Monthly Archives: January 2008

Pathways to the doctor: "clinical iceberg" and "the long tail"

I have been reading and taking some wiki notes about ‘Pathways to the Doctor’ in the Information Age: the Role of ICTs in Contemporary Lay Referral Systems written by Nettleton and Hanlon. The article stars explaining the ‘clinical iceberg’ concept identified by social scientists (Last, 1963; Wadsworth et al., 1971) during the post-war years. This concept refers to how and why individuals do, or do not seek medical help. In 1973, Zola’s study of the reasons given by outpatients revealed that it was not symptoms per se that prompted people to seek help but rather it was their social circumstances. He identified five ‘distinct no-physiological’ triggers to the decision to seek medical aid’:

  • the occurrence of an interpersonal crisis;
  • the perceived interference of an illness with social relationship;
  • ‘sanctioning’ by another person that a visit is warranted;
  • perceived interference whith physical activities;
  • and temporalizing symptoms -’if its no better by Monday’ (p.58).

In other words medical and health advice was proffered and sought within what came know as the ‘lay referral system’ (Freidson, 1970). Sociologists therefore cast light on the informal health care work undertaken by lay people and demonstrated that in seeking formal health care professionals saw only the tip of the iceberg of illness (p.58).

Echoing Pickstone’s periodisations of medicine, Smith (2002) conceptualises a move from what he calls ‘industrial age medicine’ to ‘information age healthcare’:

Going over my notes, I have found points in common between the ‘clinical iceberg’ and ‘the long tail’ concept. But even in this ‘Information age health care’ Nettleton and Hanlon concluded that people’s pathways to care are rooted in their wider social circumstances, their particular health care needs and, in terms of gender at least, are structurally constrained. But somewhat paradoxically there seem to be two processes at work here. On the one hand there is a growing diversity of health care provision and use, and yet on the other hand the norms and values that underpin notions of health care use are concurrently contributing to reinforcement of the caution and conventionality. It appears that the Internet use is actually more contextually specific and so the circumstances of use tend to be both embedded and embodied.

Digital Natives and eHealth

The Spanish Health Minister has published a press release talking about its collaboration with Microsoft to launch Robot Robin, a Windows Live Messenger Assistant that helps young people through the Messenger to resolve doubts about health issues related with sex, pregnancy and alcoholic drinks. It is said that people can add Robin to the personal contact list and interact with him taking into account legal, privacy and security issues.

This initiative points out some trends detected in relation with health and the Internet as Innovative Health Technology:

  • The importance of the private sector and the interest of the big companies like Microsoft and Google to get into this huge market.
  • The importance of analyze the supply and the demand side, in this case digital natives as a heavy Internet users (demand) and the Internet as a tool to reach this audience, taking into account the possible digital divide.
  • The importance of the understanding about how people use existing technologies everyday to develop new uses.

Understanding Innovative Health Technologies by Andrew Webster

I have been reading Health, Technology & Society. A Sociological Critique written by Andrew Webster, who has also written other articles and books about this issue. I would like to share my notes about the first chapter titled Understanding Innovative Health Technologies, partially  based on other author’s paper Innovative Health Technologies and the Social: Redefining Health, Medicine and the Body.

The book explores fundamental changes in the way we understand and manage our health and our bodies, and how this understanding has been shaped by, and given expression through, developments in medical and related technologies (p.1)  from a sociological perspective. This perspective argues that these technologies and the techniques, models and assumptions on which they are based, are given meaning through the way they are tied into other technologies ans social practices… The meaning of health technologies will also vary in different settings (from clinic, to the home, to the Internet), and vary in the way shape diverses notions of ‘health’ found within and between cultures. In this sense, technologies (not only the health but all fields) are best understood as an expression of, and thereby always expressed through, social relationship (p.1) .

The author states that medical technologies are two-sided: they provide new, more detailed, sources of information about our illness but at the same time new forms of uncertainty and risk. These relate not only to our understanding of the illness but also the expectations that inform and guide the social relationship through which we define and manage it. If technologies are congealed social relationship, those that disrupt existing relationship can be specially problematic.

Therefore,  new health technologies not only disrupt relationship we have with other people, they can also redefine our relationship towards our own body and our sense of being well or ill, our sense of control over our body and its parts (p.2).  A sociological perspective is also interested in the processes through which new health technologies are introduced in the first place, and what factors have shaped their introduction. Health and its definition depend not merely on a person’s sense of well being, but on powerful professional, commercial and institutional interests that captures health in order to define, control and exploit or deliver ‘it’ (p.3) .

New technologies, new health?

Webster identifies three innovative health technology based on those areas that are receiving disproportionately large levels of public and private funding upstream or those appearing in documents of health policy world that spends all its time scanning for the ‘horizon’ for ‘disruptive’ technologies…(p.6):

  • Genetics-related developments
  • Informatics-based systems and eHealth
  • Tissue-related biomedicine

Even these three broad areas are strongly related with the development of the Information and Communication Technologies I wil just focus on Informatics-based systems and eHealth. The author refers to E-Health as a mix of digital technologies whose function is to diagnose, monitor, store and relay information about health, the patient, and the huge volumen of management data-flows that characterize national health systems today. They reflect a time of audit, standardization, technocracy and ambitions towards more efficient systems for managing health resources (p.11) . Based on the studies of other author, Webster describes some consequences of these technologies, talking about ’citizen-terminals’, ‘virtual human’, ‘smart homes’, ‘health Internet seeker’ and ‘e-scaped medicine’.

Developing the sociological critique

The author remarks there had been a much longer tradition in social theory that located health squarely within the wider structural and cultural dynamics of society (p.15)  and wonders How, we might ask are these structural patterns of health mediated by the new technologies sketched mentioned above: will, for example, the introduction of e-health exacerbate or ameliorate access to health care and advice? (p.16)

What then can we say provides the core issues that would inform a sociological critique of the relations between health, technology and society? Such a critique, he suggests, would explore and challenges the implications of medical technoscience with respect to:

  • the socio-economic factors shaping innovation and how these affect the structuring of health care delivery;
  • the patterns of inequality in morbidity and mortality;
  • the public and the private institutions that are investing huge amounts of political and economic capital in existing and novel areas such as genetics, informatics and tissue engineering fields;
  • the regulation and control of new medical technologies;
  • embodied knowledge about experience of health and disease. (p.17)

These are the main issues, they need to be understood as part of a wider range of structural and institutional changes characterizing contemporary societies that are not restricted to the field of medicine and health (p.18)

  • The growing individualisation of our lives;
  • The changing relationships between lay and expert knowledge;
  • The increasingly globalised contest over (health) rights and resources;
  • The tension between the political regulation and economic promotion of innovation by the state. (p.18)

We can see developments in technoscience in terms of three broad but related changes that have opened up clinical medicine to new influences and actors:

  • Socialisation of medical innovation refers to the ways in which lay people are enrolled as active participants in the development of new technologies from the very early stage of develpment.
  • Socialisation of clinical diagnosis refers to the fracturing of the medical monopoly over the meaning of health and disease, specially through the arrival of what has been called a ‘new medical pluralism’.
  • Socialisation of clinical implementation refers to the ways in which lay people are required, but also perhaps actively embrace a turn towards taking greater responsability for making new health technologies ‘work’.

These three processes have then redefined the spatial, experimental and epistemic boundaries of convetional medicine and clinic. The critique must be the attentive context of use of technologies to reflect any notion of technological determinism across different contexts. It must explore the ways in which users (patients, carers, clinicians, etc.) make sense of technologies and how re-order the meaning of health. It must examine the expectations and hopes that surround them, and the subtle and not so subtle forms of inequity and insecurity they create.

Health Literacy in a Network Society

It has come to my notice that MedlinePlus has a new page on Health Literacy where Health literacy is defined as “the ability to understand health information and to use that information to make good decisions about your health and medical care. Health information can overwhelm even people with advanced literacy skills”.

eHealth has been tackled the issue of literacy (see as an example eHealth Literacy: Essential Skills for Consumer Health in a Networked World) putting the emphasis on “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem”.

Talk about health literacy in the Network Society may include aspect related to the Internet, not as a separate world but as an integrate world where this technology is embedded, directly or not directly, in many aspects of our life. According to that it’s difficult to understand why the word Internet doesn’t appear on the first page of the Health Literacy or on the Quick Guide to Health Literacy  page. It’s probably time to integrate the Internet in all the activities related to health and try to avoid the “e” label.