Health and Society Exam 3

What helps predict a "healthy" aging experience?

"(1)Social factors: SES/access to resources. Social support and emotional connections. Purpose and social engagement. Cultural perception of aging. Some cultural subgroups value the elderly. (2)Physical environment: Sense of home. Safe environment. (3)Individual factors: Adopting health behaviors such as physical activity and healthy eating. Avoiding high-risk health behaviors (e.g. smoking, excessive drinking)" (12/6 Slide 20).

How does aging population concerns relate to the second epidemiological transition we talked about at the beginning of the semester?

"...an increase in average life expectancy from about 30 years to about 50 years of age, and more sustained population growth that eventually becomes exponential. This transition occurs in the early modern period and is characterized by a shift in patterns of disease and mortality from primarily infectious diseases to what have come to be called "chronic" diseases. The theory proposes that this shift is accompanied by a shift in the population age distribution as early infectious disease deaths decline and deaths from chronic and degenerative disease increase, the latter a result not only of the receding competing risk from infectious diseases, but also of the new environmental hazards that came with industrial development and increasing urban living" (Robert E. McKeown).

What about the challenges in terms of costs?

"Aging is expensive for individuals. 60% of personal bankruptcies are due to medical expenses. OUt of pocket expenses for elderly, even on Medicare. Increasingly high medical costs as individuals age. Aging is expensive for society. Medicare recipients are more expensive every year, until they reach age 96. What Medicare beneficiaries paid in to the system covered only between 10-40% of the services they received. End-of-life care expensive, dying even more so. Medicare beneficiaries who died in 2011 had costs that were four times as much as those recipients who lived through the year. Costs of care are not sustainable" (12/6 Slide 11).

In what ways does Morone say morality and politics shape public health policy?

"Beliefs about morality shape public health. Political differences can become moral disputes" (11/15 Slide 7). "Morone argues that the two U.S. political traditions each have a different moral frame that shape views on public health. (1) Puritanism - focuses on sinful behaviors and individual accountability for personal choices. (2) Social Gospel - looks at fixing an unjust system and taking care of others victimized by the system" (11/15 Slide 7).

How might biological sex and gender intersect to shape health outcomes? How do Rieker et al. explain the connections in their "Constrained Choice Model"?

"Biology and social effects both matter! Rieker et al. argue we must consider how both biological sex differences AND the social effects of gender intersect to fully explain different health outcomes and disease trajectories between men and women. Constrained Choice Model: Social policies, community actions, work and family relationships (which are gendered) shape individual choices (which are gendered) and biological processes (which are also both marked by sex and gender; e.g. stress responses), which in turn shape health outcomes" (11/5 Lecture Slide 22).

What are the public health challenges of an aging population in terms of increased rates of chronic illness?

"Chronic illness strains relationships. Functional limitations often mean increased dependence for elderly. May change context for relationships. Elderly often outlive close relatives and friends, and must rely on distant social relations. Living arrangements for elderly less than optimal. Medical model and the imperative to treat at odds with demographic realities of population growth. Need more geriatricians. Need more caregivers" (12/6 Lecture).

What personal relationships and experiences shape experiences of aging?

"Chronic illness strains relationships. Functional limitations often means increased dependence for elderly. May change context for relationships (e.g. no more weekly golf game). Elderly often outlive close relatives and friends, and must rely on distant social relations. Children increasingly live far away. Living arrangements for elderly less than optimal. Nursing Homes are medical environments" (12/6 Slide 9).

How does morality relate to the commodification of FSD and the obesity epidemic?

"Commodification: The act or process of treating something as a mere commodity." I THINK it is a moral issue because, it can be argued that, big pharma created FSD as a way to sell more drugs. Obviously, if this is true it could be immoral. It diagnoses women, who are statistically "normal," with a medical ailment in order to manipulate their bodies to perform as the average male would like them to. I THINK the obesity epidemic is a moral issue because (1) stigma wrongly blames the person for their state, (2) large corporations sell and market their unhealthy foods to obese people, (3) the medical community treats them poorly, (4) social stressors perhaps pushed them into obesity, and (5) large corporations lobby legislation towards deregulation so that they can continue to subsidize corn products and produce highly unhealthy products, etc. ""Medical model decontextualizes social problems" (Conrad 1992). E.g. FSD" (11/27 Slide 19).

What are the structural features of the health care system that make end-of-life care so difficult?

"Economic factors: Healthcare system interested in profits, efficiency, and innovation, not about meaning of life or quality of time left. Conversations about death take time. No billing code for talking about end-of-life decision-making or care" (12/6 Slide 25). "Cultural: aversion to discussing death: Dying has only recently become a prolonged process due to increased life expectancy and technological innovations. Cultural denial of "accepting" death; we don't see death, and we don't accept it. Family members frequently intervene to prolong life, often despite patients' wishes. Perception that hospice hastens death (which is not true) so hospice is culturally underutilized" (12/6 Slide 25).

What are some obstacles to truly tackling the opioid abuse epidemic?

"Increased federal funding. Grants to train first responders. Alternatives to incarceration. Prescription Drug Monitoring Programs. Doctors and pharmacist groups complained program would be "burdensome: and would constrain doctors and pharmacies. Politicization of treating addicts in funding bill. Where should federal dollars go? Who is worthy of treatment?" (11/27 Slide 17). "For many years, naloxone [overdose antidote] was available only in an injectable formulation and was generally only carried by medical emergency personnel" (11/27).

What do I mean when I say that politics is not merely about partisan issues, but also about power?

"Individuals and groups who have more resources have more power to make choices, advocate for their interests, and influence the distribution of resources. Health is correlated to our fundamental access to resources" (11/15 Lecture Slide 4). "You can use politics (power) to direct the cultural conversation around a certain health problem or public health issue. Pay lobbyists to advocate for your special public health interests. Influence the FDA to approve drugs/technologies. Shape health care policies" (11/15 Lecture Slide 5).

How might cultural norms about masculinity shape health behaviors and expectations? What does Courtenay say about this?

"Masculinity and Health: Courtenay looks at health behaviors as constructions of masculinity. Men are active agents in constructing and reconstructing dominant norms of masculinity. Health behaviors are ways to "do" gender. Men are more likely to engage in risky behaviors to prove their masculinity. In pursuit of power and status is when men harm themselves and others. Smoking, unhealthy eating, dangerous activities., fighting, aggressive behavior. Men are less likely than women to see a doctor for preventative care or health problems. Men are less likely than women to have supportive friendships" (11/5 Lecture Slide 21).

Define medicalization and what are several examples?

"Medicalization describes a process by which non-medical problems become defined and treated as medical problems, usually in terms of illnesses or disorders" (11-27 Lecture, Slide 8) Medicalization transforms "badness" into sickness and transforms normal processes, conditions, and human variation into sickness. (11-27 Lecture, Slide 9) Childhood hyperactivity -> ADHD Public drunkeness-> alcoholism Childbirth Aging menopause

Why are these alternatives underutilized?

"Nothing is as easy as taking a pill" → alternatives take time to work, the physician has time constraints, and there are fewer alternative practitioners in some geographic areas

What forces (biological, social, cultural, economic, political) have helped cause the current opioid abuse epidemic?

"Opioids are incredibly addictive. Increased chronic pain nationally (due to recognition and an aging population). Increased prescriptions written to people. Lack of regulation of the opioids. Opioids are a cheap and effective way to treat pain. Pharmaceutical companies have much to gain by selling them. Alternative treatments are more costly and many don't have scientific evidence (Opioid lecture). Biological: Opioid tolerance leads to increase intake of the drug. Opioids decrease brain's own opioid system. Adverse reactions with alcohol and benzodiazepines (anxiety/sleep medication). 31% of these interactions were the cause of overdoses. Social: "Opioid prescriptions are higher per capita in rural areas. Populations are older, have more chronic pain. Strong social networks with family and friends. Substantial poverty and unemployment; low rates of high school graduation. Out-migration of young. Those left might have a greater accumulation of risk factors. Downward "social drift." Limited access to health care. Prescription drug abuse of stimulants and benzodiazepines is also increasing" (11/27 Lecture). Cultural: Economic: Opioids are cheap and effective way to treat pain. Pharmaceutical companies have much to gain by selling them. Alternative treatments are more costly and many don't have scientific evidence. Political: "Trump recently declared the opioid problem a "national emergency." In his op-ed in the NYT, Carl Hart says opioid addicts, "are now patients in need of our help and understanding, rather than criminals deserving scorn and incarceration." Most opioid abusers are white. Opioid abuse have ravaged white, rural communities. Punitive policies for Black users. Rehabilitation for White users" (11/27 Slide 25).

What "frames" are used by different sides or vested parties to promote their understanding of the issue? How do existing power relations between individuals and groups shape the debate?Is the issue important for an individual's health or for public health?

"Public health is limited by the politicization of science and health. If medical science is produced in social contexts shaped by power relations, isn't it always shaped by politics?" (11/15 Slide 10). "Individuals and groups who have more resources have more power to make choices, advocate for their interests, and influence the distribution of resources" (11/15 Slide 4). Governors of Texas said HB 2 Law "would improve patient safety and hold abortion clinics to safer standards. Opponents said that it amounted to an unconstitutional attack on legal abortion in Texas and that many of the restrictions were found to be medically unnecessary by physicians groups" (11/15 Slide 40). Naming: language, like how we say Pro choice or Pro life

What does Rauch say are the real "roots of Midlife crisis"?

"The age U-shape [midlife crisis] in life satisfaction is driven by unmet aspirations that are painfully felt during midlife but beneficially abandoned and felt with less regret during old age" (Rauch 13). "Younger people are fertile, but older people need to find some other way that they can contribute tot he survival of the species. Competitiveness may be more favored in the young, and more emotional regulation, more tolerance of diversity, more insight in older people" (Rauch 15).

What is the Second Epidemiological Transition?

"The second proposition was: "During the transition, a long-term shift occurs in mortality and disease patterns whereby pandemics of infection are gradually displaced by degenerative and man-made [sic] diseases as the chief form of morbidity and primary cause of death" (Robert E. McKeown).

What are the traditional models of American politics Morone say help explain our current system of morality-laded health policy decisions?

"Traditional models of American politics that shape policy making: (1) Individualism (Puritanism) - Limited government, politics of self-interest at odds with medical science. (2) Communal Tradition (Social gospel) - collective goals and common good are focus. Some collective goals may be dangerous" (11/15 Slide 6).

What is the connection between gender, stress, and health?

"Women's relative lack of control and social power as compared to men shape incidence and prevalence of disease, but also the experience of illness. Women experience higher levels of chronic stress than men throughout the life course. Stress creates higher levels of morbidity among women" (11/5 Lecture Slide 18).

Can you give some examples of how this might play out at the individual level? At the state and federal levels?

"You can use politics (power) to direct the cultural conversation around a certain health problem or public health issue. Pay lobbyists to advocate for your special public health interests. Influence the FDA to approve drugs/technologies. Shape health care policies" (11/15 Lecture Slide 5). "Different parties/groups choose language to stake a political claim on a health issue, or to set the moral terms of the debate." "Affordable Care Act vs. Obamacare" "Regulating tobacco industry. Tobacco control: Individual liberty vs. public health. Tobacco industry: Big government vs. individual freedom (then local control)." "SSD (sugar-sweetened soft drink) researchers doing the same thing." "Abortion: Pro-life (anti-abortion) vs. Pro-choice (anti-life). "Late-term vs. "partial-birth"" (11/15 Slide 11). "Politicization shapes individual choices and decision-making. Politicization shapes public health policies" (11/15 Slide 12).

What are the two frames of morality politics that he discusses?

(1) Puritanism (Individualism) - focuses on sinful behaviors and individual accountability for personal choices. Limited government, politics of self-interest at odds with medical science. (2) Social Gospel (Communal Tradition) - looks at fixing an unjust system and taking care of others victimized by the system. collective goals and common good are focus. Some collective goals may be dangerous" (11/15 Slide 6-7).

What processes converged to make pharmaceuticals a huge part of the current health care industry? (Hint: think Conrad that we discussed in class).

-pharmaceutical reps are meeting with doctors (free lunches) to teach them how to diagnose -paying physicians to be "experts" and advocates; they can see how often the doctor is prescribing their drug -politics: lobbying and FDA -direct consumer advertising

What are alternatives to prescription opioids for pain management?

Acupuncture, massage, meditation, chiropractic therapy, physical therap, cognitive behavioral therapy.

What are the moral implications of a system that looks at health as a commodity?

Are we treating the patient with their interest or are we just trying to make a profit?

What are different types of medicalization? What factors shape medicalization?

Badness -> sickness Normal human variation -> sickness

What role did the women's health movement play in emphasizing the gender effects on women's health?

Based on the answers to #4 and 5, I THINK it brought attention to sexism's massive role in generating negative health outcomes for women via multiple pathways. "Theories of how gender shaped women's health were brought into the mainstream." (11/5 Lecture Slide 14) "Gender Violence: Reframing violence against women as "gender violence." Victim blaming is pervasive and part of the problem. Need to ask what is going on with men? Why are they the ones abusing women and children? Gender violence is not about individual perpetrators. Gender violence is a social problem. Violence embedded in various institutions (sports culture, religious institutions, family structure, etc.) that hurts women, and justifies it. Bystander approach-combatting silene. If we ask "Why don't women who are abused just leave?" we're not looking at the system, only the individual" (11/5 Lecture Slide 20).

How is female sexual dysfunction (FSD) medicalized (as depicted in the Moynihan article)?

Basically, big pharma is funding this push towards "normal" sexual behavior/performance for their financial gain, contrary to their own statistical data that shows most women (43%) have similar behavior/performance. "Female sexual dysfunction was discussed as part to the first international consultation on erectile dysfunction in Parin in 1999, hosted chiefly by urology associations and sponsored heavily by pharmaceutical companies..." "with one aim being the adoption of an "internationally accepted instrument for assessment of sexual function"" (Moynihan page 1). "A Californian firm offering "business intelligence: announce that..." "Greater public awareness and acceptance of sexual dysfunction as a common and treatable disease will heavily influenece market growth, predominantly for women" (Moynihan page 2). "An inhibition of sexual desire is in many situations a healthy and functional response for women faced with stress, tiredness, or threatening patterns of behaviour from their partners. The danger of portraying sexual difficulties as a dysfunction is that it is likely to encourage doctors to prescribe drugs to change sexual function -- when the the attention should be paid to other aspects of the woman's life" (Moynihan page 2). "Real dysfunction is much less prevalent than 43% and that the figure has contributed to an overmedicalisation of women's sexuality, where changes in sexual desire are the norm. "I think there is dissatisfaction and perhaps disinterest among a lot of women, but that doesn't mean they have a disease"" (Moynihan page 2).

Connect the dots between chronic pain, the pharmaceutical industry, and the spread of HIV and Hepatitis C in certain parts of the country.

Because people can get heroin more than they can get opioids because they are cheaper, they are getting addicted to heroin and for those who can't afford it, it leads to the sharing of needles.

What is the difference between biological sex and gender when understanding men's and women's outcomes and health?

Biological "sex" and social "gender" processes can interact and may be confounded. We use gender to refer to observed differences in men's and women's lives, morbidity, and mortality (Rieker) ← from past study guide Sex differences are based on biological factors. Gender is associated with behavior, lifestyle and life experience. Gender determines access to health care, use of the healthcare system and the behavioral attitudes of medical personnel. Biological sex determines the diseases a person may be at risk of (i.e. cervical cancer or prostate cancer), while gender determines the social forces one is subject to in health care (i.e. Female Dysfunction Disorder [Subjective and social] vs Erectile Dysfunction [Objective and biological]).

How does biological sex explain different health outcomes?

Biological Explanation → hormones buffer women from the effects of aging, at least until after menopause (ex. Heart disease for women comes later). The same hormones that protect women put them at risk in other ways. The female immune system may be heightened in some ways, but can become overactive (ex. Women are susceptible to autoimmune disorders and other hormone-linked problems.) Women live longer, but live sicker. Women have higher rates of nonfatal diseases, and they also have more acute and chronic conditions. Women are more likely to suffer from depression and anxiety, while men are more likely to have substance abuse problems. Men also have much higher heart disease at earlier ages.

What are the three engines that are taking away the power and authority of medicine?

Biotechnology/Industry Interests (e.g. pharmaceutical companies) Consumer Demands (demand diagnoses, prescriptions and other "enhancement" technologies) Managed Care/Health Insurance Companies (emphasize profits over patient care) (11-27 Lecture, Slide 21)

How does medicalization relate to the commodification of health (making health into a commodity)?

By making normal functions into a health issue or dysfunction, big companies are able to make more profit by making pills or solutions to health problems that aren't really problems to begin with. Loss of sexual desire or being stimulated is normal, but by medicalizing it and making it a dysfunction, it makes women think there is something wrong with them and will make them want to become "normal" again by seeking treatment. When they seek treatment, the companies that make the pills make a profit.

What does Gawande argue in Being Mortal? What are the general ideas of each chapter?

Ch. 1: Society doesn't talk about death/dying, medicine is focused on staving off death as long as possible through any means possible. Ch. 2: Process of dying is long and slow. Things randomly break down over time, not all at once. Ch 3: People are not prepared for the downward slope of aging. Nursing homes are made to fulfil societal obligations but the priority is never on the residents. Ch. 4: Assisted living homes are a better alternative to nursing homes because the residents have more autonomy. In most nursing homes the residents have no control over their lives, like prison. Ch 5. Need to give residents a reason to live. "The battle of being mortal is the battle to maintain the integrity of one's own life-- to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be." Ch. 6. Making disabled/senile people's health better involves curbing medical imperatives to treat (get involved, fix it, meddle, esp. control). This overtreatment and overmedicalization worsens quality of life in the end, as there is always something doctors can do but they really should stop at some point. Doctors are not prepared to have this discussion about when to stop treatment with their patients. People live longer with focused and curbed medical care at the end. Ch. 7. People prefer to die at home than at the hospital. Result of the 3rd epidemiologic transition. 3 different types of doctors: paternalistic (makes all the decisions, no patient input), informative (lays out all the information and lets the patient decide), interpretive (ask about the patient's priorities and use their knowledge to achieve them). Need to have hard conversations about what people value and how to prioritize those values (interpretive). Ch. 8 It is courageous to have the difficult end-of-life discussions. Needs to be done. Better to go out with dignity & least amount of suffering possible, but need to know patient's desires and values to do this. "Death with dignity."

How prevalent is the opioid abuse epidemic?

Deaths from prescription opioids are at record highs. "In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. 2014, 1.9 million people in U.S. suffered from substance abuse disorders related to prescription opioid pain medicines. 586,000 suffered from heroin use disorder. Drug overdose is the leading cause of accidental death in the US, with 47,000 lethal drug overdoses in 2014. 19,000 overdose deaths related to prescription pain relievers, and 10,000 related to heroin" (11/27 Slide 4).

What are the obstacles to adopting mandatory prescription drug monitoring programs? Why?

Doctors and pharm. Cos. said it would be "too cumbersome"

Given a health problem or disease, could you explain how both sex and gender might have a role to play in shaping the outcomes?

Ex. Mental health: depression Sex Influences: Women are twice as likely as men to experience depression, with some women experiencing mood symptoms related to hormone changes during puberty, pregnancy, and perimenopause. Gender Influences: women are more likely to admit to negative mood states and to seek treatment for mental health issues in contrast to men. "Intimate partner violence, depression, autoimmune diseases and contraception/birth control all work together to shape health outcomes. Women are twice as likely as men to experience depression, with some women experiencing mood symptoms related to hormone changes during puberty, pregnancy, and perimenopause. Women exposed to intimate partner violence are: twice as likely to have alcohol disorders, 16% more likely to have a low birth-weight baby, 1.5 times more likely to acquire HIV, 1.5 times more likely to contract syphilis infection, chlamydia or gonorrhea. 42% of these women have experienced injuries from partners. 38% of all murders of women globally were reported as being committed by their intimate partners" (11/5 Lecture slide 23-25).

What does it mean that medicine rewards "doing" or as Gawande says, "saving lives"?

Gawande says that doctors are judged on success in saving lives, or doing everything possible to prolong life. This involves embarking on risky procedures which could prematurely end a terminal patient, rather than allowing them to live out the rest of their life the way they want. The "doing" means that doctors are expected to do things for the patients, like surgeries, treatments, etc even when they know not much can actually be done.

How does this combine with the medical imperative to treat dying patients that Gawande talks about in Being Mortal?

Gawande talks about how a lot of times, people try to extend life as much as possible when in reality, if we let people go naturally, their quality of life would be better and in some cases, palliative care extends life longer than life sustaining measures. We look to develop things, such as technological innovations, in order to extend life.

How does gender shape health for men and women? Through what pathways?

Gender inequality shapes differential access to societal resources and power for women and men. It shapes scientific understandings and health research → gender shapes how we see biological processes and gender belief shapes how we do science (ex. There was a prioritization of certain research agendas and women were excluded from clinical trials because women have factors that cannot be controlled (menstruation)) Gender shapes health behaviors and interactions with healthcare providers. Gender shapes healthcare policies and healthcare Men are more likely to: be insured than women, have more economic resources for their health, be exposed to occupational hazards, smoke, drink, engage in risk-taking behavior,. Men are less likely to: pursue mental health treatment and go to the doctor Women are more likely to: go to the doctor, pursue mental health treatment and be the gatekeepers of the family's health (this includes more than just immediate family) Women are less likely to: be insured (???) "(1)Gender inequality shapes differential access to resources and power in society for women and men. Men more likely to be insured than women. Men have more economic resources to draw on for health. (2) Gender shapes scientific understanding and health research. Gender shapes how we "see" biological processes. Gender beliefs shape how we "do" science. Clinical trial bias. Prioritization of certain research agendas. What we pay attention to. (3) Gender shapes health behaviors. Men more likely to be exposed to occupational hazards, smoke, drink. Men more likely to engage in risk-taking behavior. Women more likely to go to the doctor. Men less likely to go to the doctor. Men less likely than women to pursue mental health treatment. Women more likely to be gate-keepers of family's health. They keep other family healthy. (4) Gender shapes interactions with health care providers. How we "do" respect in institutional settings. Are we able to be vulnerable? How are we seen as patients? For example Fibromyalgia and CFS. (5) Gender shapes health policy and health care. What health concerns are important at the state and national levels? Is violence against women/girls considered an important public health issue for society? Or is it a "women's issue" alone? Politicization of women's health (abortion, HPV, contraception). Do we pay for caretaking of an aging population? What procedures and conditions are covered by insurance (i.e. erectile dysfunction vs fertility treatments)? How do we "do" health (or encourage screenings like "Mammo Mixers")" (11/5 Lecture Slide 15-17).

Is medicalization dangerous? Why or why not?

Giving doctors too much authority can lead to medicalization of things that support the beliefs that they have and have absolutely no medical backing. Critics say that there is a muddy line between treating illnesses and "achieving the American Ideal" by playing on social insecurities and vulnerabilities. "Critics warn that medicalization often reflects cultural values that are antithetical to health. Slippery slope between treating disease and achieving that "American Ideal," but often we conflate the two. → enhancement technologies Many emerging industries, procedures, therapies capitalize on social insecurities and vulnerabilities." (11.27.17, Slide 22)

What other health topics are also morally suspect and/or politicized?

HPV Vaccine "Healthcare reform, Medicaid, gun violence, vaccines, sexual health issues" (11/15 Lecture Slide 13).

What does it mean when we say that health care in the U.S. is commodified?

Health care/insurance providers emphasize profits over patients health.

What different dimensions within the current health care system that make their utilization more difficult and why?

Health insurance covers prescription pills, but not usually alternative forms of treatment. They cite the fact that these alternative treatments generally don't have loads of scientific evidence backing up their effectiveness. However like we talked about in class, that evidence, research, and studies claiming the pills work are often biased and skewed because they are funded and executed by the very same pharmaceutical companies that are selling them. So essentially, alternative methods of treatment are not studied or "proven to be effective" because pharmaceutical companies do not stand to benefit from them. Instead, they benefit from studying and marketing the pills they sell.

Why are reproductive technologies (contraception use and abortion among them) so politicized? Discuss several of the key issues we discussed in class.

I THINK (I don't have what we discussed in class and no slides address this) it's because they contain a lot of highly moral dimensions for people. They usually contain a dichotomy between individual choice vs. big government. Many religions preach clearly about appropriate sexual behaviors that are contradictory to popular culture. For example, sex education, abortion, and HPV vaccination.

How do both of these frames shape the moralizing of certain public health problems? Be sure to be able to apply his conceptual model to theorize about different public health issues today, especially with regards to school-based clinics and obesity that he references in detail.

I THINK (no slides directly address this question, add anything you find) Puritan morals say someone is immoral if they break a law which contributes to public health. Social gospel morals say some social system is immoral if it contributes to a person breaking a law which contributes to public health. School-Based clinics- "Morone traces moral history of school-based clinics in schools. Opponents leveraged "moral complaints" about removing parental authority, and the concern that sexual health education would encourage promiscuity. Proponents of these clinics countered with "down-to-earth descriptions of kids getting care" and improved health measures (Morone 21)" (11/15 Slide 9). Obesity → some blame the companies for focusing on poor people to indulge in unhealthy food by putting fast food machines in schools distributing food stamps, and changing the school lunches to make poor people who are already overweight to eat more (Communalism argument). Others blame the obese individual for their food choices, saying that they are responsible for the food they eat (Individualism argument). "One backlash against fast food muckrakers simply shifts the blame. If some liberals demonize the industry, some conservatives blame overweight individuals. Heavy people lack willpower, they make foolish food choices, they live in unhealthy ways. Like smokers, drug abusers, and heavy drinkers, obese people have made personal choices; they should just say no and push away from the table. The distinct echo from other substance abuse controversies has another unhappy parallel: obesity tends to concentrate in poor and minority communities. Each picture of blame—the industry versus the individual—carries different policy implications. A focus on the industry suggests requiring better food labels, rethinking school nutrition, restricting advertising, regulating fat content, punishing misleading claims, taxing unhealthy ingredients, and so on. Successfully demonizing big food—directing popular anger at the industry—may cut through the checks and balances of the political system and provoke action. However, the politics of demonization cuts two ways. Some observers charge that food stamps and school lunches only encourage poor people—who are already fat enough—to overeat (Kaufman 2003). Others have suggested an insurance premium tax on heavy people. Once policymakers begin condemning heavy people, the list of possibilities rapidly grows." (Morone p. 23)

How does the "puritanism" frame map onto the politics of individualism and how does the "social gospel" frame relate to a more social justice/collective responsibility orientation?

I THINK (no slides directly address this question, add anything you find) that the "puritanism" frame represents the individualism of libertarians and their ideology which purports that everyone is responsible for their actions. They blame bad people for social issues. The "social gospel" frame relates to a social justice orientation in that their ideology blames poor institutions within society for social issues. They blame society for social issues.

What does Gawande say about nursing homes as places to spend one's final months/years?

It is better than dying in an unfamiliar hospital, but most deaths in nursing homes are lonely too. Better to die at home surrounded by loved ones. Gawande anecdotes one example where a grad med student takes over a nursing home and changed the elderly's lives dramatically by incorporating pets. "The most important finding of [the] experiment wasn't that having a reason to live could reduce death rates for the disabled elderly", he writes. "The most important finding was that it is possible to provide them with a reason to live." This means providing care, while also giving them a quality of life, support and other things to make their experience better. Experience is everything. Foster a solid social network in the nursing homes and give the elderly a purpose in life.

How might American cultural conventions work against longevity? How so? What evidence can you point to in our readings throughout the term?

I THINK American individualism, lacking social groups and competitiveness (tendencies toward social comparisons) push people under 50 towards the constant disappointment and people above 50 away from pleasant surprise as described in Rauch's midlife crisis article. High levels of social comparison from the internet make the younger people constantly feel less than adequate, and individualism acts a barrier for older people who need close relationships to feel happy. I THINK the Ted Talk by Buettner can be applied too. Americans don't move naturally, instead people are sedentary all day and maybe perform strenuous exercise occasionally. Americans don't have regularly scheduled times to relax for themselves unless they are religious. We don't drink in moderation, rather we drink to get drunk on nights and weekends with a diet high in meat and fat. People don't typically have a tightly knit group of 5 people they stick with throughout their entire lives. Instead you're lucky to have 1 or 2. We don't have a great give and take relationship with these people, we can be self-centered. We also live increasingly farther and farther away from our family and cut close ties.

What is particularly American about the technological imperative?

I THINK capitalism and private businesses and interest groups in America thrive off of feeding new consumer demands via their own new technologies and research and producing new solutions en masse that don't necessarily solve the core problem, rather they exploit for money.

How is the technological imperative related Conrad's shifting engines of medicalization?

I THINK it means that Biotechnology industries are more in control over healthcare since they have to incentivize technological innovations to treat diseases

Can you explain medicine's imperative to treat?

I THINK it's because doctors are only taught how to treat in medical school. They are not taught about the deep and underlying causes of health disparities (i.e. SES, education, racial/gender disparities, etc.). They also just simply don't have the time to talk to patients about these things. They are not "big picture" people, they are solve immediate problems.

How does one's moral status relate to health and health care? (Think about abortion and obesity here, among others.)

I THINK one's moral status is determined by whether they value the individual (social gospel) or the institution (Puritan) more. Puritanism blames individuals for their poor health and would argue for minimal health care legislation. They blame the woman for her sins if she gets an abortion. They blame laziness for obesity. Social gospel blames society for an individual's poor health and argues for strict health care legislation. They blame social forces for a woman who gets an abortion or for an individual's obesity.

In what ways is health politicized?

Interest groups politics are going to politicize ideological differences. Politicization shapes our cultural conversations of health issues using framing, public health policies, individual choices and decision-making. "Ideological differences are often politicized by interest group politics. Politicization shapes our cultural conversations about health issues. Politics shapes framing (or dismissal) of medical and scientific opinion. Moral frames are used to legitimize one's position, and the tactics used. Politicization shapes individual choices and decision-making. Politicization shapes public health policies" (11/15 Lecture Slide 12).

Why is an intersectional analysis important when considering gendered effects on health?

It will look at all of the social categories that a person is a part of. "Intersectionality is a theoretical approach that considers how multiple social categories (e.g. race, class, gender, sexual orientation) have overlapping or interdependent systems of disadvantage. Stress is greatest for those women with the least social power or "multiple marginalities." i.e. Women from racial/ethnic minority groups, low-income women, gender" (11/5 Lecture Slide 18).

What factors are likely to precipitate a fatal overdose?

Lecture 11/27/17 page 10 Having multiple prescribers Already taking opioids (so taking more can lead to super high dosages) Living in rural and low income areas Having a mental illness or history of substance abuse

How do the social factors we've been discussing throughout the term relate to aging?

Low SES have higher rates of chronic disease and disability. Blue Collar & labor-intensive jobs leading to ailments Stressors (financial, family, work) negatively affect health/longevity High SES have greater resources so they have better treatment options. Working class accept the pain. Gender → women seek more care than men, but also pay more for care than men. They are more likely to live alone in old age. Although they are sicker,they manage better than men.

What other factors explain why it is difficult for patients, families, and caregivers to "let go" (be especially conversant with Chapter 6 in Gawande)?

Majority of people do not come to terms with the fact that they are dying. We try to extend life at the end which just prolongs the inevitable and makes it harder to let go because it makes us hold on to hope for something that probably won't happen.

How has childbirth been medicalized? How is this good? How is this bad? What factors might shape one's answers to these questions?

Medicalization → anesthesia, routine episiotomies, epidurals and C-sections. Good: Takes precautions to ensure that the mother and baby are safe throughout the birthing process. Bad: Takes away the mothers authority and choice in having a natural birth if any complications (even if they are small problems) arise. Increased medical intervention in births create a costs burden on healthcare system Medical intervention introduces problems (slow labors and increased C-sections from epidurals and restricted movement in labor; C-section rates are not explained by high-risk factors)

Who is most at risk of opioid abuse? Why? Where do these people live? How do prescription opioids relate to heroin use?

Men are more likely to abuse opioids than women. Older people who are in chronic pain and the people in strong, social networks in rural areas. Family and friends are great distribution networks. The rural areas will have a limited access to healthcare. Is also more likely in poverty, unemployed individuals, and in places with low high school graduation rate. Those that stay in these areas might have a greater accumulation of risk factors, like a downward social drift, that makes them at higher risk for opioid abuse. Is more likely for those with mental illness or those with substance abuse history. Those obtaining overlapping prescriptions from multiple providers are at greater risk. 4 in 5 heroin users started out misusing prescription painkillers. 94% of heroin users said they chose heroin as it was cheaper and more easily obtainable than opioids. Older people who are in chronic pain and the people in strong, social networks in rural areas. The rural areas will have a limited access to healthcare.

Who gets sick first? Who is sick longest? Who deals with it best?

Men, men, and women respectively.

What are prescription drug monitoring programs?

Monitor which doctors prescribing opioids and if one patient is going to multiple clinics for prescriptions

Why is an aging population increasingly a concern in the U.S.?

More people are living longer, but many are living with chronic illnesses. They are alive but disabled and ill. Increased dependence. We are having an increase in the amount of older population, but we are having a decrease in the amount of geriatricians to treat them. Training doctors are running away from this specialty because doctors do not like dealing with old people. Not only that but other doctors are not trained in palliative care. If an elderly person comes to them they only know how to give them medical care, they do not know how to recommend hospice or any end-of-life (palliative) care. (Gawande)

How does Conrad say medicalization is "shifting"?

Physicians had less authority. Increased role of managed care organizations. (11-27, slide 20)

What does it mean when we say that health care in the U.S. is politicized?

Politics shape healthcare policies, which has been shown by interest group politics of the past. Politics is able to limit public health by politicizing a health issue. A way that politicians do this is by choosing a health issue and making a political claim for or against it, or to set the terms for a moral debate. (ex abortion, gun control, tobacco, etc.) (11.15.17, Slide 8 and 11): "Different parties/groups choose language to stake a political claim on a health issue, or to set the moral terms of the debate." Basically, it's a hot button issue that draws money and power towards a bigger ideology. "Politics is a particular set of ideological or partisan beliefs. Politics is MORE than just partisan affiliation. Politics includes the structure, distribution, and effects of power in society. Debate or conflict among individuals and groups hoping to maintain or achieve power. Actions undertaken by individuals and groups to maintain or achieve power" (11/15 Lecture Slide 3).

How does medicalization relate to medical authority?

Obstetricians and childbirth (11-27 slide 13) Medical authority gained power in society and doctor's still have power (doctor's note). When individualism is highly valued, societies develop therapeutic styles of social control. In these systems the patient is encouraged to choose responsible behavior and there are many mechanisms for getting the patient involved with treatment.

What evidence does Moransky use to argue that we are over medicalized?

Oransky says people are not dying from the conditions they have, but rather from the complications that arise from treatment There are higher rates of people getting diagnosed with pre-conditions than rates of people with actual conditions All aspects of women's lives (periods, pregnancy, menopause) are becoming medicalized Another piece of evidence is the role of pharmaceutical companies Pharma companies are the ones who control what is "normal" or not They are in control of what drugs are pushed and advertised

What do each side in FSD debate say about the recent FDA approval of Addyi?

Pro Addyi: Dr. Woodcock said the FDA was "committed to supporting the development of safe and effective treatments for female sexual dysfunction" (Pollack page 2). "A drug to improve women's sex lives was long overdue, given the many options available to men" (Pollack). "The FDA said the drug was approved for women whose loss of sexual desire causes marked distress or interpersonal difficulty and isn ot the result of illness, relationship problems or side effects of other medicines" Pollack page 2). "The drug's availability would encourage many women to talk to doctors about their sexual problems for the first time" (Pollack). Con Addyi: "The campaign behind Addyi had made a mockery of the system that regulates pharmaceuticals" (Pollack). "It was "absurd" to expect that young women taking Addyi would refrain from drinking alcohol." "The drug was based on the mistaken notion that lack of spontaneous sexual desire, absent stimuli, was abnormal." "It's going to be more trouble than it's worth." Insurance companies might not pay for Addyi "..."unprecedented and unwarranted manufacturer-funded public relations campaign" may have confused the advisory committee member." "The drug was based on the mistaken notion that lack of spontaneous sexual desire, absent stimuli, was abnormal."

What are the pros and cons of medicalization?

Pros: Can decrease social stigma or a status or condition (ex. homosexuality), Medical diagnosis often allows for treatment (ex. Gender dysphoria) Cons: Increased medical authority takes away power of others in society (e.g. parents, teachers), medicalization diminishes or restricts non-medical options, medical model "decontextualizes" social problems (11-27 Lecture, Slide 18)

What is the role of the pharmaceutical industry in the commodification of health?

Research design Research process Interpretation of data They determine what is the norm of health and what can be given to fix the the problem. → they are what shapes health

How was social constructionism used to understand biological processes in "The Aggressive Egg"?

Social and cultural beliefs shape science and how we interpret biological processes. Martin found that the imagery taught of reproduction didn't map onto actual scientific discoveries. Sperm is actually caught by the egg and makes feeble attempts to escape. But scientists describe sperm to reflect the idea of masculinity so the sperm "torpedoes" and penetrates the egg, while the egg is described like a "damsel waiting in distress."

How are health and illness socially constructed?

Social constructionism: theoretical perspective that posits our lived experience is shaped by social and cultural forces Society defines what is healthy and what is an illness after a while (ex. drapetomania). We may define disease differently based on social attitudes/norms/values (eg. when homosexuality was considered to be a mental health issue and labeled a disease, but not anymore) ← exam 1 review answer They happen in a specific social context and can change over time. 11.27.17 (Slide 6)

What does the shift in our aging population mean for our society's demographic composition?

The demographic composition gets older. We have "slow growth" aging and population change in the U.S. The population pyramid becomes a rectangle.

How do behaviors shape outcomes according to Buettner?

The behaviors from the last question all shape longevity and health in life. He claims that 90% of your behavior determines your life health and longevity.

What do critics say is problematic about the medicalization of FSD?

The danger of portraying sexual difficulties as a dysfunction is that it is likely to encourage doctors to prescribe drugs to change sexual function - when the attention should be paid to other aspects of the woman's life (stress, tiredness, threatening patterns of behavior from their partners, etc). Pharmacological research runs the risk of oversimplifying the sexual difficulties of men and women because it 'promotes genital function as the centrepiece of sexuality and ignores everything else "If you break an ankle while you're dancing you go to a doctor. But your doctor doesn't take a dance history and wouldn't advise you whether your dancing is normal. The medical model is about defining what's healthy and what's sick — but sex isn't like that" (Moynihan page 3). "The potential risk, in a process so heavily sponsored by drug companies, is that the complex social, personal and physical causes of sexual difficulties -- and the range of solutions to them -- will be swept away in the rush to diagnose, label, and prescribe. Perhaps the greatest concern comes from..." "the ever-narrowing definitions of "normal" which help turn the complaints of the healthy into the conditions of the sick" (Moynihan page 3).

Where are the Blue Zones? What kinds of things does Dan Buettner say we should do if we want to live to 100?

The highlands of Sardinia (island), Okinawa (island), Loma Linda, California (7th Day Adventists specifically), and the Nicoya Peninsula of Costa Rica (almost an island). (1)Move naturally: this means living a life that is naturally active (walking, moving, gardening, etc.). Not intentional exercise as we would do in the U.S. (2)Right Outlook: Schedule time regularly to relax every week or so. Also to have a higher purpose for your life to wake up every morning. (3)Eat Wisely: Drink alcohol regularly (5pm) and in moderation. Eat plenty of legumes and nuts. Stop eating when you are 80% full because it takes 30 min. For your body to recognize when you're full. (4)Connect: Prioritize your loved ones first (friends and family). Have a group of friends that you belong to (around 5) that stay together for life. Take care of these friends so that they take care of you. This helps you get through life in difficult times and spreads good fortunes when one friend receives them.

How does morality shape our conceptualization of medical conditions and treatments?

The individualist approach would say that it is up to the person to choose how they go about getting treated (ex. get vaccinated or not), while the communal approach would be for there to be required health policies for everyone to get specific treatments for the good of the whole society (ex. getting required vaccination like TB and polio vaccines) ← Osbakken Approved "Beliefs about morality shape public health. Political differences can become moral disputes" (11/15 Slide 7). "Public health is limited by the politicization of science and health. It's already hard to disseminate info about public health. Politicizing health issues makes it harder (Schaffner on HPV). If medical science is produced in social contexts shaped by power relations, isn't it always shaped by politics?" (11/15 Slide 10). "Moral frames are used to legitimize one's position, and the tactics used. Politicization shapes individual choices and decision-making" (11/15 Slide 12).

How is hospice different than medical care?

The purpose of hospice is to make the patient as comfortable as possible when dying so that they can have a "good death" There is a lot more flexibility in hospice care. It is designed to make the patient's experience of death what they want it to be rather than medical care which is a more curative approach that attempts to keep someone alive. There is a realization that there is no cure left, its a switch in understanding from trying to fix their disease, to letting the disease take its course and giving the patient quality final days.

How do gender beliefs support and/or undermine health for men and women?

They shape the kind of care they receive. What these are getting at is, if a woman goes to the hospital for pain and the doctor holds the beliefs written below, they are going to attribute all of the ailments to "just being a girl". Whereas if a man goes in for pain, they will think the man is weak and they should just tough it up. Men: they need to be tough, take risks, strong-stoic figures, and they need to defend their honor. They don't need help, they are smart, active, adventurous, and they can't have emotions or else they are seen as girly. Women: passive, vulnerable, less competent and intelligent than men, weak, child-like, their bodies are shameful distractions to men, their bodies belong to men so they should be sexually available at all times

How are scientific knowledge and medical evidence socially constructed?

Through medicalization (non-medical things being treated and defined as medical problems). It takes things that are considered bad behavior and turns it into sicknesses and diseases → removes stigma from certain conditions (ex. Alcoholism came from public drunkenness) and shines light on misunderstood and rare conditions (ex. tourettes). Transforms normal processes, conditions and human variations int sickness. → childbirth is now dangerous and childhood hyperactivity is now ADHD, shyness is Social Anxiety Disorder, and aging is a disease and dysfunction (menopause needs to be "fixed".)

What is the fundamental philosophy of hospice that Nancy McCranie discussed in class?

To make the disease/illness a peripheral factor, and let you live out your last days within the context of humanized care. Death should not be considered a medical event, it is a human one and should be treated as a human one. Taking death back from over medicalization.

What harm reduction strategies have been adopted?

Treating addicts as sick, not as criminals. "Grants to train first responders. Alternatives to incarceration. Prescription drug monitoring programs. Politicization of treating addicts. Emergency needle exchange programs. Naloxone (Narcan) hand-held auto-injector is now available by standing prescription for $100. Anti-overdose Public Health Campaigns" (11/27). "Alternative approaches: acupuncture, massage, meditation, chiropractic therapy, physical therapy, cognitive behavioral therapy" (11/27).

How have public health campaigns worked to increase access to Naloxone/Narcan?

We need more first responders to help save lives and sell the drug over the counter. }The opioid overdose antidote naloxone has reversed more than 10,000 overdose cases between 1996 and 2010, according to CDC. }For many years, naloxone was available only in an injectable formulation and was generally only carried by medical emergency personnel. }However, FDA has recently approved a new hand-held auto-injector of naloxone to reverse opioid overdose that is specifically designed to be given by family members or caregivers. In order to expand the options for effectively and rapidly counteracting the effects of an overdose. }Texas passed law in June 2016 for a standing prescription order for pharmacies to administer naloxone to individuals. }Drug costs $50-100

How do moral beliefs shape our perceptions of the epidemic and of those affected?

We see the addicted/affected as being "sinners," and therefore responsible for their own actions. We remove responsibility from society and place it on the individual. The individual then becomes solely responsible for his/her recovery, but addictions can not be overcome without help. Essentially we provide the means and incentives for these people to become addicted, and then when that happens, we label them as "evil sinners" and refuse to help them or hold societal factors responsible, and abandon them to their addictions without help.

Why do health issues that relate to gender issues and especially sexuality often carry a moral status?

We talked about the HPV vaccine in the discussion that answers this question. Morally right because it prevents the young girl from a host of diseases when they are older, but because it is an STD vaccine and they are a child when they receive it, the parents overlook this fact because they think it promotes promiscuity at a young age and forces them to think about their child having sex at some point in their lives. In addition to this, we talked about how the vaccine is targeted at young girls and assumes that the girl is consensually having sex, but it leaves rape victims out of the picture. I THINK (add any notes you find, slides don't directly answer this) it's because they usually contain a dichotomy between individual choice vs. social institutions. Many religions preach clearly about appropriate sexual behaviors that are contradictory to popular culture and progressivism. For example, GSM (Gender and Sexual Minorities) rights, sex ed., and abortion. In regards to school-based health clinics: "Opponent leveraged "moral complaints" about removing parental authority, and the concern that sexual health education would encourage promiscuity" (11/15 Slide 9). "Some claim/worry that promoting the HPV vaccine is an endorsement of sexual promiscuity" (11/15 Slide 24).

What groups and individuals might lose power as a result of medicalization?

Women may lose their power and choice in having a baby naturally. Any complications that arise during the natural process make the doctor want to give her a C-section right away even if that is not what the mother wants.

When and how does the perception of aging get better?

You start to appreciate what you have instead of comparing yourself to others in your 50s. Happiness takes a U-turn and the worst of it is in your 40s. "People invest in what is important, typically meaningful relationships, and derive increasingly greater satisfaction from these investments." Midlife is, for many people a time of recalibration, when they begin to evaluate their lives less in terms of social competition and more in terms of social connectedness" (Rauch p. 12). "Youth is a period of perpetual disappointment, and older adulthood is a period of pleasant surprise" (Rauch).