding the poor from health and access.
No more church to help us deal with sickness so now we are trying not to get sick. Health is secular morality.
Solomon and Green
History of non-medical opiate use and control policies in canada;
Narcotics policy has little to do with the physiological effects of the drug but rather political and moral factors;
Gregg and Saha
Use and misuse of culture in medical education;
Just like lecture. Wanted to get ride of disparities but instead they reinforce stereotypes and racial bias;
Cultural competence used to address all non-culture related disparities in care as well. Tells has that other social issues are issues of culture and not in need of attention on their own;
As long as poor don’t have health care access, bridging culture isn’t the most important way to alleviate health care disparities;
Sunday and Eyles
Diabetes in first nations people;
Control of self=control of diabetes;
First nations face the constraints of purchasing the right food;
Ehrnreich
Cancerland;
Pink culture;
Writing a cheque would be better;
Surgery and mammography make an industry out of the disease. Mammography doesn’t mean you won’t get cancer;
Jones
Relationships between health consumer groups and pharam;
Refusers, acceptors and non-disclosers;
Some groups argue that a relationship is inevitable and can be beneficial to patient and all relationships come with problems;
Weisz
Clinical Practice Guidelines;
Credentials of the doctor no longer taken as sufficient;
Doctors can’t do all lit on their own;
Protect against legal action;
Health care is publicly funded so standardization and transparency is important.
Alan Hunt
Moral regulation and responsibilisation.
Foucaultian;
Moral projects in health regulation - how you change peoples’ ethical subjectivity;
David sudnow
Study showed that being pronounced dead on arrive depended on the doctor’s moral perception of the patient
Wennebern and GIttelsohn
Rsearch documented the regional variations in health care. Differences bt two hospitals in the same city.
