Published on January 7, 2008
What is Health?: What is Health? NUR 129 Lecture 2 Lecture outline: Lecture outline Defining health and illness Illness as deviance Illness and stigma Health, illness and medicalization Medical and social models of health Percentage of people describing their health as “not good” (2001 census): Percentage of people describing their health as “not good” (2001 census) Slide4: How would you define ‘health’ and ‘good health’? Definitions of health: Definitions of health 'Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.‘ World Health Organisation: Is this reasonable? Defining illness: Defining illness The modern meaning of the word, used since the late seventeenth century, is used to describe sickness and ill-health, (but its earlier meaning was wickedness, depravity and immorality) Although its meaning has changed, it can still be used in different ways Understanding illness - lay accounts: J. Cornwell (1984) Hard Earned Lives: Understanding illness - lay accounts: J. Cornwell (1984) Hard Earned Lives Interviews with working class families in East London 3 categories of health problems: ‘normal illness’ – e.g. common infectious diseases in childhood, and non-severe infectious diseases in adulthood, as well as fevers and ‘flu. ‘real illness’ – e.g. major and life-threatening diseases, such as cancers, cardiovascular disease and coronary heart disease. ‘health problems which are not illness’ – e.g. problems seen as associated with natural processes, such as ageing and the reproductive cycle, and problems thought to stem from a person’s nature, such as allergies. Illness as deviance: Illness as deviance Deviance as departure from the norm Experiences of illness, and responses to it, can be understood as being an example of deviance – preventing individuals performing normal social roles for example In departing from the norm, some illnesses can also be a source of stigma – why? Illness as a source of stigma (Erving Goffman): Illness as a source of stigma (Erving Goffman) Stigma as 'an undesired different-ness from what we had anticipated' Identifies three main sources of stigma: 'abominations of the body' 'blemishes of individual character' 'the tribal stigma of race, nation and religion'. Erving Goffman 'Stigma: notes on the management of a spoiled identity' ‘Abominations of the body’: ‘Abominations of the body’ Example: experiences of living with psoriasis: ‘Revulsion against one’s body and a feeling of never being really clean’ (man aged 69; psoriasis for 20 years) ‘I have always felt a sense of shame. I feel it most when I look at my body. I try to hide it even from my friends, especially my friends in fact. But the scales make it difficult. It is such a dirty disease’. (woman aged 70; psoriasis for 12 years) From R. Jobling, ‘The experience of psoriasis under treatment’, in R. Anderson & M. Bury (eds) Living with Chronic Illness, 1988. ‘Blemishes of individual character': ‘Blemishes of individual character' Example: early media coverage of HIV/AIDS US GAY BLOOD PLAGUE KILLS THREE IN BRITAIN (The Sun, 8th May 1983) AIDS: WHY MUST THE INNOCENT SUFFER? (Daily Express, 25th September 1985, reporting infection from blood transfusions) 'the tribal stigma of race, nation and religion' : 'the tribal stigma of race, nation and religion' Example: race and mental illness “Many witnesses told us that the black and minority ethnic community have a very real fear of the Mental Health Service. They fear that if they engage with the mental health services they will be locked up for a long time, if not for life, and treated with medication which may eventually kill them. . . Young black men with signs of mental illness frequently, out of fear, do not go to their doctor until their illness is so pronounced that their family and friends can no longer cope with them.” (Independent Inquiry into the death of David Bennett, December 2003) ‘Medicalization’: ‘Medicalization’ Several conditions, particularly chronic conditions, have generated efforts to secure medical acceptance and recognition as an ‘illness’ – e.g. CFS/ME, RSI But since the 1960’s some writers have argued that modern medicine has become inappropriately involved in non-medical aspects of life Erving Zola on medicalization: Erving Zola on medicalization “By the very acceptance of a specific behaviour as an ‘illness’ and the definition of illness as an undesirable state, the issue becomes not whether to deal with a particular problem, but how and when.” Zola, I. (1972) Medicine as an Institution of Social Control An example: sexuality: An example: sexuality “homosexuals, formerly considered to be sinners, were labelled as ill – not bad, but mad. Commitments to mental institutions, hormonal treatments, and castrations were used to deal with unwanted sexual behaviour. . . Treatments for homosexual men – such as aversion therapy – continued until, and beyond, 1973, when the American Psychiatric Association redesignated homosexuality as non-pathological.” Hart, G. & Wellings, K. (2002) Sexual behaviour and its medicalisation: in sickness and in health British Medical Journal 324: 896-9000. How do you react to this example of medical intervention?: How do you react to this example of medical intervention? A surgeon who amputated the healthy limbs from two psychologically disturbed men at their request said yesterday that he saw nothing wrong with his actions. Robert Smith cut off the lower limbs of two patients during private operations at Falkirk and District Infirmary. The two men were suffering from an extremely rare form of body dysmorphic disorder known as apotemnophilia. Those suffering from the disease have an obsessive belief that their body is “incomplete” with four limbs and will only be complete after amputation. Slide17: “My fear is that someone will injure themselves or kill themselves” he said. “I have very serious concerns that they will go to an unlicensed practitioner or take the law into their own hands and lie down on a railway line or take a shotgun.” Mr Smith’s patients, who he said were severely disabled by their disorder, had rigorous psychological and psychiatric evaluations before their operations. The Guardian, 1st February 2000 Do you respond any differently to this example?: Do you respond any differently to this example? In 1998 three transsexuals successfully claimed in the High Court that their Health Authority had wrongly refused them gender reassignment surgery. The three, living as women, objected to the fact that the health authority had introduced a ‘blanket ban’ on the operation, as a result of which they were in an “acutely distressed mental and physical state”. Their barrister told the court that the health authority had decided they should receive counselling to reconcile them with their biological condition but this, he said, only added to their distress. (Ward, D. 1998 Three seek right to sex change operation funded by the NHS The Guardian 10.11.98, p4) “A recognized illness”: “A recognized illness” In his ruling, the judge concluded that the health authority’s decision to refuse the operation was “unlawful and irrational”. The decision was taken, he added, without consideration of, “the proper treatment of a recognised illness.” Wilson, J. 1998 Sex-change trio win NHS test case The Guardian 22.12.98 Medicalizing emotions?: Medicalizing emotions? Medicalizing relationships?: Medicalizing relationships? A 1999 article in the Journal of the American Medical Association reported a study of 1500 women aged 18-59 showing that 43% experienced “sexual dysfunction” Further analysis showed this figure included all who reported any one of seven experiences in the preceding twelve months, including a lack of desire for sex and anxieties about performance – and two of the report’s authors had connections with Pfizer (Moynihan, R., 2003, British Medical Journal, 326: 45-47). Medical model of health: Medical model of health Health is predominantly viewed as the absence of disease Health services are geared mainly towards treating sick and disabled people High value is put on provision of specialist medical services Doctors and other qualified experts diagnose illness and disease and sanction the ‘sick role’ Health services engage in remedial or curative work The medical model (contd): The medical model (contd) Disease and sickness explained within a biological framework emphasising physical nature of disease A pathogenic focus (emphasising abnormality and normality) High value put on scientific methods and knowledge – less on qualitative evidence Jones, L. (1994) The Social Context of Health & Health Work Social model of health: Social model of health Instead of emphasis on biological aspects of disease, focuses on environmental, social and economic causes Interest in lifestyle and the interaction between individuals and their environment This creates a different focus – e.g. poor housing, environmental pollution, etc., rather than role of pathogens Social model (contd): Social model (contd) More emphasis upon health promotion, rather than relying on treatment Less emphasis upon the exclusive role of medicine and experts in dealing with disease – attention to the role of self-help and community activity More attention given to issues such as health inequalities Lay and medical ideas about health and illness: Lay and medical ideas about health and illness “Medical definitions are thought to be based on universal and generalizable knowledge in scientific terms, whereas lay definitions are thought to be unscientific and based on individual experience” (Earle, 2006: 49) But lay definitions also seem to be organized: Do not mimic medical views Logical and coherent Biographical (based on experience) Culturally framed within systems of belief (Williams & Popay, 1994) Communication, health and illness: Communication, health and illness What effect do different ways of thinking about health and illness have upon communication between professionals and patients? In what ways are traditional relationships between professionals and patients changing? Focus for next lecture . . .