Michael Bury

Illness narratives: fact or fiction?

There is currently considerable renewed interest in narrative analysis in the humanities, social sciences and medicine. Illness narratives, particularly those of patients or lay people, are a particular focus in health related settings. This paper discusses the background to this interest, especially its roots in critiques of medical dominance and distinctions between disease and illness, drawn by sociologists and anthropologists in the 1970s. The current emphasis on patient or personal narratives can also be seen to stem from changes in morbidity patterns, the expansion of information about disease and illness, and in public debates about the effectiveness of medicine. The paper then goes on to outline a framework for analysing illness narratives. This involves exploring three types of narrative form: ‘contingent narratives’ which address beliefs about the origins of disease, the proximate causes of an illness episode, and the immediate effects of illness on everyday life; ‘moral narratives’ that provide accounts of (and help to constitute) changes between the person, the illness and social identity, and which help to (re) establish the moral status of the individual or help maintain social distance; and ‘core narratives’ that reveal connections between the lay person’s experiences and deeper cultural levels of meaning attached to suffering and illness. Here, distinctions are drawn between such sub forms as heroic, tragic, ironic and comic, and regressive/progressive narratives. Finally, the paper discusses some of the methodological issues raised by narrative analysis. Given the complex character of illness narratives, their social and psychological functions, together with the motivational issues to which they relate, it is suggested that they constitute a major challenge for sociological analysis. From this viewpoint current claims about narrative analysis in medicine need to be treated with caution.

Health and illness in a changing society

Introduction: Health, Illness and Sociology 1. From Illness Behaviour to Health Beliefs and Knowledge 2. Inequalities in Health 3. Doctors, Patients and Interaction in Health Care 4. Chronic Illness and Disability 5. Death and Dying 6. The Body, Health and Risk.

The Sociology of the health service

Introduction Jonathan Gabe, Michael Calnan, and Michael Bury 1. Medical Sociology and Health Policy: an Historical Overview Margaret Stacey 2. Privatisation in the British Health Service: a Challenge to the NHS John Mohan 3. The Politics of Professional Power: Medicine in a Changing Health Service Mary Ann Elston 4. Health Service Management - A Sociological View Griffiths and the Non-Negotiated Order of the Hospital David Cox 5. Evaluating the Outcomes of Health Care Angela Coulter 6. Recent Developments in General Practice: a Sociological Analysis Michael Calnan and Jonathan Gabe 7. Knowledge and Control in Health Promotion: a Test Case for Social Policy and Social Theory Alan Beattie 8. The Confused Boundaries of Community Care Hilary Land 9. The Agenda for Sociological Health Policy Research for the 1990s Margot Jefferys

Impairment, disability and handicap in chronic respiratory illness

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. 92 patients suffering from COAD were interviewed in order to assess impairment, disability and handicap. Measures included spirometric tests of lung function; the Fletcher breathlessness grading scale, the oxygen cost diagram and a visual analogue scale of dyspnoea; the Functional Limitations Profile (FLP); and the shortened 12 item General Health Questionnaire (GHQ-12), supplemented by the 7-item GHQ sub-scales of anxiety and severe depression. Low correlations were found between lung function and disability (-0.38, P less than 0.001), accounting for only 14% of the variance, and high correlations were found to exist between measures of dyspnoea and disability (-0.90, P less than 0.001). Major areas of disability and handicap included; household management, ambulation, sleep and rest, recreation and pastimes and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper goes on to discuss both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families and for a complementary social perspective and approach to COAD and its treatment.

Living with asthma: the experiences of young people at home and at school

This study is concerned with how young people with moderate to severe asthma live with and explain the disorder and manage the resulting symptoms. Based on in-depth interviews with 55 young people aged 11-16 living in West London, it shows that asthma restricted their lives at school and recreationally but that they were actively involved with their condition and its management. The study reveals that while prescribed medicines in the form of inhalers were used as the primary means of coping with asthma episodes, the young people were concerned about being dependent on such medicines, in line with more general ambivalence in late modern cultures about the long term use of prescribed medicines. It also demonstrates how social relations in particular contexts help to determine the extent to which asthma episodes can be managed.

Tranquillisers as a social problem

This paper attempts to highlight the value of the ‘social problem’ perspective for the sociology of health and illness by applying it to the issue of tranquilliser use and dependence. The approach involves focusing on the emergence of benzodiazepine tranquilliser dependence as a social problem and the extent to which it has been legitimated by the media and by the state. In the conclusion we draw out the implications of our case study for the development of a ‘natural history’ of social problems.

Researching patient–professional interactions

This paper explores the nature and future of social research on patient-professional interactions. It first sketches the historical background to such research and notes that in the UK and US this was characterised by a focus on the doctor-patient relationship. This research embodied a sceptical view of the power of the medical profession in sustaining and promoting social inequalities, and a critique of ‘medical dominance’ over other health care professionals and patients. The paper then goes on to outline changes occurring in the nature of professional practice that suggest a fundamental shift in the social relations of health care and the role of medicine. These include a putative loss of public confidence in the medical profession and the authority of science, an increased role of the media in informing patients, and a change in the states relationship with health care professionals. Finally, the paper outlines some items for a future research agenda, including the need to understand better patient preferences about changes in health care delivery, including a willingness to engage in ‘partnership’, and the possibilities and barriers to change in professional practice.

Halcion Nights: A Sociological Account of a Medical Controversy

This paper offers an analysis of the events surrounding the suspension of the licence for the widely used sleeping tablet Halcion (triazolam) by the British Licensing Authority in October 1991. It is argued that these events highlight a growing crisis in modern medical treatments and in the social relations of health care. This is illustrated by focusing on four elements which have contributed to Halcion becoming a public issue and to its suspension and subsequent banning, namely the claims-making activities of medical experts, the development of legal challenges to medicine, the role of the media and the response of the state.

The ICIDH: A review of research and prospects

This paper reviews developments in thinking about disablement, especially in response to publication of the ICIDH and from the perspective of a sociologist. The background was provided by changes in perceptions of illness and its consequences, following the emergent predominance of chronic disorders and an ageing population. The ICIDH set out to organize concepts relevant to disablement in response to these alterations. Difficulties have been encountered on two planes--conceptual issues and measurement issues--and these are both discussed briefly. The hazard in future research lies in attempts to avoid the problems, particularly by focusing on disability to the neglect of handicap. It is argued that handicap must be central to developments in disablement research and in rehabilitation.

'Breathtaking': the consequences of chronic respiratory disorder.

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. This paper reports on 92 patients suffering from COAD, who were interviewed in order to assess impairment, disability and handicap, and a smaller subsample of 24 of these patients who were followed-up using open-ended, semi-structured, tape-recorded interviews in order to cover in more detail some of the issues raised in the first quantitative stage of the study. Low correlations were found between lung function and disability (-0.38 p less than 0.001), accounting for only 14% of the variance, and high correlations between measures of dyspnoea and disability (-0.90 p less than 0.001). Major areas of disability and handicap included: household management, ambulation, sleep and rest, recreation and pastimes, and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper then attempts to explore the relationship between impairment, disability and handicap, drawing on both the quantitative and qualitative data collected in order to illustrate the variable nature of this relationship. The paper concludes by suggesting both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families, and for a complementary social perspective and approach to COAD and its treatment.