Howard Waitzkin

Consumerism in medicine : challenging physician authority

Chapter One Power and Health Chapter Two Legitimative Power Chapter Three Gathering the Evidence Chapter Four The Realities of Public Challenge and Physician Responses Chapter Five Reasons Why -- The Public Chapter Six Reasons Why -- The Physicians Chapter Seven Consumerism and Physician Utilization Chapter Eight Identifying Consumerisms Effects Chapter Nine Consumerism in Medicine References Appendices

Economic crisis, restrictive policies, and the population's health and health care: The Greek case

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a populations well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Healths total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greeces population health to further risks.

Information control and the micropolitics of health care: Summary of an ongoing research project☆

Abstract Policy changes suggested by “macro” research on the medical care system will not in themselves correct critical gaps and misunderstandings that persist at the “micro” level of the doctor-patient relationship. This paper presents a summary of an ongoing research project concerning one element of this relationship—the doctors communication of information about illness to the patient. Information transmittal is closely related to the clinical problems of history taking, medical records, compliance, satisfaction, physiologic response to therapy and patient delay in reporting symptoms. The sociological considerations guiding the research are summarized under four headings: (1) the problems of uncertainty and power; (2) the definition of information; (3) sociolinguistics and the diffidence of the sick poor; and (4) ethnomethodology and common-sense constructs. The doctor-patient relationship is viewed as a micropolitical situation, in which information control is used, at least in part, to maintain patterns of dominance and subordination. The over-all methodological objective of the research project is to develop a research design, linked to these sociological perspectives, which allows reproducible and generalizable conclusions about the informative process in a variety of clinical settings. Based on a pre-test,a multivariate model has been operationalized; an association is hypothesized between transmitted information—the dependent variable—and several independent variable, which are classified as physician characteristics, patient characteristics, and situational characteristics. The measures of the dependent and independent variables, sampling procedures, and approach to data analysis are described. Questionnaire materials are presented in appendices.

The Social Origins of Illness: A Neglected History:

Although interest in the social origins of illness has grown recently, the sources of this concern in Marxist thought have received little attention. Friedrich Engels, Rudolf Virchow, and Salvador Allende made important early contributions to this field. Engels analyzed features of the workplace and environment that caused disability and early death for the British working class. Virchows studies in “social medicine” and infectious diseases called for social change as a solution to medical problems. Allende traced poor health to class oppression, economic underdevelopment, and imperialism. These analysts provided divergent, though complementary, views of social etiology, multifactorial causation, the methodology of dialectic materialism, an activist role for medical scientists and practitioners, social epidemiology, health policy, and strategies of sociomedical change. The social origins of illness remain with us and reveal the scope of reconstruction needed for meaningful solutions.

Medicine, superstructure and micropolitics.

Abstract How are macro-level structures of domination and oppression reproduced in the everyday micro-level interaction of individuals? This paper examines this theoretical problem through observations of doctor-patient encounters. A review of recent theoretical advances leads to the proposition that face-to-face interaction between health professionals and clients helps maintain broad patterns of ideology and social control. A theory is proposed that links professional-client interaction with ideology and consciousness, social institutions, social relationships of daily life, and the material conditions and class relationships of the workplace and economic system. Quantitative data from an empirical study of doctor-patient interaction are analyzed with reference to this theory. Qualitative analysis from the same study reveals themes of ideologic reproduction and social control concerning relations of production, class relations, the role of science under capitalism, and medical control of everyday life. Counterhegemonic strategy suggested by this work includes challenging the assumed objectivity of medical science, clarifying the partly political nature of messages that clients receive from professionals, and working against domination based on expert knowledge.

Prevalence and Correlates of Mental Disorders Among Native American Women in Primary Care

OBJECTIVES We examined the lifetime and the past-year prevalence and correlates of common mental disorders among American Indian and Alaska Native women who presented for primary care. METHODS We screened 489 consecutively presenting female primary care patients aged 18 through 45 years with the General Health Questionnaire, 12-item version. A subsample (n = 234) completed the Composite International Diagnostic Interview. We examined associations between psychiatric disorders and sociodemographic variables, boarding school attendance, and psychopathology in the family of origin. RESULTS The study participants had high rates of alcohol use disorders, anxiety disorders, and anxiety/depression comorbidity compared with other samples of non-American Indian/Alaska Native women in primary care settings. CONCLUSIONS There is a need for culturally appropriate mental health treatments and preventive services.

Ethics in Public Health Research: Global Trade and Public Health

Global trade and international trade agreements have transformed the capacity of governments to monitor and to protect public health, to regulate occupational and environmental health conditions and food products, and to ensure affordable access to medications. Proposals under negotiation for the World Trade Organizations General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement cover a wide range of health services, health facilities, clinician licensing, water and sanitation services, and tobacco and alcohol distribution services. Public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date.

Medicina social latinoamericana: aportes y desafíos

This piece presents and analyzes a number of issues related to social medicine: the context of the emergence of social medicine; the differences between social medicine and public health; the theories, methods, and debates in social medicine; the main subjects or problems considered in social medicine; and the difficulties of disseminating the concepts of social medicine among English-speaking persons and among medical and public health professionals in general. Latin American social medicine has challenged other views by contributing to an understanding of the determinants of the health-disease-health care process and by using theories, methods, and techniques that are little known in the field of public health. Introducing Latin American social medicine, especially among English speakers, will be difficult due to the conceptual complexity of this field for persons who are accustomed to the theoretical framework of public health and medicine and also due to skepticism concerning research coming from the Third World. A multidisciplinary team is facing this challenge through two primary initiatives: 1) the creation of an Internet portal and database where there are structured abstracts in English, Portuguese, and Spanish of books, book chapters, and articles on social medicine and 2) the electronic publication of two journals on Latin American social medicine.

Safety-Net Institutions Buffer the Impact of Medicaid Managed Care: A Multi-Method Assessment in a Rural State

OBJECTIVES This project used a long-term, multi-method approach to study the impact of Medicaid managed care. METHODS Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. RESULTS After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. CONCLUSIONS In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured.

Report of the WHO Commission on Macroeconomics and Health: a summary and critique

1culminates a series of WHO projects on economic issues in health policy, health services, and public health. A focus on economic development and productivity partly indicates increased funding of WHO activities by the World Bank. Many of the conceptual and methodological approaches discussed in the report mirror those of the World Bank (panel 1). 1–3