Lecture 1 – Cultural influences on Medicine
Biomedicine is based on a set of scientific knowledge. Other cultures may base their medicine on different sets of knowledge.
Disease = organic dysfunction. Illness = patient experience.
Lecture 2 – Hidden Values
Dualism = mind has a distinct non-physical substance, different to that of the physical body. Cures are often viewed as requiring manipulation of the body. Can also lead to viewing illness as a moral state.
Attempts at integration: Psychosomatic medicine, cites hysteria in women as example of illness and physical disease are caused by psychology. Treatment is to reassert rationality (eg. Cognitive behavoural therapy). Problem – discount illness experience.
Alt. intergration attempt: View individual's suffering as context dependent. Do not discount illness.
Lecture 3 – Nosologies
Nosology = system of classifying disease. Eg. of classificatory schema include by symptom, by causes outside the body, by disease mechanism.
Syndrome = idiopathic but discrete clusters of symptoms.
Eg. Yellow fever – initially classified by symptoms, but many attempts to define by aetiology (cause), such as poor morals, poor environment, dysfunction of the liver or blood, or due to a microbe.
Eg. Homosexuality – DSM 1: Sociopathic Personality Disorder. Classified by symptoms. DSM III – Classified as a biological pathology. Note cultural context may dictate which of two states is desired, and which is diseased.
Biomedicine – views pathologists as nosological referees. However, most illnesses have many causes, and most therapies treat symptoms not causes. Beware of cultural bias is pathologising a state.
Lecture 4 – Embodiment
Embodiment = subjective experience of the body. Merleau-Ponty described body as the subject-object (simultaneously seen and seeing). Mode of expression of an illness often mirrors a social/cultural inequality.
Eg. SLUDGE from organophosphate poisoning. Sufferer was in debt, lived in a poverty stricken country. The more distal, socio-cultural causes of suffering need to be considered in addition to proximal organic ones.
Western culture-bound syndromes: Social phobia, chronic fatigue, PMS, postnatal depression.
Lecture 5 – Medical modes
Parentalist mode – tell patient what to do. Acknowledges knowledge asymmetry, but doctors aren't parents, may lead to problems with patient autonomy.
Partnership mode – ask patients which of a range of doctor-preferred options they would like. Acknowledges patient autonomy, but susceptible to third party interference and doctors may be viewed as failing to advise.
Consumerist mode – total priority given to patient autonomy. Role of doctor is to provide information . However, this assumes choice is liberating, and ignores power hierarchies in consultation.
Psycho-dynamic mode – Seeks underlying causes (often socio-cultural) for patient's illness. Takes into accounts the many determinants of illness, but takes too long for acute care.
Lecture 6 – Placebo
Placebo = a simulated medical intervention which has a beneficial effect.
Nocebo = a simulated medical intervention which has a malignant effect.
Patient and doctor expectations + conditioning seen as key.
Nocebo may be triggered by changing drugs to find ones without side-effects, over-investigating, and not recognising pre-existing conditions.
Ethical concerns abound with deliberate use of the placebo effect. The doctor may themselves be a placebo, if patient has increased expectation + past experience (conditioning) of increased wellness after visiting.
Lecture 7 – Suffering and social inequity
Health transition: shift from acute, infectious disease to chronic and lifestyle diseases.
McKeown thesis: the determinants of health are largely socio-economic.
Malthus: disease as a consequence of overpopulation
Other frameworks for considering causes of disease outbreak include virulence factors (agent), culture and biological factors (host), service delivery failure (environment).
Eg. Ebola outbreak in Uganda - highly virulent bug, social inequality, culture factors, and warfare disrupting health care.
Countries that cope (Sri Lanka, Costa Rica): sustained political commitment to social equity, education particularly of women, training of health workers, health infrastructure.
Lecture 8 - Inequity and plague
Great plagues: bubonic plague, Syphillis, influenza
The cause of AIDS was much debated, with poor morals, witchcraft and AZT therapy all being claimed as causative agents. Famine is made worse, or possible entirely caused by social inequity. Famine and AIDS both distributed along lines of social inequity.
Questions
Which of the following is not a foundational principle of biomedicine?
- Immunology
- Anatomy
- Phrenology
- Genetics
- Physiology
Ben: “The doctors said I must have had HIV for the last two years at least. But until a month ago, I felt fine. Then I developed an oral thrush." When did Ben become ill?
Responses to Ben's (a South African) condition were varied. They included:
"This disease is punishment for immoral behaviour."
"People need to shower after sex. Then they won't get sick."
"The growing prevalence of HIV infections like this demonstrate the inadequacy of the South African sex ed programs."
"As a pathologist, I have found overwhelming support for the theory that cases of AIDS like is are the result of HIV infection"
What nosologies are being used in each statement?
Jane Smith goes to see a GP, for a breast checkup. Afterwards, she complains that the doctor outlined several options for monitoring the health of breast tissue, and although they outlined the advantages and disadvantages to each approach, they failed to identify which option would be best for her. Instead, they stated that this was something she must decide for herself. What was the mode of this interview? Which mode would Jane Smith have preferred?
A 31 year old women presents to a plastic surgeon requesting plastic surgery and augmentation of the breasts. She has a small scar on one breast from a lumpectomy. What mode of doctor-patient interview is appropriate here, and why?
Which of the following is a good reason to use the parentalist mode?
- Acute illness
- Chronic condition
- A request for cosmetic surgery
- When dealing with a syndrome, rather than a recognised disease.
- None of the above
A headline in the newspaper reads “Flesh-eating bacteria savages young girl in hospital”. The follow table gives explanations for the event. Complete the table, indicating what element of the epidemiological triad is invoked, and what type of response the health system is likely to prioritise.
Australia is widely regarded as the premier example of a rapid and effective response to the HIV epidemic. Outline the elements of this response.
A lecturer repeatedly tells her class that particular topics are 'difficult'. Many in the class struggle to understand the material presented. What effect are future warnings of difficulty likely to have, and why?
Doctor A: The brain is merely electronic circuitry composed of meat
Doctor B: Any purely organic explanation of disease fails to take account of psychology
Doctor C: Arguments against smoking due to the possibility of lung cancer in old age don't make much sense if you live in such poverty you are unlikely to see old age anyway.
Doctor D: Pain is what the patient says it is
Which of the following concepts go with the above statements? Embodiment, Dualism, McKeown thesis, Materialism
Which of the following are culture bound conditions?
- Influenza
- Stress
- Susto
- AIDS
- Hysteria
- Chronic fatigue
