David Coburn

Income inequality, social cohesion and the health status of populations: the role of neo-liberalism

There has been a recent upsurge of interest in the relationship between income inequality and health within nations and between nations. On the latter topic Wilkinson and others believe that, in the advanced capitalist countries, higher income inequality leads to lowered social cohesion which in turn produces poorer health status. I argue that, despite a by-now voluminous literature, not enough attention has been paid to the social context of income inequality--health relationships or to the causes of income inequality itself. In this paper I contend that there is a particular affinity between neo-liberal (market-oriented) political doctrines, income inequality and lowered social cohesion. Neo-liberalism, it is argued, produces both higher income inequality and lowered social cohesion. Part of the negative effect of neo-liberalism on health status is due to its undermining of the welfare state. The welfare state may have direct effects on health as well as being one of the underlying structural causes of social cohesion. The rise of neo-liberalism and the decline of the welfare state are themselves tied to globalization and the changing class structures of the advanced capitalist societies. More attention should be paid to understanding the causes of income inequalities and not just to its effects because income inequalities are neither necessary nor inevitable. Moreover, understanding the contextual causes of inequality may also influence our notion of the causal pathways involved in inequality-health status relationships (and vice versa).

A Library of Yeast Transcription Factor Motifs Reveals a Widespread Function for Rsc3 in Targeting Nucleosome Exclusion at Promoters

The sequence specificity of DNA-binding proteins is the primary mechanism by which the cell recognizes genomic features. Here, we describe systematic determination of yeast transcription factor DNA-binding specificities. We obtained binding specificities for 112 DNA-binding proteins representing 19 distinct structural classes. One-third of the binding specificities have not been previously reported. Several binding sequences have striking genomic distributions relative to transcription start sites, supporting their biological relevance and suggesting a role in promoter architecture. Among these are Rsc3 binding sequences, containing the core CGCG, which are found preferentially approximately 100 bp upstream of transcription start sites. Mutation of RSC3 results in a dramatic increase in nucleosome occupancy in hundreds of proximal promoters containing a Rsc3 binding element, but has little impact on promoters lacking Rsc3 binding sequences, indicating that Rsc3 plays a broad role in targeting nucleosome exclusion at yeast promoters.

Medical dominance then and now: critical reflections

Abstract The publication of Evan Willis’ notable book coincided with the appearance of similar Anglo-American accounts. Now, there are retrospectives on medical power. Why then and why now? Professional power was central because health care was the focus of political discussion at the time but is now less important vis-a-vis political struggles over neo-liberalism. Freidson played a key role in bringing medical power into focus. Medicine is also less sociologically prominent now because it is in fact less powerful than it was. There is a convergence between the power of the traditional professions and that of numerous other expert occupations. Despite assumptions to the contrary it is noted that neither the linkages of knowledge/expertise/power nor the existence of putatively self-regulatory organizations is sufficient to ensure professional dominance or control. Closure theory, the pre-eminent approach in the area of the professions, cannot adequately explain these changes in medical power. Rather, both challenges to medical power and the changing salience of medical dominance within sociology can be illuminated using the type of political economy approach which Evan Willis helped to pioneer.

Population Health in Canada: A Brief Critique

An internationally influential model of population health was developed in Canada in the 1990s, shifting the research agenda beyond health care to the social and economic determinants of health. While agreeing that health has important social determinants, the authors believe that this model has serious shortcomings; they critique the model by focusing on its hidden assumptions. Assumptions about how knowledge is produced and an implicit interest group perspective exclude the sociopolitical and class contexts that shape interest group power and citizen health. Overly rationalist assumptions about change understate the role of agency. The authors review the policy and practice implications of the Canadian population health model and point to alternative ways of viewing the determinants of health.

The Development of Canadian Nursing: Professionalization and Proletarianization

In this article, the development of nursing in Canada is described in terms of three major time periods: the emergence of lay nursing, including organization and registration, 1870–1930; the move to the hospital, 1930–1950; and unionization and the routinization of health care, 1950 to the present. This development is viewed in the light of the orienting concepts of professionalization, proletarianization, and medical dominance (and gender analysis). This historical trajectory of nursing shows an increasing occupational autonomy but continuing struggles over control of the labor process. Nursing is now using theory, organizational changes in health care, and credentialism to help make nursing “separate from but equal to” medicine and to gain control over the day-to-day work of the nurse. Nursing can thus be viewed as undergoing processes of both professionalization and proletarianization. As nursing seeks to control the labor process, its occupational conflicts are joined to the class struggle of white-collar workers in general. Analysis of nursing indicates the problems involved in sorting out the meaning of concepts that are relevant to occupational or class analysis but which focus on the same empirical phenomenon.

Job Alienation and Well-Being

This paper analyzes the relationships between alienation conceived as monotonous, repetitive work and alienation as job-worker incongruence to a variety of measures of worker well-being among a population of workers from Victoria, British Columbia. The data show weak relationships between work perceived as monotonous and general psychological and physical well-being and between alienation as job-worker incongruence and health. While weak in variance-explained terms, the relationships show the predicted patterns are robust and are independent of a large number of control variables. Percentage differences in well-being between the alienated and nonalienated workers are fairly substantial. Some societal implications of the findings are discussed.

Freidson Then and Now: An “Internalist” Critique of Freidson's Past and Present Views of the Medical Profession

Freidson is a foremost analyst of the medical profession. Most recently Freidson attacks those who claim that medicine is declining in power. He insists that medicine has not lost the core elements that make it a powerful, indeed, the dominant, health profession. The author compares Freidsons early writings on medicine with his most recent ones, and shows that there are critical confusions in Freidsons central concepts of professional autonomy and dominance. This difficulty is illuminated by viewing dominance, autonomy, and subordination as on a continuum of control. Using this continuum, the author argues that Freidson implicitly admits what he set out to deny (that medicine has not declined in power) by shifting his focus from medical dominance to that of autonomy. Freidson also now rejects valid parts of his earlier work (that which emphasizes social structural determinants of behavior over socialization). In equating medicine in the United States with teaching in that country, Freidsons contention of “little change in medical power” meets its own refutation. Finally, despite his derogation of others, Freidsons lack of an adequate framework to explain the dynamics and not simply the structure of health care produces purely normative, Utopian (and unhelpful) policy recommendations.

Work and General Psychological and Physical Well-Being

This article describes a study of the influence of job factors (e.g. job control, pay, etc.) on job attitudes (satisfaction, alienation, stress) as well as the joint influence of job factors and job attitudes on general psychological and physical well-being. Satisfaction/alienation and felt stress were found to be two different modes of response to work. Prestige, control, variety, and opportunity for promotion were powerful predictors of satisfaction/alienation. Number of deadlines and job overlap with family life were important predictors of stress. The job factors and job attitudes showed substantively important relationships to general well-being. The testing of various alternate hypotheses supported the inference of a causal work-health link. Implications of the findings are that work must be viewed in a wider context than simply as a form of economic activity if the well-being of the population is to be improved and that a focus on individual “life-styles” as causes of lowered well-being leads to neglect of the underlying social structural bases of dis-ease.

Phases of capitalism, welfare states, medical dominance, and health care in Ontario.

There has been a lacuna in previous studies of medicine and health care of concepts or structures relating changes in health care with their contextualizing social structures. That is, there is a need to more adequately account for health care and social structure in terms of dynamic rather than static concepts. This article reports the application of a general schema outlining the transformation of capitalism through the phases of entrepreneurial, monopoly, and global capitalism, first presented by Ross and Trachte, to help understand both the changing role of medicine in Canada and the historical trajectory of the development of health insurance. These related events are shown to be partly reflective of the transformed class dynamics involved in a changing capitalist mode of production. The recent history of challenges to medicare in Canada as well as evidence of the declining power of medicine are both related directly and indirectly to the increased power of business and the decline in the relative autonomy of the state accompanying globalization. The application of the phases of capitalism sequence does roughly fit the Canadian instance although some modifications will be required to account for the specifics of the Canadian case. The schema also helps resolve two previously competing class arguments about the rise of health insurance in Canada.

Health inequalities: a response to Scambler

Scambler presents an interesting selective review of the health inequalities literature. I leave to others a critique of his explanatory model. I focus, rather, on his main point: that the basic social structural and political determinants of health inequalities have been neglected. Health inequalities in the developed nations require contextualisation. Today we are faced with a famine in East Africa, not the first, and, unfortunately I believe, not the last. We also live in a world of immense contrasts in wealth and in health between and within nations. While there are high relative inequalities in both wealthy and poor nations, the largest absolute health inequalities occur in the poorer countries. Moreover, in OECD nations SES differences explain only a part of the variance in total health inequalities.