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This paper focuses on constructions of research ethics by primary care physicians in the USA as they engage in contract research for the pharmaceutical industry. Drawing first upon historical studies of physicians as investigators and then upon 12 months of qualitative fieldwork in the South Western US, this paper analyzes the shifting, contextualized ethics that shape physicians’ relationships with patients/subjects and pharmaceutical companies. Just as physicians followed professional codes of ethics prior to the codification of acceptable research conduct in the 1980s, physicians today continue to develop tacit systems of research ethics. This paper argues that private-sector physicians primarily conceptualize their ethical conduct in relation to the pharmaceutical companies hiring them, not to human subjects they enroll in clinical trials. This is not to say that these physicians do not follow the formal U.S. regulation to protect human subjects, but rather that their financial relationships with the pharmaceutical industry have a greater influence on their identities as researchers and on their constructions of their ethical responsibilities.

The basic premise of the paper is that Western medicine's co-opting of specific technologies and materials from other (indigenous) medical traditions, stripped of the original theories underlying their use, has problematic consequences for the practitioners and patients of both source and recipient traditions. The paper begins by illustrating the historical continuity of this process by way of an example from India's colonial era. The fact that specific practices or materials are regarded as biomedically useful because they ‘work’ (are efficacious) does not mean that the ‘traditional’ theories underlying them are seen as correct. The knowledge contained in these traditions is not counted as legitimate, as the emphasis in biomedicine (the legitimate canon) on an identifiable concrete location in the body for the source of health problems creates difficulties—both for patients when their problems are not provided with a cause that matches their subjective awareness, and for the practitioners of other traditions whose patients have been exposed to biomedicine. The paper goes on to demonstrate, using case examples from extended ethnographic fieldwork in southern India, how this is played out in a setting in which an educated Indian patient population accepts this form of knowledge as legitimate but espouses ayurvedic therapy. Notions of ‘evidence’ are shown to be central to the interplay between biomedical and other medical traditions, since objective tests and measures in biomedicine are accepted as the only legitimate ‘evidence’ of cure, but these do not necessarily accord either with the premises of these other traditions or with patients’ subjective perceptions of well-being. Returning to an acceptance and practice of other traditions, consequently, requires nothing less than a fundamental cognitive shift in the grounds for what constitutes ‘evidence.’

Sociological investigation of informed consent has generated rich and complex descriptions of the clinical encounter, often challenging the straightforward picture painted by medical ethicists. This paper builds on this work, drawing on ideas from the Sociology of Science and Technology, to explore informed consent issues surrounding the use of the drug Herceptin, widely cited as an example of a novel approach to drug development called pharmacogenetics. Drawing on qualitative semi-structured interviews with 25 UK-based breast cancer specialists, this paper explores Herceptin's disputed epistemological status, as an example of pharmacogenetics or as something out of the ordinary in terms of clinical practice. It considers how, in turn, this impacts on the way in which informed consent is sought and influenced by clinicians' desire to protect patients from possibly distressing test results. It highlights the flexible, contingent and context dependent nature of informed consent in the clinical setting.

Although the relevance of patients' views about medicines for their medicine taking behaviour is now well established, little is known about the ways in which these views are discussed in primary care consultations. In particular, many studies have demonstrated patients' aversion to medicines. This paper examines the form that aversion talk takes in the consultation and how doctors respond to patients' expression of aversion to medicines. It is based on a dataset of 35 case studies of general practice consultations in England. In interviews with researchers, aversion to medicines was expressed in 34 of the 35 cases. In consultations with doctors, aversion was expressed in 10 cases. The interactional dimension of aversion talk in consultations was analysed using Conversation Analysis, and two general patterns were identified. Aversion could be used as an interactional resource, or it could be a topic in its own right. If used as an interactional resource, no real discussion of patients' views of medicines took place. When aversion was a conversational topic in its own right, two situations were observed. Firstly, the doctor elicited patients' views directly. Secondly, patients initiated aversive talk using a range of indirect strategies to do so. Even when patients managed to express their aversion to medicines, doctors did not engage them in any real discussion of their views. A scheme of interpretation is suggested to explain these findings. In this scheme patients perceive medicines to be an extension of the doctor and to be beneficial. In this view it is right for doctors to prescribe medicines and for patients to take medicines. The results of this paper suggest that using aversion as an interactional resource might be the only safe way for patients to express their aversion without seeming to breach the social contract.

In recent years what can loosely be described as a sociology of complementary and alternative medicine (CAM) has begun to emerge. Although work has been conducted with lay therapists, orthodox practitioners, and consumers, overall, research in this area remains patchy and underdeveloped. Despite its role at the forefront of integration, the sociological study of the apparent affinity between nursing and CAM is virtually non-existent. This paper provides an exploratory analysis of how writers within the CAM nursing sub-world adopt a recourse to history (nostalgic and nostophobic referencing) as a strategy to authenticate the relationship between nursing and CAM and so facilitate continuing integration. A text analysis, of articles written on CAM in four nursing journals, was conducted. Eighty papers satisfied the inclusion criteria. Evidence is presented of the way in which writers attempt to authenticate integration of CAM through reference to its apparent interconnectedness with the historically grounded core of nursing values, and more specifically, with the key historical figure of the nurse Florence Nightingale (1820-1910). It is argued that these rhetorical strategies can be understood in the context of the need to engage in (primarily) intra-professional persuasion: to protect and develop the values of their nursing sub-world over alternatives. The findings are preliminary. Themes identified are illustrative of the potential offered by an analysis of nostalgic and nostophobic referencing in this context, and not a definitive account of it. Further research should examine individually produced texts from other sources, and documents produced by relevant professional bodies. © 2002 Elsevier Science Ltd. All rights reserved.

Today it is estimated that over 100 million women worldwide have taken the oral contraceptive pill since 1956, when the first clinical trials were undertaken. Since its introduction on to the American market in 1960 and the British one in 1961, the pill has become one of the most popular contraceptives in both countries. Unlike other forms of drugs, which have primarily been formulated to prevent or cure illness, the oral contraceptive pill was designed to be given to healthy women over long periods of time, making the necessity for regulation and medical monitoring that much more pertinent. Focusing on the USA and Britain, this paper concentrates on the different ways in which each country has monitored and secured the safety of the pill between 1960 and 1970. While the British government decided to phase-out high dose oestrogen contraceptive pills associated with thrombotic disease in 1969, such pills continued to be available in the USA through to the 1980 s, with measures instead being directed towards supplying better information to patients about the possible side-effects of the pill. The paper explores the reasons for this difference in policy, showing how it was shaped by the particular research orientation of each country as well as the specific legal, medical, social and political traditions within Britain and the USA.

Ours is the age of science and technology. The conclusions of modern medical science and theories are derived from experimental research developed since the last century by the life sciences, with the methods of the exact and physical sciences, and the invaluable aid of technology. This paper compares past systems of medicine with our own, and examines the role of science and theory in medical practice, in the remote and recent past and at present. Has medical science and theory in the past been of benefit to medical practice? Has it helped the physician to understand disease? To treat the sick? Finally, the paper looks at a number of uncomfortable questions raised by medical practice in our own time. The widespread rejection of today's medical practice with its flawed doctor-patient relationship, its super-specialization and mechanization, and its incessantly growing reliance on technology, is examined in the light of the prodigious advances of modern medical science and some of its abuses and exorbitant claims as well as its rejection of the value of past medical systems. Our need is for an integration of the old and the new, in a synthesis that will lead us back to a more human medicine.

Studies of the lay evaluation of pain-relief clinics are rare, particularly in the U.K. Hence, in an attempt to rectify this lacuna, this paper reports the findings of a small-scale qualitative study which charts the vicissitudes of hope and despair of attenders at pain-relief clinics in London. In doing so, we demonstrate the complex interplay between peoples' pain careers, their styles of adjustment, socio-demographic characteristics, and their evaluations of medical treatment. Sadly, for many of these patients, this was the end of the road and their last hope of finding relief. Unfortunately, however, the overarching feeling was of medicine having "failed" them. The paper concludes with a discussion of these findings and some suggestions for possible future research in this area.

In contexts where healthcare regulation is weak and levels of uncertainty high, how do patients decide whom and what to trust? In this paper, we explore the potential for using Signalling Theory (ST, a form of Behavioural Game Theory) to investigate health-related trust problems under conditions of uncertainty, using the empirical example of ‘herbal clinics’ in Ghana and Tanzania. Qualitative, ethnographic fieldwork was conducted over an eight-month period (2015–2016) in eight herbal clinics in Ghana and ten in Tanzania, including semi-structured interviews with herbalists (N = 18) and patients (N = 68), plus detailed ethnographic observations and twenty additional key informant interviews. The data were used to explore four ST-derived predictions, relating to herbalists' strategic communication (‘signalling’) of their trustworthiness to patients, and patients' interpretation of those signals. Signalling Theory is shown to provide a useful analytical framework, allowing us to go beyond the primary trust problem addressed by other researchers – cataloguing observable indicators of trustworthiness – and providing tools for tackling the trickier secondary trust problem, where the trustworthiness of those indicators must be ascertained. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty., Highlights • Applies Signalling Theory (ST) to patient-herbalist trust in Ghana & Tanzania. • Herbalists communicate trustworthiness to patients via observable ‘signals’. • Patients interpret signal reliability based on perceived costs and pay-offs. • In conditions of uncertainty, informational mismatches result in misplaced trust. • ST allows us to go beyond description, enabling prediction and comparative work.

The fourth and most recent generation of hormones used in oral contraceptives has stirred a significant amount of debate regarding the safety of these compounds. Drospirenone, a new type of synthetic hormone used in popular oral contraceptives Yaz and Yasmin, has been found by epidemiologists to increase the risk of blood clots when compared to the previous generations of pills. North American regulatory bodies have investigated the health risks of drospirenone and concluded that the increased risks do not require pulling the new contraceptive technology off the market. Instead, the FDA and Health Canada along with several medical associations have actively managed the Yaz/Yasmin controversy through official statements and press releases between 2010 and 2014. This study provides an analysis of these documents and how risk information about drospirenone-containing pills has been presented to the public. The analysis addresses a gap in our knowledge about cultural factors that impact contraceptive risk assessment. Prevalent risk models used by professionals are highlighted and examined through the use of critical discourse analysis methods. More specifically, this paper highlights the main strategies used to put drospirenone risks into perspective and classify it as safe. I argue that while risks related to pregnancy and the postpartum period are overly-emphasized, other risks are downplayed through a selection process underscored by normative beliefs about women's bodies and sexuality. Future research needs to address consumer perspectives and bridge the gap between lay and scientific risk/benefit assessment of oral contraceptives.

This paper reports on a rapid ethnographic assessment methodology (REA) that was developed as an essential component of the dietary management of diarrhea (DMD) program. The DMD program is an interdisciplinary research project that has been developed to design intervention programs to reduce or eliminate the nutritional complications of diarrhea in Peru and Nigeria. Anthropological data gathering was an important component of the intervention design, but time and budgetary constraints required a rapid methodological approach. This paper outlines the REA methodology, describes the advantages and disadvantages of the approach, and discusses future applications for international primary health care interventions.

This paper reviews the literature on AIDS in Africa. By 29 February, 1988, 9760 cases of AIDS had been reported in Africa. This review addresses the currently accepted belief in the African origin of AIDS, the distribution (cluster) of AIDS in Africa, identified modes of transmission, and changing sexual and drug use behaviors in Africa. There is no conclusive evidence to show that the AIDS virus originated in Africa. Even if the progenitor virus had a habitat in central Africa, certain high-risk sexual behaviors which were introduced in the 60s and 70s may have initiated the infectious process. The distribution pattern does not suggest a transcontinental spread; rather, it suggests a contigual and transatlantic spread. The primary mode of transmission is heterosexual activity. This paper raises a number of questions relating to heterosexual behaviors. Other issues addressed include drug use behavior, homosexuality, and high-risk sexual activities of Africans and foreigners in Africa. Other modes of transmission are transfusion of contaminated blood and blood products, use of nonsterile needles, and perinatal transmission. It is not likely that traditional (folk) medicine will contribute to the spread of AIDS. Traditional doctors use fresh razor blades for cuts and not hollow instruments such as needles. The impact of the political and socioeconomic climate in most of Africa during the 60s and early 70s is evaluated. Finally, we make suggestions for future direction, which include confirmatory testing of HIV Positive samples, conducting clinical epidemiology and social science-based research, and developing innovative education programs that are culturally relevant.

This paper examines the concept and management of deafness among 98 randomly selected healers in Ile-Ife. We are concerned with deafness because in an earlier study mothers of deaf children reported that they had consulted these practitioners. All of the healers distinguished congenital and non-congenital deafness, and in their efforts to cure patients they were guided by experience and specialist knowledge. A higher proportion of the herbalists associated congenital deafness with natural causes than did the other type of healers. The babalawos and indigenous faith healers who mentioned a natural cause of congenital deafness believed that the primary causative agents were supernatural. Half of the indigenous faith healers and more than half of the babalawos we interviewed attributed non-congenital deafness to malevolent forces, while only 12.5% of the herbalists made this attribution. Treatment procedures and preventive techniques were based on conceptions of causality. While the majority of the herbalists prescribed a herbal ear drop, a majority of the babalawos and the indigenous faith healers prescribed sacrifices to appease the aggrieved parties. Some interesting points that emanated from the study include the healers' explanation that a person's essence is transmitted to his personal effects, which are used with incantation to inflict the deaf person. Closely associated with this is the healers' warning that patients need to maintain good-neighbourliness to avoid further harm. The paper further highlights the adherence to pregnancy taboos to avoid congenital deafness.

Some health care planners and scholars who work in developing countries have advocated the promotion of some form of cooperation, collaboration, or even integration of the medical services of biomedical practitioners with the services of local healers. This paper discusses issues that must be addressed in the consideration of such a possibility in a rural community in Zaire where the ‘dual use’ of medical resources is evident. After briefly outlining the characteristics of the biomedical and ethnomedical systems that now exist, the strengths and weaknesses of each system are evaluated and compared. In promoting cooperation between different types of practitioners, project planners, it is argued, should consider the strengths and weaknesses of each type of medical practice and should seek to improve the use of existing medical resources. The paper concludes by outlining a series of progressive stages of contact among practitioners that could lead to a system of mutual referral.

This paper traces the history of the theory of focal infection—which related a number of general conditions to septic foci from which toxic products spread to different parts of the body—and its application to dental diseases in early 20th century Britain. Bad teeth were said to be one of the major sources of infection and a cause of many diseases. The paper focuses on the social and professional context in which the theory emerged and flourished. It shows that in spite of its lack of scientific foundation. The theory of focal sepsis was readily accepted by the dental profession and used to advance its claims for professional recognition. Thus the paper attempts to illustrate the point that the acceptance of a medical theory by health practitioners is as much determined by social and economic factors as by its therapeutic potential or its scientific validity.

Higher rates of reported illness among women than men and more frequent use of medical services by women in Western societies have been of considerable interest to medical sociology. In contrast, relatively little attention has been paid in medical anthropology to gender differences in illness rates and utilization of medical services in non-Western areas. In a study of four urban Filipino healers and their patients, it was found that women outnumbered men in the clienteles of all the healers. However, the gender imbalance was significantly greater in one healer's practice than in the practices of the other three. This quintessential case of a practice predominated by women is the focus of this paper. The paper examines various aspects of women's roles, including those than are given metaphorical expression in folk etiology. The special importance that these role factors assume in the practice of the healer appears to be implicated in the extraordinarily high ratio of women among her patients.

The use of complementary/alternative medicine (CAM) is typically modeled as a function of individual health beliefs, including changes in perceptions of conventional medicine, an orientation toward more holistic care, and increasing patient involvement in health care decision-making. Expanding on research that shows that health-related behavior is shaped by social networks, this paper examines the possibility that CAM usage is partly a function of individuals' social network structure. We argue that people are more likely to adopt CAM when they function as bridges between network members who are otherwise not (or poorly) connected to each other. This circumstance not only provides individuals with access to a wider range of information about treatment options, it also reduces the risk of sanctioning by network members if one deviates from conventional forms of treatment. We test this idea using data from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative study of older Americans. Analyses of egocentric social network data show that older adults with bridging potential in their networks are significantly more likely to engage in a greater number of types of CAM. We close by discussing alternative explanations of these findings and their potential implications for research on CAM usage.

The use of medicines has increased markedly in many countries over recent years, providing clear evidence of the increasing 'pharmacaeuticalisation' of society. This paper contributes to the sociological analysis of pharmaceuticalisation by starting to explore how we can begin to make judgements as to when and to what extent some medicines are being overused--an important aspect that, rather surprisingly, has not so far been the focus of attention those analysing the process. It considers the World Health Organisation's criteria for the 'rational' use of medicines, pointing to some of the issues they raise. It then develops a typology of over and underuse derived from these criteria. This provides a framework for the discussion of assessing overuse that focuses in particular on the widespread and increasing use of medicines that are not very effective for the conditions for which they are prescribed, and their use where the issue of clinical need is in doubt. Some of the factors that encourage overuse are also considered.

Health systems in many African countries are failing to provide populations with access to good quality health care. Morbidity and mortality from curable diseases such as malaria remain high. The PRIME trial in Tororo, rural Uganda, designed and tested an intervention to improve care at health centres, with the aim of reducing ill-health due to malaria in surrounding communities. This paper presents the impact and context of this trial from the perspective of community members in the study area.Fieldwork was carried out for a year from the start of the intervention in June 2011, and involved informal observation and discussions as well as 13 focus group discussions with community members, 10 in-depth interviews with local stakeholders, and 162 context descriptions recorded through quarterly interviews with community members, health workers and district officials.Community members observed a small improvement in quality of care at most, but not all, intervention health centres. However, this was diluted by other shortfalls in health services beyond the scope of the intervention. Patients continued to seek care at health centres they considered inadequate as well as positioning themselves and their children to access care through other sources such as research and nongovernmental organization (NGO) projects.These findings point to challenges of designing and delivering interventions within a paradigm that requires factorial (reduced to predictable factors) problem definition with easily actionable and evaluable solutions by small-scale projects. Such requirements mean that interventions often work on the periphery of a health system rather than tackling the murky political and economic realities that shape access to care but are harder to change or evaluate with randomized controlled trials. Highly projectified settings further reduce the ability to genuinely ‘control’ for different health care access scenarios. We argue for a raised consciousness of how evaluation paradigms impact on intervention choices.

In this paper we seek to understand the influence of gender on the different approaches to managing poor sleep by older men and women through the conceptual framework of existing theoretical debates on medicalization, healthicization and 'personalization'. In-depth interviews undertaken between January and July 2008 with 62 people aged 65-95 who were experiencing poor sleep, revealed that the majority of older men and women resisted the medicalization of poor sleep, as they perceived sleep problems in later life were an inevitable consequence of ageing. However, older men and women engaged differently with the healthicization of poor sleep, with women far more likely than men to explore a range of alternative sleep remedies, such as herbal supplements, and were also much more likely than men to engage in behavioural practices to promote good sleep, and to avoid practices which prevented sleep. Women situated 'sleep' alongside more abstract discussions of 'diet' and health behaviours and drew on the discourses of the media, friends, family and their own experiences to create 'personalized' strategies, drawn from a paradigm of healthicization. Men, however, solely relied on the 'body' to indicate when sleep was needed and gauged their sleep needs largely by how they felt, and were able to function the following day. © 2012 Elsevier Ltd.

Feminist research has shown repeatedly the extent to which medical accounts pathologize menstruation, yet there has been very little examination of how clinicians and medical researchers actually study and assess menstruation. This paper analyzes 30 US medical journal articles to examine how researchers work to distinguish the specific menstrual disorder of menorrhagia, or excessive bleeding, from normal menstruation. I focus specifically on measurement as a key process in diagnosing menstrual pathology, arguing that measurement practices construct women's bodies as appropriate objects of medical attention in ways that also shape women's positions as participants in knowledge production. I begin with the alkaline hematin method's narrow focus on physical proof of bleeding that proves or disproves women's complaints and trace the emergence of new methods that incorporate women's own assessments of bleeding. Changing ways of measuring menstruation point to shifts in understandings of the body as the object of medical treatment and of patients as medical subjects.

Researchers examining the relationships between traditional medicine and biomedicine have observed two conflicting tendencies. Some suggest that the use of biomedicine and biomedical concepts displaces the use of traditional medicine and medical beliefs. Other scholars have found that traditional medicine and biomedicine can co-exist, complement, and blend with each other.\ud \ud In this paper we use an econometric model and quantitative data to test the association between individual knowledge of pharmaceuticals and individual knowledge of medicinal plants. We use data from a survey among 136 household heads living in a rural indigenous community in Oaxaca, Mexico. Data were collected as a part of long term fieldwork conducted between April 2005 and August 2006 and between December 2006 and April 2007. We found a significant positive association between an individual’s knowledge of medicinal plants and the same individual’s knowledge of pharmaceuticals, as well as between her use of medicinal plants and her use of pharmaceuticals. We also found a negative association between the use of medicinal plants and schooling. Our results suggest that, in the study site, individual knowledge of medicinal plants and individual knowledge of pharmaceuticals co-exist in a way which might be interpreted as complementary. We conclude that social organization involved in the use of medicines from both traditional medicine and biomedicine is of particular significance, as our findings suggest that the use of pharmaceuticals alone is not associated with a decline in knowledge/use of medicinal plants.

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and 'expert' patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008-2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use 'traditional' medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally. (C) 2009 Elsevier Ltd. All rights reserved.

The project of modernising Western herbal medicine in order to allow it to be accepted by the public and to contribute to contemporary healthcare is now over two decades old. One aspect of this project involves changes to the ways knowledge about medicinal plants is presented. This paper contrasts the models of Evidence-Based Medicine (EBM) and Traditional Knowledge (TK) to illuminate some of the complexities which have arisen consequent to these changes, particularly with regard to the concept of vitalism, the retention or rejection of which may have broad implications for the clinical practice of herbal medicine. Illustrations from two herbals (central texts on the medicinal use of plants) demonstrate the differences between these frameworks in regard to how herbs are understood. Further, a review of articles on herbal therapeutics published in the Australian Journal of Herbal Medicine indicates that practitioners are moving away from TK and towards the use of EBM in their clinical discussions.

The movement of scientific research from the bench to the bedside is becoming an increasingly important aspect of modern 'biomedical societies'. There is, however, currently a dearth of social science research on the interaction between the laboratory and the clinic. The recent upsurge in global funding for stem cell research is largely premised on the promise of translating scientific understanding of stem cells into regenerative medicine. In this paper, we report on the views of biomedical scientists based in the United Kingdom who are involved in human embryonic stem cell research in the field of diabetes. We explore their views on the prospects and problems of translational research in the field of stem cell science. We discuss two main themes: institutional influences on interactions between scientists and clinicians, and stem cell science itself as the major barrier to therapies. We frame our discussion within the emerging literature of the sociology of expectations.

The development of "integrative health care" (IHC) settings combining various aspects of Western biomedicine and complementary/alternative medicine (CAM) is a relatively recent phenomenon among biomedical and CAM professions. While IHC is recognised internationally and occurs in many different contexts (e.g. clinic or hospital), patterns of interaction between biomedical and CAM practitioners, and the nature of IHC settings, are largely unknown. This paper presents findings from a research study of two newly established IHC settings in Canada. The main research question was: how are biomedical and CAM practitioners integrating or not integrating with each other at the level of professional interaction in IHC settings? Using a case study design, in-depth interviews were conducted with 13 biomedical and eight CAM practitioners during 2002-2003, and ethnographic observation and document analysis was conducted at each site. Drawing from closure theory of the professions, comparative analysis of the sites revealed that biomedical practitioners enact patterns of exclusionary and demarcationary closure, in addition to the use of "esoteric knowledge", by: (a) dominating patient charting, referrals and diagnostic tests; (b) regulating CAM practitioners to a specific "sphere of competence"; (c) appropriating certain CAM techniques from less powerful CAM professions; and (d) using biomedical language as the primary mode of communication. CAM practitioners, in turn, perform usurpationary closure strategies, by: (a) employing their own "esoteric knowledge" in relation to biomedicine and other CAM professions; (b) appropriating biomedical language and terminology; (c) increasing their professional status by working with biomedicine; and (d) referring among CAM practitioners to increase patient flow. The findings suggest that when attempts are made to integrate biomedicine and CAM, dominant biomedical patterns of professional interaction continue to exist. Despite continued patterns of social closure, biomedical and CAM practitioners continue to provide a certain form of integrative care that may be of benefit to patients, albeit not as integrative as current models of integration would prefer.

Many subjects in early phase clinical trials expect to benefit in some way from the research intervention. It is understandable that people hope for improvement in their condition, no matter what the evidence. Yet unreasonable expectation of medical benefit may reflect problems with informed consent: Investigators may not disclose clearly that direct medical benefit from an early phase experimental intervention is unlikely or impossible, or subjects may not appreciate the differences between treatment and research. This paper presents findings from recent interviews with researchers and subjects and analysis of consent forms in early phase gene transfer research, a cutting-edge technology often called 'gene therapy'. We use three variables to construct a composite measure of therapeutic misconception TM, tapping misconceptions about the purposes of early phase research and the potential for direct medical benefit in these trials. Our multivariate model demonstrates the importance of both subject- and study-level factors as predictors of this TM index: education, disease type, and communication by study personnel about the likelihood of benefit. We hope that this work will deepen the discussion of how to define and measure TM, and refine the specification of factors that are related to subjects' TM.

There has been an explosion of literature on the attitudes of a variety of health care providers, particularly physicians, to the growing utilization of complementary and alternative medicines and modalities (CAM). What is most seriously lacking is a conceptual framework that helps to distill this mountain of literature into a manageable and more understandable amount. In this paper, we address these important issues by examining the literature that surveys the attitudes and behaviour of providers regarding CAM comparatively across the professions of medicine and nursing and across settings. We do so by drawing upon existing, more general theoretical contributions to the area of CAM in order to propose a comparative conceptual framework with which to interpret the diverse and at times discrepant results of this body of research.

This paper examines the reactions of leaders of established health professions in Ontario, Canada to the efforts of selected complementary and alternative (CAM) occupational groups (chiropractors, naturopaths, acupuncture/traditional Chinese doctors, homeopaths and Reiki practitioners) to professionalize. Stakeholder theory provides the framework for analysis of competing interests among the various groups in the healthcare system. The data are derived from personal interviews with 10 formal leaders from medicine, nursing, physiotherapy, clinical nutrition and public health. We conceived of these leaders as one group of stakeholders, with both common and conflicting interests. The findings demonstrate that these stakeholders are reluctant to endorse the professionalization of CAM. They propose a series of strategies to contain the acceptance of CAM groups, such as insisting on scientific evidence of safety and efficacy, resisting integration of CAM with conventional medicine and opposing government support for research and education. These strategies serve to protect the dominant position of medicine and its allied professions, and to maintain existing jurisdictional boundaries within the healthcare system. The popular support for CAM will require that health professional stakeholders continue to address the challenges this poses, and at the same time protect their position at the apex of the healthcare pyramid.

In recent years, non-conventional medicine (NCM) has grown tremendously in popularity and economic importance. This paper explores a relatively unresearched phenomenon: patients’ dissatisfaction with non-conventional medical treatment they have received. 16 out of 20 patients who had severed their contact with a large, hospital-adjacent multi-modality NCM clinic in Israel were interviewed. Two of these patients had severed their relationship with the clinic right after being referred to a certain practitioner and 18 did not keep their next appointment while in the process of treatment. The narratives through which participants understand and communicate their experience regarding dissatisfaction with NCM are organized around three main topics: independence versus paternalism, foreign versus familiar, and care versus cure. Findings illustrate the patients’ views concerning the desirable doctor–patient relationship and their expectations of non-familiar treatments. Patients are characterized as “smart consumers” who place utmost importance on outcome and do not hesitate to discontinue treatment. Findings are further discussed in the context of domestication and the minimizing of cultural difference through the integration of NCM into a biomedical setting.

In this paper I consider 30 Finnish women's written narratives about the process of getting back pain diagnosed. From the beginning of the early discomfort of back pain, the women were sure of its bodily and subjective reality. They struggled repeatedly to be taken seriously, and only after years of medical disparagement did they encounter medical professionals who were able solve the riddle and give it a name, a diagnosis. Since back pain is a baffling problem and challenges the central biomedical epistemology-objective knowledge and measurable findings separate from subjective experience-it allowed the doctors to show a disrespectful attitude toward back pain sufferers. The moral essence of the women's common story was the stigmatizing experience when doctors did not take subjective pain seriously. Instead, doctors' neglectful attitudes became part of the prolonged problem. During the long-lasting uncertainty, women tried multiple coping strategies to ease their lives and developed mental attitudes to endure the pain. Since the protagonists did not give up the lived certainty of back pain they were gradually able to challenge medical uncertainty and to demand a thorough medical examination, and/or through random circumstance they encountered doctors who were willing to take their symptoms seriously. This triggered turning points that immediately or very soon resulted in solving the riddle of the puzzling pain. To be finally diagnosed was a great relief. However, to be taken seriously as a person was considered to be the greatest relief.

This paper focuses on lay and professional ideas about the nature of chronic fatigue syndrome (CFS), and in particular, the ways in which understandings of the disorder are developed in a clinical setting. Our data are drawn from observations of consultations between sufferers and physicians in a UK medical out-patients clinic. We treat the clinic as a political field. That is to say, as an arena in which 'problems' (about the management of illness) are constituted, and alternative approaches and solutions to such problems are pressed. We note that in the realms of symptoms, aetiology and treatment evaluation, lay people in the CFS clinic have quite distinct ideas about what their problems are and how they might be analysed and managed--ideas that are often in conflict with those of medical professionals. Thus, lay sufferers, for example, operate within a different conceptual terrain from that of many professional experts. They are more likely to refer to a disease (myalgic encephalomyelitis or ME), rather than a syndrome. They call upon different kinds of hypotheses to explain their symptoms. They hold to conflicting ideas about the order of causal sequences, and they give emphasis to different kinds of phenomena in their accounts of illness. As a consequence, clinical consultations can often take on the form of a political contest between physician and patient to define the true and real nature of the patient's disorder--a micro political struggle in which neurological symptoms can be re-framed as psychiatric symptoms, and psychiatric symptoms as neurological. In short, a contest in which the demarcation lines between mind and body are continually assessed and re-defined, and the tenets of 'biomedicine' are constantly challenged.

Awareness of variations in the delivery of medical care has resulted in considerable research activity focused on developing measures to assess the appropriateness of health service provision both internationally and within Great Britain. As in other areas of health service provision there is evidence of variation in advice provided alongside sales of non-prescription medicines and variation in response to requests for advice about the treatment of minor ailments within community pharmacies in Great Britain. However, there is little research which has explored the extensive methodological problems associated with developing criteria to assess the appropriateness of these-two activities. Following a critical review of relevant existing research, this paper describes a methodology and empirical findings from a study which aimed to develop criteria to measure the appropriateness of advice provided in community pharmacies. Firstly, details of advice-giving episodes occurring between consumers and pharmacists or medicines counter assistants were captured and documented using a combination of audio tape-recording and non-participant observation. Secondly, the nominal group technique was used to develop a set of explicit criteria for assessing the appropriateness of advice. Thirdly, an assessment instrument was developed in order to operationalise the criteria. The devised criteria include both process and output components. We discuss the utility of these criteria in relation to developments in self-medication practice affecting community pharmacy and the deregulation of medicines within the UK. The criteria have been subject to rigorous statistical testing to establish standards of validity and reliability (Ward, Bissell & Noyce, 2000a [Ward, P. R., Bissell, P. & Noyce, P. R. (2000a). Criteria for assessing non-prescription drug therapy in community pharmacy, Annals of Pharmacotherapy (in press).]). The developed criteria will allow us to identify dimensions of both appropriate and inappropriate advice provided in community pharmacies and provide the basis for education and training initiatives identified as a result of the research. In addition, we suggest that this research is highly relevant to informing the content, structure and operationalisation of protocols and/or guidelines associated with the management of minor ailments and the sale of medicines through community pharmacies.

Hanbang, the Korean medical practice with origins in classical Chinese texts, is a prominent part of the Korean health care system. Hanbang physicians, called hanuisas, are looked down on by biomedical doctors, but their practice has enjoyed increasing popularity for several decades. As the market for herbal preparations has become more lucrative, biomedical pharmacists have begun to participate in it. The Pharmaceutical Act in 1993 explicitly allowed pharmacists to prescribe and dispense herbal drugs. This provoked a bitter public conflict between hanuisas and pharmacists, involving street demonstrations and strikes. The hanuisas asserted that the pharmacists were unqualified to assume their traditional practice. They also agitated for recognition in the state-sponsored system of health care and for the state’s support for developing Hanbang medicine. This paper attributes the conflicts concerning Hanbang to the expanding market for herbal preparations, Korean nationalism, and to the oversupply of biomedical pharmacists.

This paper describes naturopathic practitioners with two different world views — holistic and scientific, and explores the relationship of practitioners' socialization experiences and practice patterns with these two world views. Data were gathered by a variety of methods including: (1) a 14-page questionnaire mailed to all 296 naturopathic practitioners licensed in Canada; (2) a participant observation study at the Canadian College of Naturopathic Medicine (CCNM); and (3) open-ended interviews with 16 students attending CCNM and 41 naturopathic practitioners which were audio-taped and transcribed verbatim. Individuals with both holistic and scientific world views entered naturopathic training and none of the practitioners who were interviewed reported a change in world view while at naturopathic college. However, practitioners reported a new-found appreciation of the “other” world view on completion of their training, indicating the occurrence of a socialization effect. Many decisions involved in setting up a practice and seeing patients were affected by the practitioners' world views. For example, there were distinct differences in the way the practitioners with different world views who were interviewed chose treatment modalities. Practitioners with scientific world views reported choosing treatments based on the available “scientific evidence”, while practitioners with holistic world views included a careful exploration of the patient's spirituality and their own intuition in their treatment decisions. In addition, practitioners with holistic world views reported significantly longer patient visits than practitioners with scientific world views. The data presented here suggest that one's world view influences one's perceptions of socialization experiences and social situations, and modulates the effects of both on practice patterns.

The prescribing of proton pump inhibitor (PPIs) drugs has increased by 456% in the past 4 yr, despite no evidence of increased morbidity for gastrointestinal conditions. There has been no full explanation for this dramatic increase. Doctors attribute the rapid and apparently unjustified increase in prescribing of this new and expensive drug to patients' demands and not to the extensive advertising campaign. This paper presents the findings from interviews with 20 patients who were taking PPIs. The results revealed that the prescribing of PPIs was mainly initiated in primary care, with little evidence of overt patient demand for PPIs, influenced by the media or social contacts. Patients' perceptions and beliefs about PPIs are explored and discussed. Patients modified the prescribed regimen to suit their perceived needs. Patients felt PPIs were more effective than other drugs they had tried previously and expressed their concerns about stopping PPIs, or changing to another drug. However, despite these reservations, the majority of patients interviewed said they would change if their general practitioner (GP) suggested it. PPIs led some patients to abandon, or not to attempt, lifestyle changes. The consequences of this and the implications of the continued prescribing of PPIs are discussed.

This paper reports on research conducted in a large Canadian city during 1994-1995. The study examines the motivations of patients who choose to seek care from one of five different types of practitioners: family physicians, chiropractors, acupuncturists/traditional Chinese doctors, naturopaths and Reiki practitioners. We use the Andersen socio-behavioural model to help explain why people choose orthodox medicine or a type of alternative care. The data are derived from face to face interviews with 300 patients: 60 from each of the five modes of treatment. The findings demonstrate that this model can explain the use of alternative as well as orthodox medical services. Patients choose specific kinds of practitioners for particular problems, and some use a mixture of practitioners to treat a specific complaint. The choice of type of practitioner(s) is multidimensional and cannot solely be explained either by disenchantment with medicine or by an "alternative ideology".

Both the medically and non-medically qualified homoeopaths in Britain have engaged in a number of changes to the way that their knowledge is constructed and communicated. In this paper we describe these changes and link them to claims for legitimacy, status and authority in the health care market. The public presentation of homoeopathic knowledge claims are thus linked to a 'professional project'.

This paper tells about a 'dialogue group', consisting of alternative and modern health practitioners, that was started in Norway in 1989, how it works and what has been achieved up to now. WHO has strongly advocated promotion of cooperation between traditional and modern health practitioners. In Botswana, where one of the general practitioners in the group has practiced, 'United Health Committees' have been established aiming at creating a dialogue between the different types of health professionals. In industrialized countries little seems to have been done so far. Many patients in Norway, as in many other countries, consult ordinary doctors as well as alternative practitioners. In Norway, members of these two professions almost never meet, other than as opponents. They receive information about each other mostly through discontented patients who have been unsuccessfully treated by the other part. In this way practitioners get an insufficient and biased report of one another's practices, as well as an unrealistic and distorted picture. If patients know that both parts respect one another, then most of them dare to tell that they use both types of practitioners. Otherwise many patients conceal this.

Gandy and Zumla offer a contribution to a burgeoning debate within the tuberculosis (TB) community and public health more generally around the need for interdisciplinarity in research and intervention. Their paper provides further evidence of an apparent consensus among those working in TB which is based on the understanding that research and intervention efforts would become more effective by using the whole range of perspectives and approaches available within the academy. The key issue in TB control is not whether researchers should become more inter-disciplinary or whether social science is important or even whether the directly observed treatment short course strategy is the answer. The real issue is how care is delivered to patients. Much can be gained through thoughtful application of care communication and social justice. There should be a shift in perspective from a focus on the microbe to a focus on the terrain; from standardized short term interventions with an emphasis on outputs to an approach that is responsive to context with longer term objectives and a focus on process. This will assist in the integration of technical advances with the truly old fashioned human aspects of disease control that emphasize relationship community partnership and care.

Family use and understanding of modern medicines was studied in two villages in rural Bahia, Brazil. It emerged that pharmaceuticals figure in the treatment of most reported health problems. Nursing infants above all are treated with drugs frequently and intensively. The three most commonly used medicine-groups are antibiotics, analgesics and vitamins. The majority of these medications are 'prescribed' by a pharmacy attendant or the patient himself. Roughly half of the applied medications appear on neither the WHO list nor the Brazilian national list of 'essential drugs'. In almost one third of the cases studied 'dangerous' substances were used. If we consider the medications in use from a strictly biomedical viewpoint, it must be said that between half and two thirds of them ought to be regarded as irrational. A lot of money, moreover, is being spent on modern medicines. In one of the two villages, each week every family spent, on the average, a full day's wages to obtain a wide range of medications. The attitude of the families studied towards modern pharmaceuticals was highly positive. In general, people held the view that medicines should be used in the event of any sickness or discomfort. Possible hazards accruing from the use of modern medicines were scarcely acknowledged, if at all. Furthermore the notion obtained that many drugs should be used at the same time in cases of severe illness, or whenever a quick recovery was desired. A remarkably vigorous interest in diseases and their treatment was observed. Perhaps in this keen interest was a potential solution to problems of over-medication and the irrational use of pharmaceuticals in the Third World. The paper closes with a plea for providing more information about pharmaceuticals to consumers.

In rural communities in the Ecuadorian Highlands, gastrointestinal disease is the leading cause of death. This paper proposes a model of the world view that specifies the factors that condition illness or health and a traditional taxonomy that relies on certain criteria to categorize three classes of diarrhea. These determine whether ethnomedical or medical treatment will be used to 'cure' a child. The three illness classes: diarrhea produced by supernatural forces, by humoral imbalances, and by 'infection' differ etiologically. The ambient air and its temperatures, the constitution, humoral state and overt personality characteristics (character) of the individual, and the predelictions of the evil spirits that seek to sap their vital essence all figure in the origins of illness. The model of the world view is related to a folk taxonomy, which, it is asserted, provides a charter for families' responses to child illness, that more often than not, are appropriate under the economic conditions they suffer.

This paper deals with the encounter between the Chinese and Western medical missionaries in early twentieth century China. Based on data of two Canadian Protestant missions in China before 1937, this study reveals that medical missionaries were generally ignorant of Chinese medicine, and they regarded Chinese medicine as part of an inferior, heathen culture. Such a 'mission-centric' perspective prevented the missionary doctors from creating an effective doctor-patient relationship with the Chinese patients. To the Chinese, missionary health care provided an additional health care pathway. The functional complementarity of Western medicine to the pluralistic Chinese medical structure enabled missionary medicine to gain increasing credibility from the Chinese, although few Chinese actually understood the basic principles of Western medicine. Implications of this missionary doctor-Chinese patient relationship in China are discussed.

The problem of integrating the two major medical systems in Africa can be approached from many sides. This paper focuses on the attitudes of Western-trained practitioners. They are seen as a major force to be reckoned with in any serious attempt at cooperation or corporation. Nevertheless, substantive information in this area remains minimal. In the light of the well documented history of the struggle for control of the medical field by University-trained physicians in the West, and Freidson's discussions on professional dominance' the author theorized that the issue of integration in Nigeria would stir professional anxieties. The Western-trained physicians can be expected to object to serious moves-to integrate the two systems. Given this approach, it was hypothesized that. 1. (1) Western-trained medical doctors will not like attempts to be integrated with indigenous healers (personnel) into a unified medical system. 2. (2) Of the various aspects of the indigenous system, they will be interested in the quantifiable as compared to the nonquantifiable. One hundred and three self administered questionnaires were analysed. These were obtained in February 1978 from members of the Nigerian Medical Association attending a conference in Ibadan. The results supported the first hypothesis. For although two-thirds of the respondents said they favoured integration in general, when pressed, such suggestions as the development of ‘joint clinics’ were rejected by a significant majority and the ‘separate development’ of each system favoured. The second hypothesis was not however supported. There was ample evidence of interest in the less tangible, as yet not quantifiable aspects of the medical practices of indigenous practitioners.

Diarrheal disease prevention and diarrheal disease control with oral rehydration therapy are major goals of the World Health Organization and the international health community. This paper promotes the use of ethnographic research in this endeavor. It illustrates the use of ethnography in a diarrheal disease prevention and control program in Honduras by illustrating how knowledge of local beliefs and practices partially shaped promotion efforts. It confirms the validity of the original ethnographic findings by reporting the results of a survey conducted two years after program onset.

In this paper I present a detailed case study of an exorcist in rural Nepal who has abandoned the explanatory paradigm of exorcism and taken up certain aspects of Brahmanical tradition, medical science and temple healing in order to establish a place of medical resort, called the Tīsīyāhī klinīk. In particular, I investigate the intracultural field of relations of the exorcist and analyse the way in which these different health systems, each with its own domain and powers of explanation, were brought together to form one system at the clinic. In conclusion, I argue that these other health systems served to authenticate and legitimate the folk therapy of the exorcist so that his rural clinic might be seen by villagers as a medical centre of southern Nepal.

The paper explores the various factors that appear to constrain the implementation in sub-Saharan Africa of the WHO/UNICEF Alma Ata resolutions that member states support the use of indigenous health practitioners in government health programs. It also presents arguments and evidence that suggest ways to overcome the constraining factors. Discussion focuses on traditional healers as distinct from traditional birth attendants. The question posed in the title is not fully answered, but a considerable amount of fact, programmatic experience, and observation related to the issue is assembled and discussed in order to approach an answer, and to inform those who hold a variety of positions with regard to the Alma Ata resolutions.

The paper's aim is to show how moral concerns may be kept segregated from strictly medical concerns. To do this, the doctor's speciality is characterized in terms of disease. Doctors may plausibly make special claims qua doctors when they are treating disease. Since mental diseases are sometimes thought to be more than immoral behavior, the concept of disease receives detailed treatment. So-called ‘antipsychiatric’ arguments against the existence of purely mental disease are restated. It is accepted that these arguments illustrate the need to insist that genuine diseases have, at least in principle, an underlying physical pathology. It is then argued that prevalent philosophical analyses which seek to do away with the physical pathology requirement do not adequately meet antipsychiatric arguments, and threaten to allow the annexation of morals by medicine. Finally, some conclusions are drawn as to what conclusion might reasonably be drawn concerning psychiatry if it is allowed that diseases must involve physical pathology.

This paper describes beliefs and practices associated with jaundice and its treatment by ayurvedic physicians (vaidyas) in Kathmandu. It documents continuity of ancient ayurvedic ideas and practices as well as syncretism between ayurvedic and allopathic (Western, biomedical) traditions in modern Nepal. Popular beliefs about the cause of jaundice appear to have evolved to fit therapeutic practices adopted by vaidyas from allopathy. An implication of this finding is that beliefs about causation do not necessarily precede and channel therapeutic choices; they may also function to rationalize and provide meaning to experiences of illness and therapy. The data also suggest a number of hypotheses about the efficacy of ayurvedic treatment for jaundice.

Although contemporary anthropological studies of African medical systems have indicated their pluralistic and complex nature, many studies still suggest a stark contrast between folk and cosmopolitan medicine, implying that ethnomedicine is primarily concerned with mystical causation. The present paper outlines ethnomedical practices in southern Malawi, stressing the distinctiveness of herbalists and diviners, and the important role of herbal remedies in the empirical treatment of all illnesses.