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Biomedical subjects

D Coburn

Publications and source records attributed to D Coburn.

At least 19 recordsLinked to original sources
PubMed2000

Income inequality, social cohesion and the health status of populations: the role of neo-liberalism.

There has been a recent upsurge of interest in the relationship between income inequality and health within nations and between nations. On the latter topic Wilkinson and others believe that, in the advanced capitalist countries, higher income inequality leads to lowered social cohesion which in turn produces poorer health status. I argue that, despite a by-now voluminous literature, not enough attention has been paid to the social context of income inequality--health relationships or to the causes of income inequality itself. In this paper I contend that there is a particular affinity between neo-liberal (market-oriented) political doctrines, income inequality and lowered social cohesion. Neo-liberalism, it is argued, produces both higher income inequality and lowered social cohesion. Part of the negative effect of neo-liberalism on health status is due to its undermining of the welfare state. The welfare state may have direct effects on health as well as being one of the underlying structural causes of social cohesion. The rise of neo-liberalism and the decline of the welfare state are themselves tied to globalization and the changing class structures of the advanced capitalist societies. More attention should be paid to understanding the causes of income inequalities and not just to its effects because income inequalities are neither necessary nor inevitable. Moreover, understanding the contextual causes of inequality may also influence our notion of the causal pathways involved in inequality-health status relationships (and vice versa).

Health Status↗
PubMed1999

Phases of capitalism, welfare states, medical dominance, and health care in Ontario.

There has been a lacuna in previous studies of medicine and health care of concepts or structures relating changes in health care with their contextualizing social structures. That is, there is a need to more adequately account for health care and social structure in terms of dynamic rather than static concepts. This article reports the application of a general schema outlining the transformation of capitalism through the phases of entrepreneurial, monopoly, and global capitalism, first presented by Ross and Trachte, to help understand both the changing role of medicine in Canada and the historical trajectory of the development of health insurance. These related events are shown to be partly reflective of the transformed class dynamic involved in a changing capitalist mode of production. The recent history of challenges to medicare in Canada as well as evidence of the declining power of medicine are both related directly and indirectly to the increased power of business and the decline in the relative autonomy of the state accompanying globalization. The application of the phases of capitalism sequence does roughly fit the Canadian instance although some modifications will be required to account for the specifics of the Canadian case. The schema also helps resolve two previously competing class arguments about the rise of health insurance in Canada.

Delivery of Health Care↗
PubMed1998

Wealth, equity and health care: a critique of a "population health" perspective on the determinants of health. Critical Social Science Group.

In this paper we examine the recent ascendancy of a "population health" perspective on the "determinants of health" in health policy circles as conceptualized by health economists and social epidemiologists such as Evans and Stoddart [Evans and Stoddart (1990) Producing health, consuming health care. Social Science & Medicine 31(12), 1347 1363]. Their view, that the financing of health care systems may actually be deleterious for the health status of populations by drawing attention away from the (economic) determinants of health, has arguably become the "core" of the discourse of "population health". While applauding the efforts of these and other members of the Canadian Institute for Advanced Research for "pushing the envelope", we nevertheless have misgivings about their conceptualization of both the "problem" and its "solutions", as well as about the implications of their perspective for policy. From our critique, we build an alternative point of view based on a political economy perspective. We point out that Evans and Stoddart's evidence is open to alternative interpretations--and, in fact, that their conclusions regarding the importance of wealth creation do not directly reflect the evidence presented, and are indicative of an oversimplified link between wealth and health. Their view also lacks an explicit substantive theory of society and of social change, and provides convenient cover for those who wish to dismantle the welfare state in the name of deficit reduction. Our alternative to the "provider dominance" theory of Evans and Stoddart and colleagues stresses that the factors or forces producing health status, which Evans and Stoddart describe, are contained within a larger whole (advanced industrial capitalism) which gives the parts their character and shapes their interrelationships. We contend that this alternative view better explains both how we arrived at a situation in which health care systems are as costly or extensive as they are, and suggests different policy avenues to those enunciated by Evans, Stoddart and their confrères.

Canada↗
PubMed1993

State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case.

The relationships amongst the health professions and between them and the state are rapidly changing. I argue that analysis of these relationships has to take into consideration: the fact that medicine played an intermediary role (through medical dominance in health care) between the state and the other health occupations; the permeability of the boundaries of the state and the professions; and the dual nature of professional organizations (as sites of intra-occupational conflict and as possible vehicles of extra-occupational control). In Ontario the medical profession partially 'mediated' the relationships between 'non-physician' health occupations and the state through medical control over other health care occupations. National/provincial health insurance brought the state into the health care system as an actor and forced a reconsideration of its relationships with medicine and with the other health care occupations. The state came to be directly involved in 'rationalizing' health care. This involvement meant curbing the power of medicine and modifying the relationships between medicine and the para-medical occupations. State influence is partly constructed through a particular kind of professional organization, namely, the professional College. These changing relationships are illustrated by historical and recent developments regarding medicine, nursing and chiropractic in Ontario.

Chiropractic↗
PubMed1993

State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case.

The relationships amongst the health professions and between them and the state are rapidly changing. I argue that analysis of these relationships has to take into consideration: the fact that medicine played an intermediary role (through medical dominance in health care) between the state and the other health occupations; the permeability of the boundaries of the state and the professions; and the dual nature of professional organizations (as sites of intra-occupational conflict and as possible vehicles of extra-occupational control). In Ontario the medical profession partially 'mediated' the relationships between 'non-physician' health occupations and the state through medical control over other health care occupations. National/provincial health insurance brought the state into the health care system as an actor and forced a reconsideration of its relationships with medicine and with the other health care occupations. The state came to be directly involved in 'rationalizing' health care. This involvement meant curbing the power of medicine and modifying the relationships between medicine and the para-medical occupations. State influence is partly constructed through a particular kind of professional organization, namely, the professional College. These changing relationships are illustrated by historical and recent developments regarding medicine, nursing and chiropractic in Ontario.

Chiropractic↗
PubMed1992

Freidson then and now: an "internalist" critique of Freidson's past and present views of the medical profession.

Freidson is a foremost analyst of the medical profession. Most recently Freidson attacks those who claim that medicine is declining in power. He insists that medicine has not lost the core elements that make it a powerful, indeed, the dominant, health profession. The author compares Freidson's early writings on medicine with his most recent ones, and shows that there are critical confusions in Freidson's central concepts of professional autonomy and dominance. This difficulty is illuminated by viewing dominance, autonomy, and subordination as on a continuum of control. Using this continuum, the author argues that Freidson implicitly admits what he set out to deny (that medicine has not declined in power) by shifting his focus from medical dominance to that of autonomy. Freidson also now rejects valid parts of his earlier work (that which emphasizes social structural determinants of behavior over socialization). In equating medicine in the United States with teaching in that country, Freidson's contention of "little change in medical power" meets its own refutation. Finally, despite his derogation of others, Freidson's lack of an adequate framework to explain the dynamics and not simply the structure of health care produces purely normative, utopian (and unhelpful) policy recommendations.

Communism↗
PubMed1991

Legitimacy at the expense of narrowing of scope of practice: chiropractic in Canada.

A number of researchers from Australia, Britain, the United States and Canada describe the twentieth century development of chiropractic in terms of increased official and public recognition "in exchange for" a narrowing of scope of practice claims. This process in Canada is briefly described and is illustrated by examining chiropractic's relationships with naturopathy, a broad scope of practice health occupation. It is shown that chiropractic in Canada first used naturopathy to try to expand its own scope of practice, but then quickly rejected any official connections with a broad scope naturopathy in a recent drive to gain state recognition for a chiropractic "purified" of its past all-inclusive claims, a drive which has been at least partially successful. Yet, this narrowing contradicts chiropractic's frequent claims to be a holistic health discipline and presents practical problems for chiropractic. While chiropractic is in the process of gaining official recognition under proposed health disciplines legislation in Ontario, it is faced with dilemmas produced by its contradictory claims to narrowing and to holism. At the same time, chiropractic, along with many other previously subordinate health occupations, seems to be in the process of replacing medical dominance with a broader, but perhaps just as authoritarian, regime of "professional dominance." Will success inevitably bring not only an implicit acknowledgement of the claims of orthodox medicine, but also a separation of chiropractors from patients, those whom chiropractors once made a unique claim to serve?

Canada↗
PubMed1988

Naturopathy in Canada: changing relationships to medicine, chiropractic and the state.

It is said that we can learn as much about social processes from so-called 'deviant' institutions than from the more legitimate. 'Deviant' medical occupations have not attracted much attention from social scientists. Naturopathy is one of these nonconventional health occupations. It emerged in the 18th and 19th centuries and moved to Canada from the United States and Europe early in the 20th. The social history of naturopathy in Canada illustrates the importance of processes of occupational formation and organization as well as state recognition or legitimation. Furthermore, the development of naturopathy shows the importance of state-occupation and naturopathy-chiropractic relationships as well as the often noted relationships with the dominant health occupation of medicine. Incidentally noted are the changing relationships with the state and the dominance of the ideology of science.

Canada↗
PubMed1988

The development of Canadian nursing: professionalization and proletarianization.

In this article, the development of nursing in Canada is described in terms of three major time periods: the emergence of lay nursing, including organization and registration, 1870-1930; the move to the hospital, 1930-1950; and unionization and the routinization of health care, 1950 to the present. This development is viewed in the light of the orienting concepts of professionalization, proletarianization, and medical dominance (and gender analysis). This historical trajectory of nursing shows an increasing occupational autonomy but continuing struggles over control of the labor process. Nursing is now using theory, organizational changes in health care, and credentialism to help make nursing "separate from but equal to" medicine and to gain control over the day-to-day work of the nurse. Nursing can thus be viewed as undergoing processes of both professionalization and proletarianization. As nursing seeks to control the labor process, its occupational conflicts are joined to the class struggle of white-collar workers in general. Analysis of nursing indicates the problems involved in sorting out the meaning of concepts that are relevant to occupational or class analysis but which focus on the same empirical phenomenon.

Canada↗
PubMed1988

Canadian medicine: dominance or proletarianization?

Changes in the Canadian health care system since the early 1960s, especially the introduction of national health insurance and increased government control over the cost and utilization of services, have been resisted by the medical profession. The history of the conflicts between the Canadian government and the medical profession over control of the health care system provides evidence that medical dominance has declined. In spite of its loss of power over the organization of health care and medical work, however, the profession is still too powerful to be described as proletarianized. Freidson's theoretical conception of professional dominance provides the best explanation of the position of Canadian physicians, but his argument that power is preserved by having physicians control other physicians fails to take into account the profession's lack of internal cohesion.

Canada↗
PubMed1986

Limits to medical dominance: the case of chiropractic.

This paper describes and analyzes the social history of chiropractic in Canada to partially test a thesis regarding changes in the dominance of the medical profession. We earlier sketched the rise of medicine to dominance by World War I, its consolidation until after World War II, and signs of the start of a decline in dominance signalled by the 1962 doctors' strike in Saskatchewan. One test of the historical sequence described, and particularly the recent signs of decline in medical power, is to examine one of orthodox medicine's major competitors, chiropractic. To what degree has medicine been successful in its opposition to chiropractic? The development of chiropractic in Canada shows its early survival and latterly, in the 1960s and 1970s its increasing popular use and official recognition. Particularly important in its recent success was the establishment of a college in Canada in 1945 and partial inclusion of chiropractic under government health insurance in the 1970s. While chiropractic has gained in acceptance and recognition it has sacrificed many of its earlier claims to be an alternative healing art and to some degree chiropractic has become 'medicalized'. But medicine has also been forced to make concessions. Despite total medical opposition, chiropractic survives. The recent successes of chiropractic tend to confirm our earlier thesis of the beginnings of the decline of medical dominance and to show that medicine, while dominant, was never hegemenous. However, chiropractic did not produce medicine's current difficulties. Rather medicine is being challenged directly by state power and pressures to rationalize health care and indirectly is affected by the class struggle. Chiropractic itself owes much of its own early success to support by the working class and working class organizations such as unions. In this sense both medicine and chiropractic can only be adequately viewed both in relationship to one another and as part of the changing Canadian social structure as a whole.

Canada↗
PubMed1983

Medical dominance in Canada in historical perspective: the rise and fall of medicine?

Freidson's concept of medical dominance is compared to the alternative conceptions of neo-Marxist writers. Dominance is then examined in historical perspective, using medicine in Canada (mainly Ontario) as a case study. Medicine emerged as the dominant health occupation in Canada in the late 19th and early 20th centuries, consolidating its power between World War I and the Saskatchewan doctors' strike of 1962. The authors argue that medical dominance has declined since that time due to such factors as the involvement of the state in health insurance, the rise of other health occupations, increasing public or at least elite skepticism, and possible internal fragmentation. The underlying social explanation for this historical process is sought in changes in the Canadian class structure, specifically the spread of the capitalist mode of production, the decline of the petite bourgeoisie, and the rise of the state. It is suggested that Freidson's specific accounts of the history of medicine must be incorporated for explanatory purposes within the broader neo-Marxist view of medicine as an intermediary rather than an ultimately determining institution.

Canada↗
PubMed1979

Job alienation and well-being.

This paper analyzes the relationships between alienation conceived as monotonous, repetitive work and alienation as job-worker incongruence to a variety of measures of worker as well-being among a population of workers from Victoria, British Columbia. The data show weak relationships between work perceived as monotonous and general psychological and physical well-being and between alienation as job-worker incongruence and health. While weak in variance-explained terms, the relationships show the predicted patterns are robust and are independent of a large number of control variables. Percentage differences in well-being between the alienated and nonalienated workers are fairly substantial. Some societal implications of the findings are discussed.

Adult↗