Content:

In the last entry I examined some applications of WPR that highlight the need to consider underlying presuppositions and “field assumptions” in medical practices – to make explicit what is implicit in clinical medicine – and their “broader implications” (de Vries 2002: 161). I continue this analysis here (see also Research Hub entry 31 May 2020 on “field assumptions”).

The work by Illife and Manthorpe (2018) on “dementia-friendly cities” picks up themes introduced in the preceding entry. They draw on WPR to analyse proposals for “dementia-friendly cities” in the UK – with links to the movement for “age-friendly cities”. They point out how these proposals appear to be informed by a social rather than a biomedical view of “ill health” but they are concerned about the limited nature of the proposals offered. In particular they note that the narrative does not incorporate a sensitivity to inequalities and hence stands to increase them (see Table 1 and page 8). Beyond this limitation in the proposals, they want to emphasize the need to probe underlying circumstances that harm all people, such as pollution, rather than constituting dementia as a disability (Iliffe and Manthrope 2018: 11; see discussion on models of disability in Murano 2020 and on social flesh in Beasley and Bacchi 2007 in preceding entry).

Ijaz (2020) draws on WPR to examine conceptions of risk in the Ontario (Canada) government’s 2006 Regulated Health Professions Act (RHPA), “under which the province’s homeopaths would ultimately be regulated in 2015”. Her analysis emphasizes that “While the RHPA is an epistemically-inclusive piece of legislation that governs biomedically-trained providers as well as T&CM (traditional and complementary medicine) professionals (e.g., Chinese medicine practitioners, naturopaths)”, the legislation is not epistemically neutral, with biomedical epistemology constituted as normative (Ijaz 2020: 8). Risk conceptions in conventional biomedicine, argues Ijaz, are substantially rooted in principles of scientific materialism, echoing the implicit biomedical underpinnings evident in Ontario’s broader legislative context, and sit in contrast to the vitalist principles of many T&CM systems.

Ijaz (2020: 3) elaborates that “scientific materialism” relies upon a mechanistic “epistemic construct of the human organism” as an “essentially physical entity”. In contrast, “Vitalist epistemologies generally hold that a ‘vital’ or functional living principle underpins and interacts with the material structures of living systems (including human beings)”. She makes the case that vitalist explanatory models may incorporate “mechanistic observations (about risk and otherwise)”, while a scientific materialist stance by definition excludes vitalist perspectives. Importantly, homeopathy-specific risk conceptions extend “beyond materialist constructions of adverse events and clinical omission to address potential harms from homeopathic ‘proving symptoms’, ‘aggravation’ and ‘disruption’”, considerations omitted in the risk management strategies ultimately mandated for practitioners. It follows that “to optimally preserve patient safety”, regulators need to actively “negotiate paradigm-specific conceptions [of risk] from both biomedicine and the occupation under governance”.

The notion of “paradigm-specific risk conceptions” opens up the topic of risk in medical practice in innovative ways. It reminds us: first, to notice how we are governed through categories of “risk” (Bacchi 2009: 63); and, second, to pay heed to incommensurable epistemic principles in the model of medicine we take for granted as “truth”. Both of these topics could be explored productively in relation to COVID-19.

Alongside WPR’s emphasis on the “embedded knowledges” in medical practices that constitute what is produced as “real” and “true” there is a commitment to consider the implications (or effects) of these modes of rule (see discussion in Research Hub entry 31 May 2020). Here we look at research that highlights the subjectification effects of policy affecting medical practices. Subjectification, as discussed elsewhere (Bacchi and Goodwin 2016: 49-53), challenges the view that policies simply act upon self-contained subjects. Instead it looks to the processes by which subjects are produced as particular types of subject by governmental problematizations. In this view, the “subject” is “an effect of politics, always in process” (Bacchi and Goodwin 2016: 49).

Cui, Lancaster and Newman (2019) look specifically at how select pieces of mental health policy in Hong Kong, China, and in New South Wales (NSW), Australia, produce mental health “subjects”. Illustrating the benefits of employing WPR in comparative analyses (Bacchi 2012: 6), they find that, while both policies constituted subjects as “unwell individuals”, “subjectivities were shaped by distinctive cultural and socio-political contexts” (2019: 740). In Hong Kong, subjects were constituted as “patientised” individuals, “encouraged to depend on professionals” to help them reintegrate into the “normal” community. In contrast, in New South Wales mental health subjects are produced as “traumatised” individuals “expected to take responsibility to guide the delivery of mental health care and respected as a part of diversity in community settings”. The strong emphasis on consumer choice and individual responsibility in NSW signals a connection with neoliberal premises, a theme developed in Pringle (2019; see preceding entry). Cui et al. conclude that, “Unfortunately, both representations [i.e. the “patientised” and the “traumatised”] make it difficult to draw attention to the influences of broader social conditions in the causation of MHIs [mental health issues], for example social exclusion and inequality” (2019: 746).

Bazira’s (2017) thesis on medical education in the UK draws attention to the individualist assumptions in the 2015 regulations produced by the UK General Medical Council (GMC). Specifically, he highlights how the regulations represent the “problem” of “patient safety” in terms of individual doctor’s or organization’s behaviours/practices rather than in terms of the responsibility of the state to provide conditions conducive to good health. “Safety” is understood to be synonymous with the absence of adverse effects or errors rather than in terms of welfare. This problematization illustrates “the implicit reductionism of medical practice to a definable set of skills and competencies” (Bazira 2017: 84). It further embraces a neoliberal focus on individual responsibility (2017: 135).

A particular concern in Bazira (2017: 132) is how these discourses interact to produce particular subjectivities in the learners, doctors, educators and organisations that are governed by means of this policy. The production of “patient safety” as the result of individual and organizational practices, with a focus on omissions and errors, privileges the practice of “evidence-based medicine”, which emphasizes “measurable competencies” (2017: 80). According to Bazira, this approach effectively excludes those aspects of medical education that require interpretation and interpretive practice (see discussion in Research Hub entry 31 May 2020).

In Bazira’s (2017: 79) view, rethinking and re-representing the problem in an effective manner requires a change in healthcare focus from therapeutic medicine to preventive public health (2017: 79). There is a need to challenge the now taken for granted focus in medical education, and the medical profession as a whole, on making ill people better, replacing this objective with an emphasis on societal health and the prevention of illness in the first place (2017: 90).

It could of course be argued that in the current pandemic we have excellent examples of “preventive public health”. Surely, you may say, “social distancing” and “contact tracing” highlight key elements of a “public health” response aimed at “prevention” of infection. Epidemiology, however, is not the form of prevention Bazira has in mind in his references to “societal health”. I pursue this topic below.

Together the arguments in Bazira (2017) and in Cui, Lancaster and Newman (2019) alert us to the possible subjectification effects of policies introduced to “combat” COVID-19 – the kinds of subjects being produced through the sorts of interventions promoted to “manage” the pandemic. I have already mentioned the distinction drawn between “vulnerable populations” and “socially responsible” others (see preceding entry). Clearly, in any such analysis, attention needs to be paid to the specifics of particular sites and proposals. For example, what kind of subject is produced by the Australian government’s tracing app (https://www.health.gov.au/resources/apps-and-tools/covidsafe-app) and how does this compare with South Korea’s tracing technologies (https://jamanetwork.com/journals/jama/fullarticle/2765252)? More broadly, what kinds of subjects are produced in the experimental approach to “managing” the crisis described in a previous entry (30 April 2020)? What does it mean to be/come an “epidemiological” “subject”?

Riemann (2018) assists us with this topic. He deploys WPR to critically interrogate the USA based violence prevention initiative, Cure Violence (CV). This initiative frames violence as a “public health” issue. More precisely, it “maintains that violence is an actual disease, which can be controlled and contained via epidemiological methods and strategies applied in disease control” (Abstract). Riemann explains the three-pronged approach of an anti-epidemic strategy (with which we are now all too familiar) – identification, interruption, and behavioural change, outlining how the approach is applied in CV. By concentrating on the need to identify “high risk” individuals, CV reduces violence to individual pathology, with the line between the “normal” and the “pathological” associated with race (2018: 7). Riemann describes the CV initiative as depoliticizing, separating socio-economic inequalities from the analysis of violence. The goal, to produce self-governing subjectivities, promotes “the production of neoliberal subjects that understand themselves as reflexive health entrepreneurs” (2018: 4) – a description that resonates worryingly with the current focus, in Australia at least, on “social responsibility” and “self-governance”.

Mabhala et al. (2020) draw similar conclusions about the limitations of epidemiological approaches; however, significantly for the current pandemic situation, their target is infectious diseases. They share Riemann’s concern that epidemiological approaches are depoliticizing and for similar reasons, that they ignore the social and political conditions promoting contagion. Using WPR as one of their analytic tools, the authors emphasize that most interventions to do with infectious diseases create such diseases as biomedical conditions. In their view, such a problematization ignores the need in southern countries to tackle socioeconomic determinants of health: “infectious diseases in low-income countries are an indication that these conditions cluster wherever poverty is widespread”.

Along related lines, Sandset (2020) uses WPR to provide a content analysis of academic articles on phylogenetic analysis for HIV transmission. Noting ethical concerns raised by such analysis, he points out that a focus on genetic transmission networks can lose sight of “structural drivers, cultural aspects and economic disparities” (2020: 6). The relevance of this critique to the increased use of phylogenetic testing in COVID-19 cases is worth considering.

The Mabhala et al. paper was published in January 2020 and hence does not include COVID-19. However, their argument provokes useful rethinking about the current pandemic. Responses to COVID-19 are almost exclusively biomedical. The focus is the disease and treatments or vaccines to bring it “under control”. “Social” distancing is also biomedical since its goal is to reduce infection rates. Michael Marmot has tried to alert people to the ways in which the disease and the responses to it can exacerbate health inequalities (https://www.abc.net.au/radionational/programs/healthreport/social-equity-and-covid-19/12189450)

To borrow a much overused and abused metaphor, the playing field is not level. “Social distancing” and WFH (“Working from Home”) is much easier for some people than for others. The emphasis on hygiene and handwashing creates unreasonable expectations for populations where water is scarce. The impact of COVID-19 on African-Americans has been “extraordinary and disproportionate”. Nearly one-third of those who have died across the USA are African-American, although they represent only 13 percent of the US population (https://www.nationalgeographic.com/history/2020/04/coronavirus-disproportionately-impacts-african-americans/)

African-Americans are also anticipated to bear the brunt of COVID-19’s economic impact (https://www.theguardian.com/us-news/2020/apr/28/african-americans-unemployment-covid-19-economic-impact).

A social flesh political imaginary, introduced in the previous Research Hub entry, may prove useful in highlighting the unequal burden of infectious diseases through insisting on the shared embodied reliance of people across the globe on social space, infrastructure and resources (Beasley and Bacchi 2007). This imaginary may become all the more necessary as “countries”, “states”, “regions” become self-managing, insular entities (O’Hagan 2020: 25). A turning inwards to protect “one’s own” may prove to be both inadequate and a “risk” to life on the planet. On this point consider how the Australian Government’s recent decision to spend Aust.$270b building larger military to prepare for a “poorer, more dangerous” world produces the “problem” (https://www.abc.net.au/news/2020-06-30/australia-unveils-10-year-defence-strategy/12408232). Consider also how the virus is exposing the inequalities and exploitation that characterize contemporary work relations. As one example, in Melbourne, Victoria, there is the disturbing “discovery” that something called “insecure work” leads to increased case numbers due to people’s inability to self-isolate without paid leave (think also of the underpayment of Victoria’s hired security guards in the contentious quarantine hotels debacle and the underpayment of workers in aged care facilities). (https://www.news.com.au/finance/work/at-work/insecure-work-is-no-good-dan-andrews-blames-casual-jobs-for-victorias-second-wave/news-story/fe58e2da479cac7fb7f7d328a2561fb2)(https://www.theage.com.au/national/victoria/hotel-quarantine-security-done-on-the-cheap-via-subcontractors-says-guard-20200724-p55f1t.html)

In the conclusion to Analysing Policy (2009) I describe WPR as a “problem”-questioning rather than a problem-solving approach. The articles in this and the previous entry (30 June 2020) suggest some areas where questioning may be needed in reflections on “the conditions of possibility of medical experience in modern times” (Foucault 1973: p. xix). By targeting what is taken-for-granted – what is implicit – in medical practices, ethical guidelines, medical education, models of health, and so on, we create the opportunity to rethink what medicine is, how it heals and how it shapes ways for us to be.  We have some work to do!

References

Bacchi, C. 2009. Analysing Policy: What’s the Problem Represented to be? Frenchs Forest: Pearson Education.

Bacchi, C. 2012. Why Study Problematizations? Making Politics Visible. Open Journal of Political Science, 2(1): 1-8.

Bacchi, C. and Goodwin, S. 2016. Poststructural Policy Analysis: A Guide to Practice. NY: Palgrave Macmillan.

Bazira, P. J.2017. Medical Education in the United Kingdom: A post-structural critical policy analysis. PhD Thesis, Doctor of Education, Faculty of Social Sciences, School of Education, The University of Sheffield, England. [Abstract available at: http://www.eurjanat.com/web/paper.php?id=180211gf]

Beasley, C. and Bacchi, C. 2007. Envisaging a new politics for an ethical future: Beyond trust, care and generosity – towards an ethic of “social flesh”. Feminist Theory, 8(3): 279-298.

Cui, J., Lancaster, K. and Newman, C. E. 2019. Making the subjects of mental health care: a cross-cultural comparison of mental health policy in Hong Kong, China and New South Wales, Australia. Sociology of Health & Illness, 41(4): 740-754.

De Vries, G. 2002. Pragmatism for Medical Ethics. In J. Keulartz, M. Korthals, M. Schermer and T. Swierstra (Eds) Pragmatist Ethics for a Technological Culture. Springer-Science+Business Media, B. V. pp. 151-165.

Ijaz, N. 2020. Paradigm-Specific Risk Conceptions, Patient Safety, and the Regulation of Traditional and Complementary Medicine Practitioners: The Case of Homeopathy in Ontario, Canada. Frontiers in Sociology, doi 103389/fsoc.2019.00089

Iliffe, S. and Manthorpe, J. 2018. Muddling along in the city: Framing the cityscape of dementia. Dementia DOI: 10.1177/1471301218817451

Mabhala, M.A., Yohannes, A., Massey, A., Reid, J.A. 2020. Mind your language: Discursive practices produce unequal power and control over infectious disease: A critical discourse analysis. International Journal of Preventive Medicine, 11:37.

Murano, M. C. 2020. A Disability Bioethics Reading of the FDA and EMA Evaluations on the Marketing Authorisation of Growth Hormone for Idiopathic Short Stature Children. Health Care Analysis https://doi.org/10.1007/s10728-020-00390-1

O’Hagan, Angela. «Introduction. “A critical practice of thinking otherwise”: Bacchi, gender and public policy analysis». En Feminismo/s, 35 (junio 2020): 13-28. Monographic dossier / Dossier monográfico: A critical practice of thinking otherwise: Bacchi, Gender and Public Policy Analysis, coord. Angela O’Hagan, DOI: 10.14198/fem.2020.35.01

Pringle, W. 2019. Problematizations in Assisted Dying Discourse: Testing the “What’s the Problem Represented to Be?” (WPR) Method for Critical Health Communication Research. Frontiers in Communication 4 (article 58). doi: 10.3389/fcomm.2019.00058

  Riemann, M. 2018. Problematizing the medicalization of violence: a critical discourse analysis of the “Cure Violence” initiative. Critical Public Health. DOI: 10.1080/09581596.2018.1535168

Sandset, T. 2020. The ethical and epistemological pitfalls of translating phylogenetic HIV testing: from patient-centered care to surveillance. Humanities and Social Sciences Communications, 7: 19. https://doi.org/10.1057/s41599-020-0522-4