Anne Lie

History Teaches Us That Confronting Antibiotic Resistance Requires Stronger Global Collective Action

Antibiotic development and usage, and antibiotic resistance in particular, are today considered global concerns, simultaneously mandating local and global perspectives and actions. Yet such global considerations have not always been part of antibiotic policy formation, and those who attempt to formulate a globally coordinated response to antibiotic resistance will need to confront a history of heterogeneous, often uncoordinated, and at times conflicting reform efforts, whose legacies remain apparent today. Historical analysis permits us to highlight such entrenched trends and processes, helping to frame contemporary efforts to improve access, conservation and innovation.

Producing standards, producing the Nordic region: antibiotic susceptibility testing, from 1950-1970.

During the 1950s it became apparent that antibiotics could not conquer all microbes, and a series of tests were developed to assess the susceptibility of microbes to antibiotics. This article explores the development and standardization of one such testing procedure which became dominant in the Nordic region, and how the project eventually failed in the late 1970s. The standardization procedures amounted to a comprehensive scheme, standardizing not only the materials used, but also the methods and the interpretation of the results. Focusing on Sweden and Norway in particular, the article shows how this comprehensive standardization procedure accounted for several co-dependent factors and demanded collaboration within and across laboratories. Whereas literature on standardization has focused mostly on how facts and artefacts move within and across laboratories, I argue for the importance of also attending to regions and territories. More particularly, while arguing that the practices, ideals, and politics related to what have been called the “Nordic welfare state” were contributing to the design of the standardized procedure in the laboratory, I also argue that Scandinavia was drawn together as a unified region with and by these very same practices.

‘Working is out of the question’: a qualitative text analysis of medical certificates of disability

BackgroundMedical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients’ health and how they support their conclusions about illness, functioning and fitness for work in medical certificates.MethodsWe performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics.ResultsSome of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert’s subtle use of language implied doubts about the claimant’s credibility, but explicit advocacy also occurred. GPs show little insight into their patients’ working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients’ working capacity, and fail to report thorough assessments.ConclusionsA number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.

Acting by persuasion— values and rhetoric in medical certificates of work incapacity: A qualitative document analysis

When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples’ lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the ‘worthiness’ of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient’s positive character in terms of universally accepted values, called for the reader’s (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers—although they argued for disability benefit—showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient’s advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

Book Reviews: Ole Bang og en Brydningstid i Dansk Medicin.

Morten Skydsgaard’s biography of the Danish physician Ole Bang (1788–1877) is an informative and important book about a period of transition in nineteenth-century Danish medicine. Bang held several of the most significant posts available to physicians in Denmark. He was a professor at the university of Copenhagen, and he was the chief physician at the largest hospital in the capital, Frederik’s Hospital. Among the prominent patients in Bang’s lucrative private practice were the Danish and Russian royal families. Throughout his career he advocated a medicine grounded on careful observation at the bedside. He reformed medical education, putting clinical teaching into practice at the medical faculty. His methods of treatment became influential among Danish medical practitioners, and he was famous for his clinical skills. Bang was also engaged in health politics, and played an important role in the formation of a common curriculum for surgeons and physicians, thus putting an end to a long rivalry between the medical faculty and the surgical academy. During his long and active professional life (he retired in 1874, aged eighty-six), Bang was respected and recognised as one of Denmark’s leading medical figures. However, soon after his death he was branded a reactionary and accused of opposing new ideas, thereby hampering progress in Danish medicine—a view which has been generally accepted in Danish historiography until now. In this carefully researched book a more complicated picture is painted. Skydsgaard confirms that Bang remained faithful throughout his life to the Hippocratic doctrine of vis medicatrix nature, or the healing powers of nature. He believed that the organism did not accept disease passively but counteracted it by trying to rectify the disturbed equilibrium. Nature was, therefore, the best physician, but the human physician could help nature to fulfil its goal by removing obstacles to its action, thus assisting in the organism’s own attempt to recover. Bang employed traditional remedies like purgatives, emetics, diapnoic drugs, sialagogues and bloodletting. However, as Skydsgaard shows, he also participated fully in the new medical debates, and, early in his career particularly, he was a proponent of change in many areas. He introduced the stethoscope to Denmark, and studied in the French style pathological changes of the bowels during typhoid fever. He also engaged in medical meteorology, trying to generate new knowledge about epidemics based on an analysis of meteorological data. Furthermore, he advocated the use of statistics in medicine, and regularly published data on morbidity and mortality from Frederik’s Hospital. Later in life, however, he became sceptical of the increasing technicality of medicine, which, he held, distanced the physician from the patient. Consequently Bang found himself in opposition to younger colleagues, who emphasised the importance of autopsies, microscopy and animal experiments. For him, medicine was centred on the individual, carefully tailored to each patient, whereas for younger doctors objectivity and regularity took precedence over the individual. The most interesting chapter is that in which Skydsgaard analyses this period of change in Danish medicine by looking at how various physicians worked with one single disease—typhoid. He demonstrates well that new and, in retrospect, ‘correct’ ideas do not spread without friction. Also, it allows him to compare treatment methods. Bang’s younger colleagues, more favourably received in Danish historiography due to their introduction of ‘modern’ methods such as microscopy and laboratory tests, basically treated typhoid fever no differently than did Bang himself. Nevertheless, while overall this is a well-constructed and interesting piece of research work, it is not without its flaws. Perhaps most importantly, Skydsgaard’s selection of sources is too limited. He has studied published articles and books, as well as newspapers and letters from the period, but omitted hospital records. It is difficult to understand why this vital primary source of therapeutic data is ignored, and second- and third-hand descriptions of such treatment used instead. Additionally, Skydsgaard is not very comfortable or convincing when it comes to medical philosophy. His discussions of nosology and diagnostics are confusing, perhaps owing to insufficient knowledge of the important change from medical semiotics to medical diagnostics in the early nineteenth century. Finally, this is very much a book about Denmark, and, if more of Bang’s professional life had been placed in an international context, the work would have gained from a wider view. But, despite these flaws, there is no doubt that Skydsgaard has written a well-researched book about this interesting period in Danish medicine.