Health prevention in the era of biosocieties: a critical analysis of the ‘Seek‐and‐Treat’ paradigm in HIV/AIDS prevention

On 18 November 2014, the United Nations launched an urgent new campaign to end AIDS as a global health threat by 2030. With its proposed strategy, the UN follows leading scientists who had declared the failure of former prevention strategies and now were promoting a ‘Seek and Treat for Optimal Prevention’ (STOP) approach as the most cost‐effective response to the pandemic to meet the goal of ‘an AIDS‐free generation’. STOP combines antiretroviral therapy and routine HIV screening to find persons unaware that they are HIV‐positive, because research has shown that people consistently change their behaviour (i.e. increase condom use, have fewer partners) after an HIV diagnosis. AIDS activists have broadly criticized this strategy on different levels. In this article, we go beyond these criticisms and try to analyse the political rationalities behind this ‘new’ strategy. We believe that it is necessary to put the rationale underpinning the STOP programme into the context of broader societal transformations that can best be captured as the development of advanced liberal societies and the new emphasis on self‐controlling or self‐responsibility rather than on disciplining behaviour.     

Discourse analysis as a methodology for nursing inquiry

Discourse analysis is a relatively recent form of inquiry without a strict step-by-step method. The methodology of discourse analysis has a longer history in Continental Europe than in other countries.¹ The complex theoretical assumptions, the goals and the target (discourse) have been explicated, but the methodology may be applied in different ways. This paper will describe discourse analysis and give examples of some of the possible variations. It is the claim of this paper that discourse analysis deserves consideration as a methodology for nursing inquiry.     

A will to health? Drinking,risk and social class

This article explores risk conceptions related to alcohol use among Danes who drink ‘too much’ (based on the National Health Board’s standards for safe drinking). It analyses drinking patterns and risk management strategies among interviewees from different socio-economic backgrounds, and explores the differences between the behaviours and conceptions of these individuals and the risk advice and definitions provided by health agencies. The article shows that people from different socio-economic backgrounds respond differently to the neo-liberal strategy of alcohol risk minimisation, with middle- and upper-class participants being more in tune with the public health ethos of alcohol consumer ‘autonomisation’ and ‘responsibilisation’. Cutting across socio-economic differences, though, are risk conceptions that clash with the public health model of risk prevention. While the risk communication of the health agencies builds on the logic of ‘a will to health’, drinkers at relatively high consumption levels tend to prefer other rationales, associating alcohol use with socialisation, pleasure and relaxation, and defining alcohol risks in terms of ‘addiction’ rather than detrimental health effects. The article contributes to the discussion of the ‘prevention paradox’, showing that rational initiatives at a general population level are not always comprehended as such at the individual level.     

Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women

Objectives

to explore the extent to which a specialist clinic meets the needs of chemically dependent women.

Design

a critical ethnography informed by theorists such as Habermas and feminists' interpretation of Foucault.

Setting

a specialist antenatal clinic for chemically dependent pregnant women at a major metropolitan women's hospital in Melbourne, Australia.

Participants

a purposive sample of twenty (20) chemically dependent pregnant women who attended the clinic.Data collection and analysis included three taped interviews (two preceding the birth and one post birth), observation of the interactions between the women and the clinic staff over a 25-month period and chart audits.

Findings

similar to other studies there were multiple factors influencing development and maintenance of chemical dependency in this group of women, including family instability, family history of drug and alcohol abuse, childhood sexual abuse, having a chemically dependent partner and having a dual diagnosis of both drug addiction and mental illness. Initially there was considerable variation between the women and the clinic staff's expectations with regard to attending for antenatal care and conforming to a set regime as the women struggled with the contradictions inherent in their lifestyle and that of the ‘normal’ expectant mother. Aspects of that struggle included their belief that their opinions and knowledge of their lives was largely ignored, leading to episodes of resistance. Several women alleged the clinics staff's relationship with them was influenced by a belief that the women were ‘hopeless addicts in need of expert medical and midwifery care' and that the clinic staff exercised control in an authoritarian manner. However, as they explored possibilities for collaboration, they realised they could exercise power and work towards a more equal relationship with staff. The quality of relationships in most instances improved over time, and if not always strictly collaborative, was situated at various points along a continuum from minimal to full co-operation, with concomitant varying levels of success in terms of outcomes. It was often the attitude of individual staff members, particularly midwives, that was the key to the way in which the women responded to care.

Key conclusions and implications for practice

comprehensive history-taking and engaging women as early as possible in pregnancy; providing continuity of care – particularly midwife care – to assist in developing a collaborative approach to care; provision of an extended period of postnatal support to at least six months for those women able to parent their children was a key recommendation.     

‘Philosophy Lost’: Inquiring into the effects of the corporatized university and its implications for graduate nursing education

Drawing on a comprehensive, pan‐national analysis of the corporatization of Canadian universities, as well as the notions of ‘parrhesiastic’ mentorship and practice, the authors examine the effects of the corporatized university, its implications for graduate nursing education and nursing's relative silence on the subject. With the preponderance of business interests, the increasing dependence of universities on industry funding, cults of efficiency, research intensivity, and the pursuit of profit so prevalent in today's corporatized university, we argue that philosophical presuppositions so crucial to critical teaching, research, and reflection on nursing as a discipline are troublingly losing ground. We lament the erosion and fragmentation of philosophy, politics, and ethics as foundations for graduate education, which are increasingly perceived as less valuable, problematic, and in some cases, even burdensome. The effect of corporatization is the suppression of the critical engagement required of faculty in the everyday workings of institutions. We argue that, when the ideals of intellectual freedom, academic responsibility, duty, and obligation, as supported by philosophical thought, are smothered by the normalizing power of corporatized research agendas, philosophical approaches to inquiry and knowledge development become marginalized as scholars find themselves floundering in the face of a seeming ‘philosophy lost’.     

The social production of an enterprise clinic: nurses, clinical pathway guidelines and contemporary healthcare practices

In this paper I critically engage with the forming of contemporary nursing practice with/in an ‘enterprise clinic’ in order to discuss the practical potential of developing a mode of reflective practice that is a critical ontology of self. Critical engagement in the paper is secured through a ‘troubling’ of the relationship between the contemporary practices of both the self and governance, without the reduction of one to the other. The paper draws on my doctoral study in which I combined the techniques of ethnography and discourse analysis in order to critically examine registered nurses’ employment of clinical pathway guidelines through an analysis of the political technologies through which that engagement was constituted. This critical purchase was applied because of the influence of the contemporary ‘problematisation’ of healthcare provision in western society on the formation and deployment of the professional identities of nurses.     

Alternative futures for health economics: implications for nursing management

As nursing has been subject to successive waves of ‘managerialism’ there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the ‘economics of nursing’ as efficiency and ‘value for money’ are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.     

The emergence of the affected adult family member in drug policy discourse: A Foucauldian perspective

Abstract

The affected adult family member has increasingly received attention in drug research, policy and practice fields; however, this development has received limited critical and theoretical examination with respect to the presuppositions underpinning its rationale. Using a Foucauldian theoretical perspective, this article traces how families have been problematised in the treatment and rehabilitation domains of Irish drug policy and considers the political implications. A post-structuralist method, Bacchi’s (2009) “What’s the Problem Represented to Be?” approach, is applied to the analysis of eight drug policy documents published in Ireland between 1971 and 2009. Families are constructed as contributing to both the problem and solution of adolescent drug use. They are imagined as a key resource in treatment of adult drug use but as needing support in this role; and, as such they are constructed as service users in their own right. Families are governed through responsibilisation. The behavioural policy solutions are individualising and preclude alternative solutions that address political, socio-economic and gender inequalities that shape the experiences of affected families. The findings may be used as a starting point for critical reflection on the assumptions and privileged forms of knowledge and expertise that are shaping policy and practices relating to affected families.