Medical Humanities Blog

On Chronic Stress, Racism, and Inequities in Adverse Birth Outcomes among Black American Women

Lisa Rosenthal and Marci Lobel (Psychology, Stony Brook) have authored a new article out in Social Science & Medicine entitled Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women.  Here is the Abstract:

The infant mortality rate for Black Americans in the US is more than twice the rate for White Americans, with similar racial disparities existing in rates of low birthweight and preterm delivery. Survivors of these adverse birth outcomes have poorer development and health in infancy, childhood, and adulthood. Increasingly, evidence suggests that maternal stress is an important risk factor for adverse birth outcomes. We offer a novel perspective on racial disparities in birth outcomes suggesting that Black American women are subject to unique sources of stress throughout their lives and particularly during pregnancy based on their multiple identities as women, Black, and pregnant. We draw on interdisciplinary work to examine three unique sources of stress for Black American women that elevate their risk for adverse birth outcomes: 1) abuses of Black American women by the medical system and issues of power in obstetrics that disadvantage Black American women; 2) contradictory societal pressures exerted on Black American women about whether they should have children; and 3) historical and contemporary stereotypes about Black American women related to sexuality and motherhood. We discuss implications of this analysis, including applications to research and intervention. Developing a better understanding of the experience of Black American women during pregnancy and throughout their lives offers insight into ways to reduce racial disparities in adverse birth outcomes and their lifelong consequences.

This article is highly recommended.  The analysis is subtle and penetrating, going several layers deep and bringing together a number of findings from across multiple disciplines to assay the several dimensions that converge to produce such stark inequalities in adverse birth outcomes among African-American women as compared to White American women.  I learned much in reading it.

Off Sick: Narratives of Illness Past and Present

Off Sick; Narratives of Illness Past and Present

Scholars from the universities of Glamorgan and Cardiff are currently breaking new ground in the Medical Humanities with the Off Sick project. This research initiative, led by Dr Martin Willis and Dr Keir Waddington, puts a new twist on the well-known concept of the ‘illness narrative’. It focuses not on the people who actually suffer from illness, but instead on those who support and care for them. In this vein the project team is currently gathering stories from carers across the South Wales area.

This is very much an interdisciplinary project, which aims to explore not only how carers construct and define their experiences through stories in the present day, but also how they did so in previous decades and centuries. Moreover, Off Sick also brings in comparative material from the literary sphere, including fictional accounts, life-writing and poetry.
The peg on which this work is hung is the encounter with ‘medical institutions’. Indeed, the very idea of the illness narrative arose partly in response to a tendency for clinicians to neglect the experiences of the patient, seeing them instead in de-personalized terms as biological problems to be solved with science. Illness narratives are often perceived as a means of reversing this trend and re-empowering the patient.

For that reason, the stories that Off Sick is particularly interested in deal with visits to hospitals and other clinical settings. However, it is the ways in which carers and family members turn their experiences of such encounters into narratives that is the real crux of this research. This emphasis on the stories of those around illness, together with its holistic and comparative approach to contemporary, historical and literary materials, is what makes Off Sick so innovative.

The project’s findings will be showcased through academic presentations and publications, and also through an exhibition (scheduled for June 2011) which is aimed not at academics but at individuals and groups whose lives have been affected by illness and who have their own stories to tell about it. In addition, Off Sick runs a lively, varied and ongoing programme of events and public talks drawing on the expertise of literary scholars, historians, social scientists and medical practitioners.

For more information on the project you can visit the Off Sick website (http://literatureandscience.research.glam.ac.uk/cissmi/offsick/), join the Off Sick Facebook group (http://www.facebook.com/pages/Off-Sick/133055340078848) or follow Off Sick on Twitter (http://twitter.com/OffSick). Alternatively please contact the project’s Research Assistant, Dr Richard Marsden, on rmarsden@glam.ac.uk.

On Relative Priorities in African Bioethics

Jacquineau Azetsop (Faculté de Médécine, Teilhard de Chardin), whose work we have noted here on MH Blog in the past, has an excellent new article out in Developing World Bioethics entitled New Directions in African Bioethics: Ways of Including Public Health Concerns in the Bioethics Agenda.  Here is the Abstract:

Research ethics is the most developed aspect of bioethics in Africa. Most African countries have set up Institutional Review Boards (IRBs) to provide guidelines for research and to comply with international norms. However, bioethics has not been responsive to local needs and values in the rest of the continent. A new direction is needed in African bioethics. This new direction promotes the development of a locally-grounded bioethics, shaped by a dynamic understanding of local cultures and informed by structural and institutional problems that impact the public's health, as well as cognisant of the salient contribution of social sciences and social epidemiology which can bring a lasting impact on African local communities. In today's post-Structural Adjustment Africa, where healthcare has been liberalized and its cost increased, a bioethics agenda that focuses essentially on disease management and clinical work remains blind in the face of a structural marginalization of the masses of poor. Instead, the multidimensional public health crisis, with which most African countries are confronted, calls for a bioethics agenda that focuses primarily, but not exclusively, on health promotion and advocacy. Such an approach to bioethics reckons with the macro-determinants of health and well-being and places clinical and research ethics in the broader context of population's health. The same approach underscores the need to become political, not only by addressing health policymaking processes and procedures, but also by becoming an advocacy forum that includes other constituencies equipped with the potentialities to impact the population's health.

Readers of MH Blog can probably guess that I am cheering all the way through this abstract.  Research ethics and clinical bioethics have their place in developing world bioethics, but the evidence is robust suggesting that attention to the macrosocial determinants of health -- rather than research or clinical care -- is likely to have the greatest impact on ameliorating disease and human suffering in the developing world.  Azetsop is at the vanguard of scholars urging the turn to population-level and public health ethics.

The article is (obviously) highly recommended. 

On the Pharmaceuticalization of Society

Simon J. Williams (Univ. of Warwick), Paul Martin (Univ. of Nottingham) and Jonathan Gabe (Univ. of London) have a new article out in Sociology of Health and Illness entitled The pharmaceuticalisation of society? A framework for analysis.  Here is the Abstract:

Drawing on insights from both medical sociology and science and technology studies this article provides a critical analysis of the nature and status of pharmaceuticalisation in terms of the following key dimensions and dynamics: (i) the redefinition or reconfiguration of health 'problems' as having a pharmaceutical solution; (ii) changing forms of governance; (iii) mediation; (iv) the creation of new techno-social identities and the mobilisation of patient or consumer groups around drugs; (v) the use of drugs for non-medical purposes and the creation of new consumer markets; and, finally, (vi) drug innovation and the colonisation of health futures. Pharmaceuticalisation, we argue, is therefore best viewed in terms of a number of heterogeneous socio-technical processes that operate at multiple macro-levels and micro-levels that are often only partial or incomplete. The article concludes by drawing out some broader conceptual and reflexive issues this raises as to how we might best understand pharmaceuticalisation, based on our analysis, as a framework for future sociological work in this field.

This is an important article, as it suggests a number of issues relevant to what Richard DeGrandpre terms "behaviorial pharmacologism" that are often not centered in current discourse on conflicts of interest.  Namely, while one issue is whether money flowing from pharmaceutical corporations privileges the preference of one drug over another (i.e., brand-name vs. generic), the larger issue for those interested in population health and inequalities is whether the enormous sums of money flowing collectively from the pharmaceutical industry privilege pharmaceutical responses to population health concerns.

While the former has tended to occupy the lion's share of the debate, it is the latter that is of more concern to me for the simple reason that the SDOH evidence base strongly supports the idea that pharmaceuticals simply are not prime determinants of health and its distribution in human populations.  On to the caveats: this is not to say that the concern over privileging one very expensive drug over a less expensive but equally effective drug is unjustified.  This is not to say that pharmaceuticals play no role in shaping health and its distribution in populations.  This is not to say that the relative effect size pharmaceuticals contribute to health is equivalent in the global North and the global South.

This is to say that in both the global North and in the global South, the social epidemiologic evidence strongly suggests that health interventions that focus on whole population approaches to ameliorating upstream and macrosocial pathways to health like income, housing, transportation, stigmatization and discrimination, violence, environment are of much greater relative priority to health and its distribution than pharmaceuticals.  Hence the ethical concern over the pharmaceuticalization of society is a very, very serious one.

Thoughts?

On Priority-Setting, Public Reason, and the Social Determinants of Health

Julianna E. Pesce, Chinwe S. Kpaduwa, and Marion Danis have a fascinating new article out in Social Science & Medicine entitled Deliberation to enhance awareness of and prioritize socioeconomic interventions for health.  Here is the Abstract:

Health disparities are, to a large extent, the result of socio-economic factors that cannot be entirely miti- gated through the health care system. While an array of social services are thought to be necessary to address the social determinants of health, budget constraints, particularly in difficult economic times, limit the availability of such services. It is therefore necessary to prioritize interventions through some fair process. While it might be appropriate to engage in public deliberation to set priorities, doing so requires that the public accept such a deliberative process and appreciate the social determinants of health. We therefore analyzed the results of a study in which groups deliberated to prioritize socio-economic inter- ventions to examinewhether these two requirements can possibly be met and to explore the basis for their priorities. A total of 431 residents of Washington, D.C. with incomes under 200% of the federal poverty threshold participated in43groups toengage in ahypothetical exercise to prioritize interventions designed to ameliorate the social determinants of health within the constraints of a limited budget. Findings from pre- and post-exercise questionnaires demonstrate that the priority setting exercisewas perceived as a fair deliberative process, and that following the deliberation, participants became more likely to agree that a broad number of determinants contribute to their health. Qualitative analysis of the group discussions indicate that participants prioritized interventions that would provide for basic necessities and improve community conditions, while at the same time addressing more macro-structural factors such as home- lessness and unemployment. We conclude that engaging small groups in deliberation about ways to address the social determinants of health can both change participant attitudes and yield informed priorities that might guide public policy aimed at most affordably reducing health disparities.

The article is highly recommended.

Call for Applications: Social Science Position, Medical Humanities and Bioethics Program, Northwestern University

The Medical Humanities and Bioethics Program at Northwestern University's Feinberg School of Medicine invites applications for a full-time tenure-track assistant professorship to begin 1 September 2011. Applicants should have a PhD (or expect it before September) in the social sciences with work relevant to medicine and present evidence of a strong interdisciplinary interest in medical humanities and bioethics, including publication commensurate with experience. Responsibilities include scholarly work of high quality, effective teaching, participation in curricular innovation, and supervision of graduate research. Salary negotiable. Applicants should submit a curriculum vitae, a representative sample of scholarly work, and the names and addresses of three referees.

In order to ensure full consideration, applications must be received by 25 March 2011. Contact Tod Chambers, PhD, Suite 625,750 North Lake Shore Drive, Chicago, IL 60611-2611. Northwestern University is an Affirmative Action, Equal Opportunity Employer. Women and minorities are encouraged to apply. Hiring is contingent upon eligibility to work in the United States.

(h/t ASBH listserv)