Transcript Slide 1

Seminar 4:
Introduction
Critical Public Health:
Conceptualizations and
Applications
Seminar Outline
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Seminar Topics
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Break
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10 minutes
Scholarly Critical Public Health Analyses (examples from the lit)
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Definitions and Genealogy of Public Health (Sana)
Critical and Poststructural Theory(s) (Ingrid)
Conceptualizing “Critical Public Health” (Ingrid & Sana)
Meta-themes in Critical Public Health (Ingrid)
60 min
20 minutes
Group Discussion based on integration of theory and guiding
questions
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60 minutes
Slide #2
Two Most Important Points
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Critical appraisal is essential to unveiling
assumptions inherent to knowledge and its
utilization
The tricky part (we believe) is maintaining a
functional balance in clinical work: i.e. where do
we draw the line? Critical assessment is vital, but
many programs that are, in fact, helpful to
improving health outcomes have been heavily
scrutinized by critical perspectives
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Slide #3
What is Public Health?
“The science and art of preventing disease,
prolonging life and promoting health through the
organized efforts and informed choices of society,
organizations, public and private, communities and
individuals”- Winslow, 1920
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What is Health?
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1948 WHO definition:
"a state of complete physical, mental and social
well-being and not merely the absence of disease
or infirmity”
Avoids the “5 d’s”: death, disease, disability,
discomfort, dissatisfaction.
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Slide #5
What is Health?
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1984 update to definition:
“Health is the extent to which an individual or group is able on
the one hand to realize aspirations and satisfy needs, and, on
the other hand, to change and cope with the environment.
Health is therefore seen as a resource for everyday life, not the
objective of living; it is a positive concept emphasizing social and
personal resources as well as physical capacities”
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Public Health- Its beginnings
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Roots in Antiquity:
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Egyptians: irrigation ditches, mosquito nets, shaving
practices.
India, Crete, Rome: Water supply and drainage
Religious restrictions on behaviours
Miasmatic Theory
1000 BC, Chinese variolation of smallpox epidemic
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Public Health- Its beginnings
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The Bubonic Plague
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3 major outbreaks starting in the 6th and 7th Centuries
14th Century: The Black Death in Europe
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Killed 75 to 200 million people
Mass graves, burning of graves
1349, King Edward III: Orders mayor of London to keep city
and suburbs clean
Led to the development of quarantine
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Public Health- Its beginnings
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Quarantine and Sanitation
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In Canada, European immigration began in 1600’s
Brought with them smallpox, measles, tuberculosis
and alcohol which destroyed many Indigenous lives.
1721, Quarantine Act- fear of Black Plague
1795, Quarantine Act of Lower Canada
1796, Edward Jenner- first effective vaccine
1816- Appoint Health Officer of Lower Canada
1823- Quarantine Bill passed with Board of Health
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Public Health- Its beginnings
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Cholera and the Birth of Epidemiology
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Early 1830’s, pandemic cholera in Europe
John Snow, polluted public water well 1854
Emergence of germ theory
1832 Cholera arrives in Quebec
Strengthening Infrastructure- Health Boards, 1848
Public Health Act, 1860’s compulsory vaccination
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Public Health- Its beginnings
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The Sanitary Idea (1867-1909)
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Post confederation, public health gains momentum
Hygiene and sanitary reform- bacteriology
Individuals and communities can do something to
prevent the spread of disease and benefit from early
detection= the sanitary idea
Growing government role in prevention of disease
through public health
1879 Census and Statistics Act, 1884 Ontario Public
Health Act
Slide #11
Critiques
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Foucault
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Quarantine
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Governmentality
Biopower
Forms of control of goods and trade
Relationships between different parts of the globe
Birth of surveillance and control over the body
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Critical and Postructural
Theory(s)
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Critical Theory
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An approach to challenging and destabilizing established
knowledge, with the goal of social change
Origins = Frankfurt School in the 1930s (Critical Theory of
Society or Critical Social Theory)
All knowledge is historical and biased, “objective”
knowledge is a fallacy
Presently there exist numerous “critical theories” or
strands of critical theories (Browne, 2002)
Slide #13
(Crotty, 1998; Lincoln & Guba, 1994)
Postmodernism and
Poststructuralism
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Poststructuralism as a facet of postmodernism
Postmodernism: A movement characterized by plurality and
diversity of thought within philosophy, architecture, art and
literature (Cheek, 2000)
Rejects the notion of a universal, scientific truth as embraced
by objectivist epistemology (Abbey; Reed & Ground, 1997)
Analysis does not reveal any immutable truth but rather
“heterogeneity, culturally constructed difference and
impermanence” (Reed & Ground, p. 17)
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Poststructuralism
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Developed out of the structuralism movement in
France (peak = 1950’s to 1960’s)
Structuralism: the individual is shaped by
sociological, psychological and linguistic structures
Poststructuralism: took issue with the assumed
objectivity of the observer/individual i.e. biases are
introduced based on the conditioning of the
examiner
Crotty (1998)
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Poststructuralism
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Key theorists: Michel Foucault, Jacques
Derrida, Gilles Deleuze, Jacques Lacan,
Rolande Barthe
A theory that emphasizes “ways in which
language, knowledge and power interact
to construct and reproduce our ways of
experiencing our selves, our bodies and
the social and material worlds”
(Lupton, 1996, p. x)
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Critical Theory and
Poststructuralism
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An example of two “strands” of critical theory:
“Modernist” critical theory (i.e. Frankfurt School, “neoMarxists”) concerns itself with “forms of authority and
injustice that accompanied the evolution of industrial and
corporate capitalism as a political-economic system”
“Poststructural” critical theory: politicizes social problems “by
situating them in historical and cultural contexts, to implicate
themselves in the process of collecting and analyzing data,
and to relativize their findings”
(Lindlof & Taylor, 2002, p. 52; Charmaz, 1995 in Lindlof & Taylor, 2002, p. 56)
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Conceptualizing “Critical
Public Health”
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Presently no explicitly defined theory of critical public health
Application of critical perspectives (namely from sociology
and social epidemiology) to public health, its initiatives and
imperatives
Sociology: Deborah Lupton and Nikolas Rose
 Lupton: regulation, surveillance, neoliberalism and the
“new” public health
 Rose: biological citizenship
Social Epidemiology: Nancy Krieger “theory of social
production of disease” (Krieger & Zierler, 1996)
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Public Health Tenets
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Implicit Assumption: Public Health as an institution acts in
citizen’s bests interests to improve health and increase the
average lifespan (Lupton, 1995)
Post-Enlightenment ideology of humanism to measure, order
and contain disease at the population level (Lupton, 1995)
Humanism: group of philosophies that embrace the value and
agency of human beings and evidence (via rationalism and
empiricism) over religious/spiritual/esoteric beliefs (Crotty, 1998)
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Approaches to Critiquing
Public Health
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The extreme Right: Challenges the right of government to
“interfere” in the everyday activities of citizens
Political economy of health position: neoliberalist infusion
into public health and health promotion, “victim-blaming”
amidst oversights of socio-political inequities
Lupton’s Approach: Critique of the fundamental principles,
discourses and practices of public health from an
epistemological position/exploration of public health as a
sociocultural practice
(Lupton, 1995)
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Guidelines for a critical
appraisal
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Explicit questioning as to whose voices are being
heard and privileged
What alliances and conflicts are involved?
What body of expertise is cited in support of the
statements made?
What counts as “knowledge”, and how is it
organized, controlled, authenticated &
disseminated?
Who has access to this knowledge, and how is this
knowledge taken up, justified and used?
(Lupton, 1995 p. 49)
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Critical Public Health a la
Lupton (1995, 1996)
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Historically, biomedicine, evaded examination by
social scientists (the knowledge was unquestioningly
“neutral” and “objective”)
Biomedicine only recently explored as socially
constructed, a symbolic system of beliefs, and a site
for reproduction of power relations (Foucault)
One aspect of biomedicine, (public health) still
evades such critique
Lupton (1995)
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Critical Public Health a la
Lupton
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Public Health and Health Promotion are sociocultural
products = their logic, practices and justifications are
subject to change based on political, economic and
other social imperatives
Critical examination of public health using
contemporary sociocultural theory demonstrates
how health knowledge and practices are socially
constructed with dominant assumptions that
underpin them
Lupton (1995)
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Population vs. Public Health
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No consensus
Pop’n health more common in Canada:
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“an approach to the study of why there are different
disease burdens or risks amongst different social
groupings” (Labonte et al., 2005)
A re-politicization of a public health practice captured by
biomedical reductionism (Szreter, 2003)
Includes health outcomes, patterns of determinants and
policies and interventions that link these two.
Slide #24
Critical Population Health
(Labonte, et al., 2005)
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Twinned goals:
1.
2.
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Deconstruction of how historically-specific ideologies
and structures reinforce conditions that perpetuate
and legitimize conditions that undermine the health
of specific populations.
Normative political project, reconstruction of social,
economic and political relations along emancipatory
lines.
Slide #25
In a (large) “nut-shell”
“A critical approach to population health research is as unavoidably moral as it is
inherently political. Its praxis—a reflective cycle of action informed by
theory/evidence/values—challenges its practitioners to blur the boundaries between
their personal and their work/career lives. Morality without evidence risks
righteousness; evidence without a moral base risks passivity. A critical approach to
population health research, then, is a rare opportunity where the moral and political
necessities for social change can become part of our daily work, as much a statement
of who we are as of what we do. While the questions and content of our research will
always be important, the social processes by which we undertake and act upon the
research (including how the questions get framed in the first instance) become
equally if not more important.” (Labonte et al., 2005, pg. 15)
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Meta-themes in Critical
Public Health Analyses
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The construction of epidemiological facts
Neoliberalism & Governmentality
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The Construction of
Epidemiological Facts
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Epidemiology
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The study of illness patterns at the population level
Rise of epidemiology as a field of research associated
with statistical techniques, calculation of probabilities
and methods of gathering data on specific groups
Increased the respectability of the 19th-century public
health movement due to the use of “scientific”
methods of data analysis
(Lupton, 1995)
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The Construction of
Epidemiological Facts
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Collection of data + laws of probability = statistics that serve
to shape individuals’ subjectivity in certain defined ways
Result = is constructed categories against which groups and
individuals are measured
 Statistics defined as a technology for defining norms and
deviations from the norm
 e.g. individuals are “normalized” via comparison with the
“average/mean”
Goal is to ensure the pathological “abnormal” is eradicated
and that individuals will engage in self-regulation
Lupton (1995)
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The Construction of
Epidemiological Facts
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Objectivist epistemology : knowledge and truth exist within
their objects, independent of consciousness and experience
(Crotty, 1998)
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Realist/naïve realist ontology: reality is “out there” , the
universe is comprised of immutable, natural laws (Crotty, 1998)
Caveat: Health and illness are themselves social constructions
and not objective “truths” (Lupton, 1995)
Variables such as “social class” and “ethnicity” are subject to
sociocultural processes that are often ignored in
epidemiological research (Krieger & Smith, 2004)
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Example: The virus as a
social construction
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In biomedicine and popular knowledge, virus = natural
phenomena
The legitimacy of the virus is established through a series of
social processes that are all highly stylized
HIV/AIDS: constructed as “scientific fact” via the practices of a
small group of virologists co-citing each other’s work
These practices served to define the field of study around
HIV/AIDS and participated in the epistemology of the virus
Understandings of illnesses are continually subject to revision
and therefore not static “facts”
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Slide #31
Lupton (1995)
Neoliberalism &
Governmentality
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Neoliberalism: a market-driven approach to economic and
social policy that favours unregulated operations of the free
market as a means to stimulate and cultivate economic
growth (Bryant, Raphael & Rioux, 2006)
Individuals are rational agents responsible for making
decisions about their own well-being and skepticism about
the capacities of political authorities to govern (Lupton, 1996)
Operates NOT by imposing control over citizens but through
the “making up” of citizens capable of exercising regulated
freedom (Rose & Miller, 1992 p. 174 in Lupton, 1996)
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Neoliberalism and
Governmentality
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Governmentality: a broad term to describe relations between
self and self, self and others, self and institutions, or within
institutions entailing some form of guidance and/or control
(Foucault, 1991)
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Operationalized in post-structural discourses as a focus on the
strategies employed by governments to govern citizens
Foucault (1991) traces the emergence of governmentality
from the 16th century and its links with “normalization” (the
establishment of disciplines and knowledges that offer
direction as to how individuals should conduct themselves)
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Neoliberalism and
Governmentality
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Governmentality ≠ state as exerting power over citizens;
rather, power relations are diffuse, drawing on the
involvement of institutions at all levels (family, mass media,
school, parliament, police force, etc)
Goal = institutions engage in the process of producing
normalized subjects via self-regulation and control
In public health, all actors (medical professionals, community
groups, epidemiologists, etc) contribute to the construction of
a certain kind of subject: one who is autonomous, directed at
self-improvement, self-regulated, and seeking self-knowledge
Lupton (1996)
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Break!!!
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Scholarly Critical Public Health
Analyses (Galvin, 2002)
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Galvin (2002) Disturbing notions of chronic illness and
individual responsibility: towards a genealogy of morals
Crux of argument: within contemporary neoliberalist
societies, health and illness are perceived as matters of
personal responsibility
Individuals with chronic illness are deemed responsible for
their situation due to the supposed knowledge of known
risks: an “instance of moral failure” (p. 108)
“Risk” is consequently a powerful instrument of government
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Slide #36
Scholarly Critical Public Health
Analyses (Aguinaldo, 2008)
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Aguinaldo, J.P. (2008). The social construction of gay oppression as a
determinant of gay men’s health: ‘homophobia is killing us’. Critical
Public Health, 18(1), 87-96
Discourse analysis of the social construction of gay men’s health
Situates the study by highlighting shift in health research: “curing”
homophobia to investigating harms of oppression and discrimination
Key notion = unpacking homophobia and heterosexism to explore how the
assumptions inherent to the language/labelling influence gay men’s
health
 Homophobia: located within individual psyches
 Heterosexism: societal-level discrimination
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Scholarly Critical Public
Health Analyses (Lupton, 2012)
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“Precious Cargo”- reproductive citizenship
Pregnant women and their foetuses = focal points for
regulation, monitoring and control
Foetus has become fetishised as precious body
Individualisation assumes agency
Pregnant women as a public figure
Fetus-centric focus in Canada in tobacco & other substance
cessation research/programs are also under increased
scrutiny (Greaves et al., 2011) (Parkes et al., 2008)
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Scholarly Critical Population
Health Analyses (Richmond & Ross, 2009)
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Aboriginal health research focused on quantifying rates of
disease and mortality
Seek to understand underlying causes of inequality,
specifically environmental dispossession as a means of
producing and sustaining health inequalities over time
Aboriginal peoples as physically displaced people
Conduct analysis to map out how the processes of
environmental dispossession work in the everyday context to
shape the health and social realities of these communities
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Group Exercise
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Consider the following questions:
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What does “critical theory/perspectives” mean to you
in your own research and work?
Can you share ways in which critical theory has
informed your work and/or practice?
What thoughts do you have pertaining to the assigned
readings? Do you agree/disagree with the position(s)
of the authors?
Slide #40
References
Aguinaldo, J.P. (2008). The social construction of gay oppression as a determinant of gay men’s
health: ‘homophobia is killing us’. Critical Public Health, 18(1), 87-96.
Bryant, T., Raphael, D. & Rioux, M. (2006). Staying Alive: Critical Perspectives on Health,
Illness, and Health Care. Toronto: Canadian Scholars Press, Inc.
Cheek, J. (2000). Postmodern and post-structural approaches to nursing research. Thousand
Oaks, CA: Sage Publications.
Crotty, M. (1998). The Foundations of Social Research: Meaning and Perspective in the
Research Process. London: Sage Publications.
Foucalt, M. (1991). Governmentality. In Burchell, G., Gordon, C. and Miller, P. (eds). The Foucault
Effect: Studies in Governmentality. Hemel Hempstead: Harvester Wheatsheaf.
Galvin, R. (1997) .Disturbing notions of chronic illness and individual responsibility: toward a
genealogy of morals. Health: A Journal for the Social Study of Health, Illness and
Medicine, 6(2), 107-138
Guba, E. G. & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In
N.K.Denzin & Y. S. Lincoln (Eds) Handbook of qualitative research. Newbury Park:
Sage.
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References
Hacking, I (1990). The Taming of Chance. Cambridge: Cambridge University Press.
Krieger, N. & Zierler. S. (1996). What explains the public’s health? A call for epidemiologic theory.
Epidemiology, 7(1), 107-109.
Reed, J. & Ground, I. (1997). Philosophy of knowledge. In Philosophy for nursing (pp. 35-53).
London, UK: Arnold.
Lalonde, M. (1974). A new perspective on the health of Canadians: a working document. Ottawa:
Government of Canada. Retrieved December 27 from: www.phac-aspc.gc.ca/phsp/pdf/perspect-eng.pdf
Lindlof, T.R. & Taylor, B.C. (2002). Qualitative Communication Research Methods (3rd Ed).
Thousand Oaks, California: Sage Publications.
Lupton, D. (1995). The Imperative of Heath: Public Health and the Regulated Body. London:
Sage Publications
Lupton, D. (1996). The New Public Health: Health and Self in the Age of Risk. London: Sage
Publications .
Medicine, 3, 167–87.
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Slide #42
References
Radley, A. (1999). Abhorrence, compassion and the social response to suffering. Health: An
Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 3, 167–
87.
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