Introduction: Patient organization movements and new metamorphoses in patienthood

The work of composition: Situated articulation of visible and invisible work within patient organisations

Patient organisations (POs) play a significant role in the transformation of contemporary health systems. This article concentrates on the mundane and invisible work that enables and maintains POs, including the contextual inscription of such work and its relational becoming with visible practices. Grounded in ethnographic study within the Russian Multiple Sclerosis Society (RuMSS), I analyse how visible and invisible work are articulated in particular situations. Though this analysis, I bring forth the work of composition - the continuous situated work of putting together a PO, with care for heterogeneity of its visible and invisible practices and without an expectation of a predetermined result. The strategically visible work builds up RuMSS expertise, making it a legitimate mediator between different health actors. Meanwhile, the invisible tactics maintain the internal porosity and flexibility of the PO, allowing its members to escape surveillance and achieve efficacy despite strategic limitations. The articulation of these two streams of work within a given situation is a specific invisible practice performed by the RuMSS members - the composition work. This work requires collective and embodied sensitivity to the effects of making work (in)visible in specific time-spaces or chronotopes, and it manifests a modality of care within POs.

At the Heart of Resilience: Empowering Women's Agency in Navigating Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death among women globally, emphasizing the need for a healthcare approach that empowers women through agency. This review focuses on the critical role of women's agency in navigating CVD, integrating insights from various fields, including medicine, education, psychology, and sociology. The review highlights the shift toward patient-centred care, a framework in which women are recognized as key decision-makers, a crucial change given the historical underemphasis on women's health issues in medical practice. The diagnosis of CVD in women often involves emotional and psychological challenges. Unexpected diagnoses significantly disrupt perceived well-being, and prolonged diagnostic processes lead to professional skepticism and neglect of symptoms, resulting in delayed or inaccurate diagnoses and strained healthcare relationships. Effective management of CVD necessitates continuous self-management and a holistic approach to care, particularly for those with trauma who are at increased risk of cardiac incidents. Empowerment for women with CVD involves promoting self-confidence, autonomy, and active patient participation in healthcare. Implementing comprehensive care models is crucial for improving chronic CVD management, highlighting the need for healthcare systems that prioritize patient agency and empowerment. From the perspective of a woman with lived experience, this article examines the impact of CVD on women's agency throughout the diagnostic journey. By highlighting women's agency rather than particular behavioural changes, this review offers a comprehensive analysis that can shape policy, stimulate new research, and foster a more equitable, efficient, and empathetic healthcare system for women with CVD.

A patienthood that transcends the patient: An analysis of patient research partners' narratives of involvement in a Canadian arthritis patient advisory board

OBJECTIVES

Incorporating the perspectives of patients and public into the conduct of research has the potential to make scientific research more democratic. This paper explores how being a patient partner on an arthritis patient advisory board shapes the patienthood of a person living with arthritis.

METHODS

An analysis was undertaken of the narratives of 22 patient research partners interviewed about their experiences on the Arthritis Patient Advisory Board (APAB), based in Vancouver, Canada.

RESULTS

Participants' motivations to become involved in APAB stemmed largely from their desire to change their relationship with their condition. APAB was a living collective project in which participants invested their hope, both for their own lives as patients and for others with the disease.

CONCLUSIONS

Our findings highlight how the journeys of patient partners connect and integrate seemingly disparate conceptions of what it means to be a patient. One's experience as a clinical 'patient' transforms into the broader notion of civic patienthood.

The different facets of 'experiential knowledge' in Swedish women's claims about systemic side effects of the copper intrauterine device

'Experiential knowledge' has been identified as a key epistemic resource used by lay people to contest medical authorities and build new knowledge related to health. The Internet has created unprecedented opportunities for such experience-based epistemic projects. This article contributes to understandings of the as yet under-theorised concept of experiential knowledge by analysing accounts of a group of Swedish women who claim that their use of contraceptive copper IUDs has led to systemic side effects not recognised by health care providers. Based on digital group interviews and written essays, we distinguish between three components or stages of experiential knowledge at work in the women's use of experience as an epistemic resource: somatic knowing, collective validation and self-experimentation. Drawing on a critical realist framework, we defend a notion of experiential knowledge as crucially, while only partially, based on a bodily and practical access to aspects of reality organised by extra-discursive principles. By providing theoretical complexity to the notion of experiential knowledge, we contribute resources for discriminating between and evaluating various experience-based claims, something that is particularly needed in the current 'post-truth' era where experience-based knowledge claims pointing in divergent directions flourish.

"There Are Many of Us": Online Testimonies From "Pill Victims" as a New Form of Health Activism

The French pill scare is usually presented as a "media debate" triggered by the case of Marion Larat, a young woman who suffered a stroke attributed to the pill she was taking. This article intends to focus on a practice that preceded, accompanied, and followed this health scare: the publication of online testimonies of thrombotic reactions posted on the website of the French Association of Victims of Pulmonary Embolism and Stroke Associated with Hormonal Contraception (Avep). Through a discourse analysis, we intend to analyze these online public self-reports as an activist practice aimed at criticizing the dominant medical discourse on contraception. Four discursive frames emerged: unpreparedness of women and doctors, denial of blame and search for the cause, breaking the silence and building solidarity, and collective action. The first two frames concern the process women put in place to obtain the right to speak about and criticize a medical practice. The right to speak is achieved through a concise narrative style focusing on facts, bodily manifestations, and risk factors. The second pair refers to the formation of pill victims as subjects with an ambivalent status and ephemeral agency. The testimonies build what we call "lone solidarity", that is, the creation of a social bond and action around a common experience of witnessing medical injustice that develops without any exchange between members. This proves to be inclusive and viral, but at the same time fiercely anti-representational with respect to political struggles or social identification.

On the verge between the scientific and the alternative: Swedish women's claims about systemic side effects of the copper intrauterine device

The article intervenes in discussions on lay knowledge production about health in the Internet era, through the case of a group of women claiming that their use of copper intrauterine devices has led to systemic side effects. Based on online group interviews and written essays, we examine how women embracing these knowledge claims navigate various sources of information, focusing on the role of scientificity in these epistemic negotiations. The women were found to be involved in an active, scientifically oriented process of knowledge formation, which we refer to as a collective labour of scientific patchworking. Meanwhile, due to a perceived lack of scientifically based expertise on their condition, the women reported having little choice but turn to resources with weaker scientific foothold. We argue that the tendency to portray these women's claims as unscientific simplifies the nature of lay knowledge production, potentially deepening divides between medical authorities and the public.

What has been preventing the emergence of a broad social movement on diabetes (and NCDs)? Insights from the mobilisation of diabetes patients' associations in Bamako, Mali

Non-communicable diseases (NCDs) are among the leading causes of morbidity and mortality globally. While international strategies for their prevention and control call for greater civil society participation, many observers regret the lack of a broad social movement to address these diseases. This study focuses on diabetes patients' associations engaged from 1991 to 2014 in Bamako, Mali, and explores what factors influenced their capacity to build a collective national movement to address this disease and shape policy reforms in this area. Our findings show that the emergence of such a movement was limited by several constraints. The focus of diabetes patients' associations on technical biomedical issues silenced the daily embodied experience of patients and reduced the use of human-rights approaches. Moreover, few financial, material and social resources coupled with a fragmented base limited the scope and strength of claims made by patients' associations to obtain treatment at reduced coasts. Finally, modes of actions performed failed to challenge more structural inequalities and imbalances of power. Exacerbated by limited political opportunities, these constraints weakened the associations' ability to drive policy change on diabetes. They reflect some of the current weaknesses of the global mobilisation to address diabetes and NCDs.

Disease surveillance infrastructure and the economisation of public health

The city government of Chicago adopted a 'racial equity' approach to tackle racial disparities in COVID-19 outcomes. Drawing on experience addressing core vulnerabilities associated with HIV risk, Chicago public health experts who designed COVID-19 mitigation initiatives recognised that the same social determinants of health drive racial disparities for both HIV and COVID-19. Yet, when building an infrastructure to respond to COVID-19, disease surveillance and data collection became the priority for investment ahead of other forms of public health work or the provision of social services. The building of a disease surveillance infrastructure that responded to and supplied data took precedence over addressing social determinants of poor health. Community-based organisations that might have otherwise organised for social service provision were incorporated into this infrastructure. Further, public health officials often failed to heed the lessons learned from their experience with HIV vulnerability. Based on qualitative analysis of 56 interviews with public health experts and policymakers in Chicago, we argue that the prioritisation of disease surveillance, coupled with a scarcity model of public health provision, undermined the city's attempt to redress racial inequities in outcomes. We argue that the economisation of pandemic response exacerbates health disparities, even when racial equity frameworks are adopted.

Cultivated co-production: Sexual health, human rights, and the revision of the ICD

STS scholars frequently have shown how science and sociopolitical arrangements are 'co-produced', typically tracing how scientific actors themselves keep 'science' and 'politics' far apart. Revealing co-production is therefore deemed the work of the STS analyst, who unearths linkages that the actors might be unaware of, or might ignore or deny. By contrast, the creation of a new chapter on 'sexual health' in the recent revision of the International Classification of Diseases (ICD) offers a case of what might be termed 'cultivated co-production'. Neither oblivious to the linkages between science and politics nor invested in obscuring them, the designers of the sexual health chapter sought support for their work by demonstrating, transparently, how science, ethics, and human rights might properly be aligned. The intentional and visible character of co-production in this case indicates awareness of the need to manage the contested nature of gender and sexuality at a transnational level. It also reflects two changes in the organization of medical politics and medical classification: a widespread recognition of the necessity of reaching out to lay stakeholders and advocates, and the rise of an emphasis on 'conventions' as the backbone of transnational biomedical consensus processes.

Rethinking Universal Health Coverage: A qualitative study of patient organisation perspectives on the Turkish health-care system

Universal health coverage (UHC) has been elevated to the status of a global policy target, but this was at the expense of losing its aspirational meaning. As a case in point, Turkey has been one of the countries that has achieved UHC, according to the technocratic definition. This article employs a combination of deductive and inductive thematic analysis methods to explore patient organisation (PO) perspectives on the Turkish health-care system based on 26 respondent interviews from 19 POs in Istanbul. Highlighting the inadequacy of the technocratic definition of UHC, the article maintains that an analysis of PO perspectives opens the way for a nuanced and bottom-up assessment of essential service coverage and financial protection by identifying elusive gaps in both dimensions that would otherwise be lost in generalist evaluations. The findings also underline the importance of keeping intact the UHC's aspirational element to enable POs to participate in the politics of priority setting in health care.

Engaging cultural humility diffractively

BACKGROUND

Conventional models of cultural humility - even those extending analysis beyond the dyad of healthcare provider-patient to include concentric social influences such as families, communities and institutions that make clinical relationships possible - aren't conceptually or methodologically calibrated to accommodate shifts occurring in contemporary biomedical cultures. More complex methodological frameworks are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very cultural and material conditions of health care and its delivery structures, and thus how power manifests in clinical encounters.

METHODS

In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine's technologising turn. A second level of intervention invites experimentation to broaden the availability of methodological tools to analyse and assess the multidimensionality of technologies and their agentic effects in healthcare encounters.

RESULTS

Drawing from new materialism theories, practices of care are approached "diffractively" as contingent and dynamic material-discursive events. Our neo-materialist framework for cultural humility expands analytical sight-lines beyond hierarchical relationships and dichotomies privileging humans (practitioner and/or patient) as sole actants in the clinical exchange. Attended to are the ongoing dynamics of practices entangling big-data driven knowledges and interventions, pharmacological technologies and material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients. We investigate the implications for clinical assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contextually emergent data moments and objects for analysis.

CONCLUSION

Engaging evaluative inquiry diffractively allows for a different ethical practice of care, one that attends to the forms of patient and health provider accountability and responsibility emerging in the clinical encounter.

Rethinking long-term condition management: An actor-level framework

To understand the complexities of managing long-term conditions and develop appropriate responses, micro-, meso- and macrolevels must be considered. However, these levels have not been combined in a single analytical framework of long-term condition management (LTCM). This article aims to describe a framework of LTCM practice and research that combines societal levels and key agents. The actor-level framework, based on the works of Abram De Swaan and Randall Collins, provides a broader understanding of LTCM as an interdisciplinary research field compared to previous contributions. The framework has three main advantages. First, it encourages knowledge production across levels and actors that address the complexity of long-term illness management. Second, it broadens the scope of LTCM as an interdisciplinary research field and practice field. Finally, it facilitates the integration of knowledge production from different disciplines and research traditions. The framework could stimulate interdisciplinary research collaboration to enhance knowledge of processes and interactions influencing the lives of individuals with long-term conditions.

Ativismo político de pais de autistas no Rio de Janeiro: reflexões sobre o “direito ao tratamento”

Resumo Este artigo refere-se às percepções e reivindicações de dois principais grupos de pais-ativistas do autismo - Azul Claro e Azul Celeste -, no percurso de “luta” por “direito ao tratamento”, no estado do Rio de Janeiro. Focaliza, sobretudo, como se constroem discursos e tensões acerca dos cuidados e dos tratamentos oferecidos no âmbito do Sistema Único de Saúde (SUS). Portanto, é nosso objetivo compreender em que medida as reivindicações referentes ao tratamento do autismo se inserem no contexto mais amplo das políticas nacionais em saúde voltadas ao segmento. Recebem destaque as legislações elaboradas por pais-ativistas em conjunto com figuras políticas, bem como os posicionamentos e vocalizações que consideram os atendimentos oferecidos pelas Redes de Atenção Psicossocial (Raps) como “insuficientes” e/ou “inadequados”. A metodologia de pesquisa envolveu trabalho etnográfico, realizado entre 2012 e 2013, em eventos, reuniões e mobilizações organizadas pelos dois grupos de pais de autistas, além de entrevistas em profundidade com informantes qualificados (mães, pais e familiares ativistas).

Health activism and the logic of connective action. A case study of rare disease patient organisations

This exploratory work investigates the role of digital media in expanding health discourse practices in a way to transform traditional structures of agency in public health. By focusing on a sample of rare disease patient organisations as representative of contemporary health activism, this study investigates the role of digital communication in the development of (1) bottom-up sharing and co-production of health knowledge, (2) health public engagement dynamics and (3) health information pathways. Findings show that digital media affordances for patient organisations go beyond the provision of social support for patient communities; they ease one-way, two-way and crowdsourced processes of health knowledge sharing, exchange and co-production, provide personalised routes to health public engagement and bolster the emergence of varied pathways to health information where experiential knowledge and medical authority are equally valued. These forms of organisationally enabled connective action can help the surfacing of personal narratives that strengthen patient communities, the bottom-up production of health knowledge relevant to a wider public and the development of an informational and eventually cultural context that eases patients' political action.

An Ethnographic-Discursive Approach to Parental Self-Help Groups: The Case of ADHD

Mutual aid groups have become a common form of help in the mental health field. Although self-help groups are associated with a range of health and social benefits, they remain poorly understood in terms of the dynamics of their interactions. Adopting an ethnographic-discursive approach, we conducted a 6-month observation of the meetings of a self-help group of parents with children diagnosed with attention deficit/hyperactivity disorder (ADHD) to analyze the discursive dynamics of the interactions that characterized the group. Using a set of discursive strategies and practices, the parents promoted a homogeneity of viewpoints and experiences within the group and constructed a shared and consensual narrative to endorse a specific understanding of ADHD. The production of both homogeneity within the group and a shared narrative served to absolve parents of guilt, helped parents to signify their experience within a blaming social context, and preserved their identities as "good parents."

The politics of health mobilization in the United States: The promise and pitfalls of "disease constituencies"

A critical review of recent literature on U.S. social movements concerned with matters of health and illness prompts reconsideration of the prevailing conception of such movements as necessarily isolated and particularistic. With a focus on disease-constituency-based mobilization-presently the most potent model of efficacious activism to be found in the domain of health and illness in the United States-I argue that such activism may tend in two directions: a specific response to an imminent disease threat, and a bridging of collective action frames and identities that can lead to connections across differences and broader mobilization. Case studies have demonstrated how patient activism has affected the management of illness, attitudes and practices of health professionals, research practices, processes of innovation, state policies, and corporate behavior. Through close analysis of patient group mobilization and its distinctive orientation toward knowledge and expertise, I argue that patient groups in practice may connect with or influence one another or a range of other forms of mobilization in relation to health, and I examine the "linkage mechanisms"-spillover, coalition, and frame amplification-by which this can occur. Rather than imagine a stark opposition between particularistic, single-issue health politics, on the one hand, and universalistic efforts to transform the meaning and practice of health and health care in the United States, on the other, I propose closer attention to the potentially Janus-faced character of many health movement organizations and the ways in which they may look either inward or outward.

Exploring the positions of German and Israeli patient organizations in the bioethical context of end-of-life policies

Patient organizations are increasingly involved in national and international bioethical debates and health policy deliberations. In order to examine how and to what extent cultural factors and organizational contexts influence the positions of patient organizations, this study compares the positions of German and Israeli patient organizations (POs) on issues related to end-of-life medical care. We draw on a qualitative pilot study of thirteen POs, using as a unit of analysis pairs comprised of one German PO and one Israeli PO that were matched on the basis of organizational category. Bioethical positions that emanated from the interviews concerned advance directives--general views, recent legal framework, and formalization; as well as active and passive euthanasia, withholding and withdrawing of treatment, and physician-assisted suicide. In addition to the unifying, within-country impact of cultural factors, we found that constituency-based organizations and partner organizations in both countries often share common views, whereas disease-based support organizations have very heterogeneous positions. We conclude by discussing how organizational contexts provide a source of uniformity as well as diversity in the positions of POs.

What binds biosociality? The collective effervescence of the parent-led conference

Questions of community are central to many research settings in the social sciences. Rabinow argued that, in the wake of the Human Genome Project, an increasingly important form of collectivity would be biosociality. Biosociality recognises a central role for biomedical knowledge in constructing genetic identities and producing and reproducing social relationships. Accordingly, it is often imagined as a new form of social solidarity. We draw on observations of parent-led conferences to explore the way in which biosociality is expressed at events organised around a particular genetic syndrome - 22q11 deletion syndrome. The parent-led conferences took place within the United Kingdom between 2007 and 2010 and were observed as part of a multi-sited ethnographic study. By bringing together a geographically dispersed group of people together within the same physical location, conferences offer an ideal platform to empirically examine sociality. Durkheim used the term collective effervescence to describe the collective expression of heightened emotion. We suggest that in the case of the 22q11 deletion syndrome activities discussed in this paper, collective effervescence is a mechanism through which individuals become a collective. We argue that parent-led conferences gather individuals in one location on the basis of common biological factors, but it is the shared emotional experience of being together that consolidates and renews the connection between members.

Solidarity by demand? Exit and voice in international medical travel - the case of Indonesia

Globally, more patients are intentionally travelling abroad as consumers for medical care. However, while scholars have begun to examine international medical travel's (IMT) impacts on the people and places that receive medical travellers, study of its impacts on medical travellers' home contexts has been negligible and largely speculative. While proponents praise IMT's potential to make home health systems more responsive to the needs of market-savvy healthcare consumers, critics identify it as a way to further de-politicise the satisfaction of healthcare needs. This article draws from work on political consumerism, health advocacy and social movements to argue for a reframing of IMT not as a 'one-off' statement about or an event external to struggles over access, rights and recognition within medical travellers' home health systems but rather as one of a range of critical forms of on-going engagement embedded within these struggles. To do this, the limited extant empirical work addressing domestic impacts of IMT is reviewed and a case study of Indonesian medical travel to Malaysia is presented. The case study material draws from 85 interviews undertaken in 2007-08 and 2012 with Indonesian and Malaysian respondents involved in IMT as care recipients, formal and informal care-providers, intermediaries, promoters and policy-makers. Evidence from the review and case study suggests that IMT may effect political and social change within medical travellers' home contexts at micro and macro levels by altering the perspectives, habits, expectations and accountability of, and complicity among, medical travellers, their families, communities, formal and informal intermediaries, and medical providers both within and beyond the container of the nation-state. Impacts are conditioned by the ideological foundations underpinning home political and social systems, the status of a medical traveller's ailment or therapy, and the existence of organised support for recognition and management of these in the home context.

The role of patient advocacy organizations in shaping genomic science

Patient advocacy organizations (PAOs) are nonprofit groups that represent patients and families affected by a significant medical condition or disease. We review some of the different approaches that humanities and social researchers use to study PAOs. Drawing on this recent scholarship, we describe some contemporary patient groups and explore how PAOs can collaborate with biomedical researchers to advance genomic science. We highlight research that aims to describe how PAOs are contributing to multiple aspects of biomedical research, including study design, definition of research goals, data collection and analysis, dissemination of results, and research funding. We also describe several challenges that genomic researchers may encounter in collaborations with PAOs. Throughout our review, we focus on the manner in which new PAO roles challenge traditional boundaries between researchers and subjects, thereby redefining the relationship of patients to science. We consider how this shift may affect our view of scientific collaborations and impact genomic researchers in the future.

Integrating medical and environmental sociology with environmental health: crossing boundaries and building connections through advocacy

This article reviews the personal and professional processes of developing an interdisciplinary approach to understanding the complex issues of environmental health in their community, political-economic, social science, and scientific contexts. This interdisciplinary approach includes a synthesis of research, policy work, and advocacy. To examine multiple forms of interdisciplinarity, I examine pathways of integrating medical and environmental sociology via three challenges to the boundaries of traditional research: (1) crossing the boundaries of medical and environmental sociology, (2) linking social science and environmental health science, and (3) crossing the boundary of research and advocacy. These boundary crossings are discussed in light of conceptual and theoretical developments of popular epidemiology, contested illnesses, and health social movements. This interdisciplinary work offers a more comprehensive sociological lens for understanding complex problems and a practical ability to join with scientists, activists, and officials to meet public health needs for amelioration and prevention of environmental health threats.

Why New Hybrid Organizations are Formed: Historical Perspectives on Epistemic and Academic Drift

By comparing three types of hybrid organizations-18th-century scientific academies, 19th-century institutions of higher vocational education, and 20th-century industrial research institutes-it is the purpose here to answer the question of why new hybrid organizations are continuously formed. Traditionally, and often implicitly, it is often assumed that emerging groups of potential knowledge users have their own organizational preferences and demands influencing the setup of new hybrid organizations. By applying the concepts epistemic and academic drift, it will be argued here, however, that internal organizational dynamics are just as important as changing historical conjunctures in the uses of science when understanding why new hybrid organizations are formed. Only seldom have older hybrid organizations sought to make themselves relevant to new categories of knowledge users as the original ones have been marginalized. Instead, they have tended to accede to ideals supported by traditional academic organizations with higher status in terms of knowledge management, primarily universities. Through this process, demand has been generated for the founding of new hybrid organizations rather than the transformation of existing ones. Although this study focuses on Swedish cases, it is argued that since Sweden strove consistently to implement existing international policy trends during the periods in question, the observations may be generalized to apply to other national and transnational contexts.

A construção do diagnóstico do autismo em uma rede social virtual brasileira

Este artigo apresenta alguns resultados de uma pesquisa realizada em uma rede social virtual brasileira, com o tema do autismo. Investigou-se a opinião pública sobre o autismo nessa rede, por meio de suas comunidades ligadas ao assunto. A opinião pública sobre determinada condição médica traz consequências diretas sobre a experiência do doente e sobre as pessoas implicadas em cuidar dos pacientes acometidos. Os resultados apontam algumas direções a respeito das representações dos usuários sobre as supostas causas da doença, os métodos de tratamento, as formas de ativismo e de busca de direitos dos portadores, e os usos paradoxais do conhecimento médico, ao qual se atribui a possibilidade de desvendar a doença, e, ao mesmo tempo, é alvo de resistência de pais e cuidadores, que priorizam o conhecimento proveniente de sua experiência cotidiana com os autistas.

Beyond the therapeutic: A Habermasian view of self-help groups' place in the public sphere

Self-help groups in the United Kingdom continue to grow in number and address virtually every conceivable health condition, but they remain the subject of very little theoretical analysis. The literature to date has predominantly focused on their therapeutic effects on individual members. And yet they are widely presumed to fulfil a broader civic role and to encourage democratic citizenship. The article uses Habermas' model of the public sphere as an analytical tool with which to reconsider the literature on self-help groups in order to increase our knowledge of their civic functions. In doing this it also aims to illustrate the continuing relevance of Habermas' work to our understanding of issues in health and social care. We consider, within the context of current health policies and practices, the extent to which self-help groups with a range of different forms and functions operate according to the principles of communicative rationality that Habermas deemed key to democratic legitimacy. We conclude that self-help groups' civic role is more complex than is usually presumed and that various factors including groups' leadership, organisational structure and links with public agencies can affect their efficacy within the public sphere.

The emergent modes of dementia activism

After decades of silencing and discrimination, people with dementia are beginning to join forces, take action and campaign for social change. Drawing on data obtained from ‘activists’ with dementia using diary interview method and participant observation, this paper considers the emergent modes of dementia activism in the context of the social movement literature, and in particular, work emphasising the role of networks in health social movements. The study identified three emergent modes of dementia activism; these were the ‘protecting-self against decline’ mode, ‘(re) gaining respect’ mode, and ‘creating connections with other people with dementia’ mode. Taken together, these modes show how a sense of elapsing time pervades this form of activism. The investigation reinforces the contention that time is a dominated force that structures human motivation and goals. Furthermore, it raises the possibility that activism can protect against decline amongst people with dementia given the appropriate temporal space.

From healing to witchcraft: on ritual speech and roboticization in the hospital

Healthcare Information Technology (HIT), touted as a panacea by U.S. political actors ranging from Newt Gingrich to Barack Obama, is central to emerging forms of healthcare governance which Holmes et al.-in their critique of the institutionalization of magical thinking brought about by Orwellian techno-Newspeak-have provocatively labeled fascistic. Drawing from data collected over 3 years of working with and teaching continuing education (CE) courses for thousands of registered nurses as lead political educator for the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), I argue that HIT is an integral component of a broader technological restructuring of healthcare and thus society, both of which are part of a social discourse that is tied to a transformative system of ritual speech, with profound implications for healthcare work, patient health, and democracy.

Health dynamics: implications for efficiency and equity in priority setting

Health dynamics are intertemporal fluctuations in health status of an individual or a group of individuals. It has been found in empirical studies of health inequalities that health dynamics can differ systematically across subgroups, even if prevalence measured at one point in time is the same. We explore the relevance of the concept of health dynamics in the context of cost-effectiveness analysis. Although economic evaluation takes health dynamics into account where they matter in terms of efficiency, we find that it fails to take into account the equity dimensions of health dynamics. In addition, the political implications of health dynamics may influence resource allocation decisions, possibly in opposing directions.

The impact of patient advocacy: the case of innovative breast cancer drug reimbursement

Current research into patient advocacy focuses on attempts of patient groups to mobilise resources and to influence researchers, pharmaceutical companies and policy-makers. This paper adopts a 'framing political opportunities' approach to draw attention to other kinds of advocacy strategies. In a case study of breast cancer patient advocacy of Herceptin reimbursement, it is shown how patient groups tried to gain access to policy-making by means of three different opportunity-framing strategies. Articulation aims at creating awareness through public-agenda building. Negotiation aims at frame alignment between interdependent stakeholders by arranging meetings. Politicisation is a strategy to influence the agendas of political arenas. Patient organisations succeeded in creating awareness and support, which had a considerable impact on other stakeholders. These impacts in turn aided the politicisation of the issue. However, the final impact on reimbursement procedures was only partially achieved due to depoliticising counterstrategies based on persistent ideas buttressing a particular division of responsibilities in the organisation of healthcare. According to these ideas cost control in healthcare is a medical responsibility, not a political one.

Who rules rare disease associations? A framework to understand their action

The inner structure of so-called 'patients' organisations' has been accorded relatively little attention with respect to their increasing role in the medical world. This comparative study in France of eight such organisations, matching six rare disorders, explores the issue of power and decision making through the description of the entities that make up the organisation (and especially which stakeholders are represented), their mutual relationships, the temporal scope of collective action, and the concrete achievements of the organisation. Two main types of organisation are distinguished: 'pluralistic' organisations (that bring together a broad array of different stakeholders who are willing to work together) and 'monistic' organisations (where a single category of stakeholders firmly takes the lead). Their operations are very different and result from the association's composition. A key finding is that both the usual opposition between lay and expert and the reference to the diseases' characteristics prove to be irrelevant to understanding these organisations. Rather, the composition of the leading group is crucial.

Anti-aging science: The emergence, maintenance, and enhancement of a discipline

Through archival analysis this article traces the emergence, maintenance, and enhancement of biogerontology as a scientific discipline in the United States. At first, biogerontologists' attempts to control human aging were regarded as a questionable pursuit due to: perceptions that their efforts were associated with the long history of charlatanic, anti-aging medical practices; the idea that anti-aging is a "forbidden science" ethically and scientifically; and the perception that the field was scientifically bereft of rigor and scientific innovation. The hard-fought establishment of the National Institute on Aging, scientific advancements in genetics and biotechnology, and consistent "boundary work" by scientists, have allowed biogerontology to flourish and gain substantial legitimacy with other scientists and funding agencies, and in the public imagination. In particular, research on genetics and aging has enhanced the stature and promise of the discipline by setting it on a research trajectory in which explanations of the aging process, rather than mere descriptions, have become a central focus. Moreover, if biogerontologists' efforts to control the processes of human aging are successful, this trajectory has profound implications for how we conceive of aging, and for the future of many of our social institutions.

Exploring one's own human condition: adults affected by cystic fibrosis

Drawing on a sample of 11 interviews in France with adults affected by cystic fibrosis, and applying grounded-theory analysis, I describe illness-related learning processes in the case of persons affected by a genetic disorder with early onset. Three outcomes might be of interest to health professionals. First, the diagnosis of genetic disease does not imply that the patients consider themselves to be ill. The meaning of being affected by a genetic disorder has to be understood. Second, these patients gain a particular knowledge of their illness that helps them undertake or avoid certain actions to achieve goals they consider important, through a process I call "critical internalization." Third, these patients exhibit similarities with Freidson's classical medical practitioner's clinical mind, although health is not at all their main priority.

Corporate colonization of health activism? Irish health advocacy organizations' modes of engagement with pharmaceutical corporations

This article is based on a study that aimed to shed light on the "cultures of action" of Irish health advocacy organizations, and particularly their modes of engagement with pharmaceutical corporations. Debates about what some interpret as the "corporate colonization" of health activism provide the backdrop for the analysis. The empirical dimension of the study involved a survey of 112 organizations and in-depth study of a small number of organizations that manifest diverse modes of engagement with the pharmaceutical industry. The varying modes of interaction are plotted along a continuum and characterized as corporatist, cautious cooperation, and confrontational. Evidence is presented of a strong and growing cultural tendency in Irish health advocacy organizations to frame pharmaceutical corporations as allies in their quests for better health. The analysis of four constitutive dimensions of organizations' cultures of action can reveal the legitimating logics underlying their diverging positions around pharmaceutical industry sponsorship. While the research shows that pharmaceutical corporations have largely succeeded in defining themselves as a philanthropic force and rightful players in Irish health activism, it cautions against a simplistic conclusion that this is evidence of corporate colonization.

'No one agrees except for those of us who have it': endometriosis patients as an epistemological community

This paper contributes to the literature on patients' claims-making work by analysing the epistemological strategies and standards used by members of an endometriosis patient community. It draws upon focus group research with members of a support group for endometriosis sufferers, and an open-ended survey of an e-mail list for women with the disease. Lynn Hankinson Nelson's (1993) concept of epistemological community is used to examine standards and practices for developing and evaluating knowledge used by women with endometriosis. Particular attention is paid to the use and centrality of the notion of experience within this community.