Health: An Interdisciplinary Journal for the Social Study of Health,Illness and Medicine

Christian Science is a form of Christianity with a strong theology of healing, the basis of which is an ontology that denies the reality of the material universe including the physical human body and affliction. An ethnographic study conducted in New Zealand in a Christian Science congregation showed that respondents have unique understandings about the nature of ‘self’ and ‘health’. These understandings underpin explanations of affliction, and healing, and inform the therapeutic strategies that are employed by respondents. The notion of integrity is put forward as a means of understanding the complex relationship between healing, health and ‘self’. A framework of integrity affords an insightful understanding of the complex meanings associated with the experience of affliction, the therapeutic strategies which are utilized to effect healing and the meanings associated with therapeutic outcomes – both successful and unsuccessful in the religious praxis of Somecity Christian Scientists.

This article proposes a theoretical contribution to critical health psychology. Charles Sanders Peirce’s semiotics provide health psychology and related fields with an analytic that centers interest at the intersection where the co-constitution of reified categories occurs. I begin with the terms symptom and sign as used in medical contexts. Symptoms and signs can be reinterpreted, drawing on the Heideggerian notion of ‘attunement’, and upon Peirce’s semiotics. Next, I present Peirce’s concept of sign, with its triadic structure of object-representamen-interpretant. An understanding of pain as a sign in this sense is developed on this basis. The value of Peircian semiotics for a critical health psychology is illustrated with some examples drawn from a qualitative study. Pain is not only something of concern and the bearer of meanings, but a way of interpreting one’s situation. This semiotics of pain furthers the project, common to phenomenological and discursive approaches in health psychology and related fields, of studying the upsurge of meaning in speech and in other acts that co-constitute it.

This article examines the relationship between social status and medical help-seeking strategies in St. Petersburg, Russia. Analysis of in-depth interviews with a cross-section of the population revealed that access to and use of medical care varied greatly across the urban social structure. Those in the highest social strata used their knowledge and connections to gain access to the best care. Their social position and understanding of the system also privileged them in interactions with physicians, enabling them to take greater advantage of ‘free’ services. Even with similar levels of material well-being, people with less education received poorer health care. Lacking confidence in their ability to assess quality and reluctant to consider options outside the impoverished, inefficient state medical system, they bore the brunt of its inadequacies. This reinforced a long-standing, culturally based predisposition to delay treatment until health problems had become more difficult and costly to manage.

Discourse communities are groups of people who share common ideologies, and common ways of speaking about things. They can be sharply or loosely defined. We are each members of multiple discourse communities. Discourse can colonize the members of discourse communities, taking over domains of thought by means of ideology.

The development of new discourse communities can serve positive ends, but discourse communities create risks as well. In our own work on the narratives of people with interests in health care, for example, we find that patients speak of their illness experiences as victims of circumstance; policy makers construct adverse experiences and challenges as opportunities to be taken; health care workers speak from a mixed perspective, seeing themselves as both victims and opportunists depending on context. To be trapped within the discourse of a particular community is to put at risk the ability to communicate across discourses. Membership of a discourse community can impair the habit of critique, and deny opportunities for heteroglossic discourse. Privileging critique as a mode of discourse perhaps might define the ethical community, suggesting that ethical community may be an antidote to the constraining effects of conventional discourse community.

This article is based on 28 in-depth interviews with Russian immigrant physicians (11 men and 17 women, age range 30–53) who decided not to seek Israeli medical license and converted to physiotherapy. This research was theoretically informed by the literature on physicians’ professional commitment. It explored the case of conversion from a perceived higher to lower status health care occupation and the ensuing changes in former doctors’ professional self-image, relations with the patients and colleagues, and adjustment to the new work role. Informants were recruited among the graduates of the retraining courses sponsored in the mid-1990s by the Israeli Ministry of Health in order to provide jobs for immigrant doctors and to fill in existing vacancies in physiotherapy. The stories of former MDs–novice physiotherapists indicate that most are well adjusted to their new role, maintain positive professional self-image, and are satisfied with the terms of their employment. At the same time, most informants admitted that their mode of thinking and relation to patients remained those of physicians rather than paramedics. Some informants gave medical advice to the patients (especially to their co-ethnics) when asked and discussed treatment options with physicians whenever the work context allowed. Ostensibly good readjustment of this group may reflect the interplay of their actual success in the new role, reluctance to disclose problems in the interview, and self-selection of this group (i.e. doctors who were ready to trade their higher status for pragmatic work benefits). We conclude that complete occupational make-over of immigrant physicians is hardly possible; their professional socialization leaves deep imprint on the mindset and conduct, regardless of subsequent career change.

In a recently completed study of the management of ‘out-ofhours’ primary healthcare for children and ways in which judgements are made about legitimate access, the construct of ‘inappropriate demand’ is investigated. This seemingly intractable health care issue has not been resolved by research that rests on a one-sided conceptualization of the ‘problem’.

In practice, ‘demand’ arises within complex processes of interaction between people taking a range of moral positions in particular contexts. This is illustrated with interpretations of some ethnographic material from the study. An argument is made for an alternative research approach to such contentious issues that acknowledges multiple and latent moral orientations, and reveals moral judgements in scientific guise.