'Lifelong investment in health': the discursive construction of 'problems' in Hong Kong health policy

This paper reflects on the contemporary health policy debate in Hong Kong, and the shape assigned to particular 'problems'. Health reform discourses are identified to reveal the tensions that exist between the dominant biomedical discourse that focuses on individual responsibility, lifestyle change and health education while articulating a community development approach to health care reform. A critical review of the Consultation Document on Health Care Reform in Hong Kong, entitled Lifelong Investment in Health, will reveal a rhetorical commitment to health care reform alongside proposals that suggest little understanding of the changes required to implement such reform. In fact, the document proposes a model of health care that not only remains within the biomedical paradigm, but which if enacted may extend the influence of medicine into the psychosocial sphere. Edelman has defined policy as 'a set of shifting, diverse, and contradictory responses to a spectrum of political interests'. The starting point from this perspective is the identification of the discursive construction of policy problems and the associated 'spectrum of political interests'. It is an attempt to reveal the operation of power in places in which administrative, political and professional discourses tend to obscure it.     

Best research – For what? Best health – For whom? A critical exploration of primary care research using discourse analysis

Health research is fundamental to the development of improved health and healthcare. Despite its importance, and the role of policy in guiding the kind of research that gets addressed, there are very few empirical studies of health research policy. This paper redresses this, exploring the means by which one area of health research policy is shaped, enabled and constrained. We ask: what are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate; and what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we employed a Foucauldian approach to discourse analysis to explicitly recognise the historical, social and ideological origins of policy texts; and the role of power and knowledge in policy development. We adapted Parker's framework for distinguishing discourses as a means of selecting and analysing 29 key policy documents; 16 narrative interviews with historical and contemporary policy stakeholders; and additional contextual documents. Our analysis involved detailed deconstruction and linking across texts to reveal prevailing storylines, ideologies, power relations, and tensions. Findings show how powerful policy discourses shaped by historical and social forces influence the type of research undertaken, by whom and how. For instance, recent policy has been shaped by discourse associated with the knowledge-based economy that emphasises microscopic ‘discovery’, exploitation of information and the contribution of highly technological activities to ‘UK plc’ and has re-positioned primary care research as a strategic resource and ‘population laboratory’ for clinical research. Such insights challenge apolitical accounts of health research and reveal how health research serves particular interests.     

Potency and vulnerability: troubled 'selves' in the context of antiretroviral therapy

The concepts of health and self have become intimately entangled in contemporary western society. Health is figured as a marker of identity, as a vehicle of self-production and self-actualisation, while the individual is also made increasingly responsible for his or her health. In this paper, we explore how "self" is constituted in discourses that shape the ways in which people understand and do health and medicine, particularly discourses of neoliberalism and of the immune system. Of interest here is how the productive and unpredictable intra-action of medicine and bodies may come to trouble these discursive selves. We situate our discussion in the context of efavirenz, an antiretroviral drug prescribed and consumed for the treatment of HIV infection. This drug, commonly described as "potent", can have a number of troubling effects on a person's everyday sense of self, including insomnia, confusion, cognitive disorders, depression, depersonalisation, psychosis, and suicidal ideation. While efavirenz may be clinically effective in its capacity to suppress the virus, these effects are at odds with the implicit aim of HIV medicine to restore and secure the self by way of immunological integrity and strength. These effects also bring into focus the predicament of choice under the contemporary political conditions of neoliberalism with its emphasis on health as an enterprise of the autonomous, rational self. In exploring first-person accounts, the paper unpacks a number of the binary concepts on which contemporary discourses of health and medicine rely, such as immunity and vulnerability, potency and fragility, rationality and madness, self and non-self, and asks whether the individual under neoliberalism is being asked the impossible.     

Policy strategies for personalising medicine “in the data moment”

Objective‘Data’ is relevant in evolving value-based healthcare that involves machine learning and artificial intelligence-based technologies which are increasingly changing the landscape of personalised medicine (PM). However, a lack in adequate data for decision making may lead to new forms of health inequalities spite of the advancement in the technological front. There exists a dearth in alignment between incentive structures for innovation and policy measures for collective action and data transparency. Against this background, this article identifies the legal challenges for a data-driven PM in Europe. Transparency, data protection and Intellectual property rights (IP) are major legal challenges for data-oriented personalised research in Europe. Consequently, there is a need for restructuring public policy strategies in the interest of patients.MethodLegal dogmatic analysis of structural inefficiencies within interrelated legal paradigm over data that limits a functional development of a data-driven PM.ResultEngaging in the data movement in personalised health care calls for special attention to strategic tools such as co-regulation and self-regulation that bridge the gap in law and practice.     

Nanomedicine and personalised medicine: understanding the personalisation of health care in the molecular era

Globally supported by public policy and investment, nanomedicine is presented as an ongoing medical revolution that will radically change the practice of health care from diagnostic to therapeutic, and everything in between. One of nanomedicine's major promises is that of personalised medicine, enabling diagnostics and therapeutics tailored to individual needs and developing a truly ‘patient‐friendly’ medical approach. Based on qualitative interviews with nanomedicine researchers in Canada, this article explores the emerging concept of personalised medicine as it becomes entangled with nanomedical research. More precisely, drawing on insights from science studies and the sociology of expectations, it analyses researchers’ perceptions of personalised medicine in the cutting edge of current nanomedicine research. Two perceptions of personalisation are identified; a molecular conception of individuality and a technical conception of personalisation. The article concludes by examining the relationship between the two conceptions and contrasts them with the normative reflex of a more expansive conception of personalised medicine.     

Advance Australia fair: social democratic and conservative politicians' discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 1972-2001

This paper reports research undertaken as part of a larger project in which we examined whether and how values and beliefs communicated by Australian politicians have shaped decades of health policy and influenced health outcomes for Aboriginal and Torres Strait Islander Peoples of Australia. To first characterise those values and beliefs we analysed the public statements of the politicians responsible nationally for the health of Aboriginal and Torres Strait Islander Peoples 1972-2001, using critical discourse analysis. We found that four discourses, communicated through words, phrases, sentences and grammatical structures, dominated public statements over the study period. These four discourses focused on the competence and capacity of Aboriginal and Torres Strait Islander Peoples to "manage"; matters of control of and responsibility for the health of Aboriginal and Torres Strait Islander Peoples; Aboriginal and Torres Strait Islander Peoples as "Other"; and the nature of the "problem" concerning the health of Aboriginal and Torres Strait Islander Peoples. Analysis of the discursive elements contributing to shaping these four discourses is reported in this paper.     

What is a national health policy?

Unfortunately, most nation states have taken "health policy" to mean "medical care policy." Medical care, however, is only one variable in a nation's health equation. The article describes what the main components of a national health policy should be, including (1) the political, economic, social, and cultural determinants of health, the most important determinants of health in any country; (2) the lifestyle determinants, which have been the most visible types of public interventions; and (3) the socializing and empowering determinants, which link the first and second components of a national health policy: the individual interventions and the collective interventions. The author discusses the indicators that should be used for each component and for each intervention. The feasibility of this approach depends to a large degree on the political will of the national authorities and the broad understanding of the actual determinants of health. A good first step is the National Health Policy plan developed by the Swedish social democratic government. This article builds on and expands on that model.     

The global reproductive health market: U.S. media framings and public discourses about transnational surrogacy

During the first decade of the 21st century a new “dramatic story” about the growing global surrogacy industry brought renewed attention to surrogacy as a social problem and a health policy issue. This paper asks: What cultural assumptions about gender, family and the global reproductive health market are revealed in current U.S. media coverage of and public discourses about surrogacy? From a qualitative analysis of prominent news accounts of surrogacy that were published in 2008, New York Times articles and blogs published on the topic between 2006 and 2010, and over 1000 online reader comments to these articles, I identify key frames used to discursively construct and debate the international surrogacy market. This study reveals the distinct contrast between the occasions when reproductive labor is rhetorically distanced from commodification processes and when it is linked to those processes. The findings contribute to intersectional analyses of assisted reproductive practices and women’s health/bodies/gametes. In particular, this study’s analysis of recent media framings of and public discourses about surrogacy across the globe serves as another illustration that national/classed/racialized bodies continue to be reproductively stratified via differently gendered discourses about women, motherhood and family.     

The world as the new local clinic: A critical analysis of three discourses of global medical competency

The effects of globalization on health are the focus of administrators, educators, policy makers and researchers as they work to consider how best to train and regulate health professionals to practice in a globalized world. This study explores what happens to constructs such as medical competence when the context of medical practice is discursively expanded to include the whole world. An archive of texts was assembled (1970–2011) totaling 1100 items and analyzed using a governmentality approach. Texts were included that articulated rationales for pursuing global education activities, and/or that implicitly or explicitly took a position on medical competencies in relation to practicing medicine in international or culturally diverse contexts, or in dealing with health issues as global concerns. The analysis revealed three distinct visions, representative of a primarily western mentality, for preparing physicians to practice in a globalized world: the universal global physician, the culturally versed global physician and the global physician advocate. Each has its own epistemological relationship to globalization and is supported by an evidence base. All three discourses are active and productive, sometimes within the same context. However, the discourse of the universal global physician is currently the most established. The challenge to policy makers and educators in evolving regulatory frameworks and curricula that are current and relevant necessitates a better understanding of the socio-political effects of globalization on medical education, and the ethical, political, cultural and scientific issues underlying efforts to prepare students to practice competently in a globalized world.     

Place, discourse and vulnerability--a qualitative study of young adults living in a Swedish urban poverty zone

This paper presents findings from a qualitative study of young adults living in a relatively deprived metropolitan area in Sweden. The analysis of interview data yielded four separate types of neighbourhood discourses, each related to a major hegemonic 'discourse of the problematic area'. The discursive model was used to disclose different patterns of vulnerability, at both the individual and the community level. The discourses are suggested to function as mechanisms through which the spatial context, defined in structural and relational terms, could be linked to health and well-being.     

Personalisierte Medizin

Background

In the middle of the 1980s and 1990s, drug research underwent a significant change. With new knowledge gained from molecular medicine, it became possible to understand the development and course of many diseases in much more detail. As a consequence, truly new therapies were developed on the basis of natural sciences.

Paradigm shift to personalised medicine

Progress in medicine is not only based on newly available therapeutic options but also implies the identification of the therapy which suits the patient best. And it is exactly here where medicine as well as drug development are currently undergoing a paradigm shift which can be characterised by the catchword “personalised medicine”.

Tandems of therapeutic and diagnostic agents

Personalised medicine encompasses defined tandems of therapeutic and diagnostic agents and leads to a therapy which is based on single patient groups rather than solely on disease diagnoses. In this therapy concept—in addition to the regular examination of the patient—a diagnostic test is performed to assess certain patient characteristics as a basis for the choice of therapy and/or therapy control. Primarily, it is the patient who benefits from personalised medicine by a higher probability of therapeutic success or by an increased tolerance. Thereby, personalised medicine may also increase cost efficiency in the health care sector.

Outlook

To introduce more personalised therapies and therefore achieve the best possible patient care as well as increased cost efficiency for the health care system in the future, all players in health care should work closely together to meet the challenges of personalised medicine.     

Framing health and foreign policy: lessons for global health diplomacy

Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts.     

Government,politics and health policy: A quantitative analysis of 30 European countries

RationalePublic health policies are often dependent on political decision-making, but little is known of the impact of different forms of government on countries’ health policies. In this exploratory study we studied the association between a wide range of process and outcome indicators of health policy and four groups of political factors (levels of democracy, e.g. voice and accountability; political representation, e.g. voter turnout; distribution of power, e.g. constraints on the executive; and quality of government, e.g. absence of corruption) in contemporary Europe.Data and methodsData on 15 aspects of government and 18 indicators of health policy as well as on potential confounders were extracted from harmonized international data sources, covering 30 European countries and the years 1990–2010. In a first step, multivariate regression analysis was used to relate cumulative measures of government to indicators of health policy, and in a second step panel regression with country fixed effects was used to relate changes in selected measures of government to changes in indicators of health policy.ResultsIn multivariate regression analyses, measures of quality of democracy and quality of government had many positive associations with process and outcome indicators of health policy, while measures of distribution of power and political representation had few and inconsistent associations. Associations for quality of democracy were robust against more extensive control for confounding variables, including tests in panel regressions with country fixed effects, but associations for quality of government were not.ConclusionsIn this period in Europe, the predominant political influence on health policy has been the rise of levels of democracy in countries in the Central & Eastern part of the region. In contrast to other areas of public policy, health policy does not appear to be strongly influenced by institutional features of democracy determining the distribution of power, nor by aspects of political representation. The effect of quality of government on health policy warrants more study.     

Young Australian women explain their contraceptive choices

New developments in female contraceptives allow women increased options for preventing pregnancy, while men’s options for reversible contraception have not advanced beyond the condom. There has been little discursive exploration of how neoliberal and postfeminist discourses shape women’s accounts of choosing whether or not to use contraception. Our thematic discourse analysis of 760 free-text responses to a question about contraceptive choice considers the social and political climate that promotes the self-governed woman who freely chooses contraception. We examine the ways in which women formulated and defended their accounts of choice, focusing on the theme of free contraceptive choice that constructed women’s choices as unconstrained by material, social and political forces. We identify two discursive strategies that underpinned this theme: a woman’s body, a woman’s choice and planning parenthood, and explore the ways in which choice was understood as a gendered entitlement and how contraceptive choices were shaped (and constrained) by women’s plans for parenthood. We discuss the implications of these discursive strategies, and neoliberal and postfeminist discourses, in terms of the disallowance of any contextual, social and structural factors, including the absence of men in the ‘contraceptive economy’.     

Discourses of disease, discourses of disadvantage: a critical analysis of National Pandemic Influenza Preparedness Plans

Growing recognition of the threat of pandemic influenza to global health has led to increased emphasis on pandemic influenza preparedness planning. Previous analysis of national pandemic preparedness plans has revealed that those plans paid scant attention to the needs and interests of the disadvantaged. This paper investigates those findings via critical discourse analysis of the same plans as well as World Health Organization guidance documents. The analysis reveals that the texts operate within and as parts of an ordered universe of discourse. Among the six discourses which emerge from the analysis the scientific, political, and legal dominate the social, cultural, and ethical. This order of discourse delineates a specific regime of truths within which the lives, needs, and interests of the disadvantaged are masked or neglected. Unless the plans recognize their discursive construction, implementation of the policies and practices they prescribe runs the risk of further disadvantaging those very populations most likely to require protection.     

Sending a message: Ecstasy,equasy and the media politics of drug classification

In February 2009, the UK government's Advisory Council on the Misuse of Drugs (ACMD) published a review of MDMA (ecstasy) which recommended a reclassification from the highest class A to the ‘intermediate category’ class B, on the basis of a review of recent scientific research. This became a matter of news attention alongside a recent journal article by Professor David Nutt, the chairman of the ACMD, in which ecstasy consumption was suggested to be no more dangerous than horse-riding. The home secretary Jacqui Smith rejected the recommendations and Professor Nutt was forced to apologise for making the comparison. Some sections of the media coverage around this topic contrasted the (implicitly irrational) political response to the review with the authority of the scientific evidence it represented, while other media accounts characterised Nutt either as an ‘out of touch’, or ‘immoral’ academic or as having a politically motivated social agenda. In this way, risk issues are played out in, and through, media discourses of science and political authority. This paper analyses the national newspaper coverage of the debate around the risks of ecstasy use and drug classification in the context of the political imperatives within media accounts, and identifies the key discursive strategies employed by those engaged in the media debate. The paper briefly discusses the relevance of a number of risk theories before focusing on the governmentality approach to risk in order to explain how, despite the conservatism inherent in recent drug policy, the neo-liberal managerialism evident in recent UK governmental discourses largely sets the agenda in the media coverage.     

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.     

Investigating global mental health: Contributions from political science

ABSTRACT

This article outlines an agenda for political science engagement with global mental health. Other social sciences have tackled the topic, investigating such questions as the link between poverty and mental health disorders. Political science is noticeably absent from these explorations. This is striking because mental health disorders affect one billion people globally, governments spend only about 2% of their health budgets on these disorders, and most people lack access to treatment. With its focus on power, political science could deepen knowledge on vulnerabilities to mental illness and explain weak policy responses. By illustrating how various forms of power pertaining to governance, knowledge, and moral authority work through the concepts of issue framing, collective action, and institutions, the article shows that political science can deepen knowledge on this global health issue. Political science can analyse how incomplete knowledge leads to contentious framing, thus hobbling advocacy. It can explain why states shirk their obligations in mental health, and it can question how incentives drive mental health mobilisation. The discipline can uncover how power undergirds institutional responses to global mental health at the international, national, and community levels. Political science should collaborate with other social sciences in research networks to improve policy outcomes.