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By L. Miguel. Mercy College of Health Sciences.

They turn up at the surgery viagra jelly 100 mg visa erectile dysfunction remedies, declaring that they ‘need a complete check-up’ generic viagra jelly 100mg on-line erectile dysfunction medicine list. The popularity of the notion that healthy young people require regular medical maintenance marks the triumph of the ideology of health promotion. As Bridget Jones also reflects, guilt is a more common response to health promotion initiatives than anger. When women have come in to the surgery worried about a breast lump, I have occasionally inquired whether they routinely carry out self-examination. The fact that even people who do not follow the dictates of the ‘awareness’ campaigns —in this case into an activity which most experts consider quite useless—still feel that they are in default of their personal and social responsibilities, reveals the impact of health promotion. The gloomy atmosphere of the smokers’ huddle confirms that who defy the injunctions of healthy living experience remorse rather than elation. Over the past twenty years personal behaviour has been exten- sively re-interpreted and reorganised around considerations of health. The very ubiquity of terms which link ‘health’ with some activity which had previously been regarded as a distinct and autonomous sphere indicates this trend—‘healthy lifestyle’, ‘health 67 SCREENING foods’, ‘healthy eating’, ‘sexual health’, ‘exercise for health’. Whereas feminists once rejected ‘women’s health’ as a form of male medical domination, their latter-day sisters have embraced ‘lesbian health’ as an affirmation of identity; in a common spirit of victimhood we now also have ‘men’s health’. The cult of exercise, pursued not for the enjoyment of sporting activity as such, but in the cause of improving physical fitness in the abstract, reflects the ascendancy of preoccupations about health over personal behaviour. The third theme is the transformation of the medical role and the emergence of new institutions that mediate between the individual and the state in the sphere of health. The change in the role of the doctor is most apparent in general practice, in many ways the front line of the advance of medical intervention in lifestyle. In the not-so- distant past, general practice was a demand-led service: patients came to the surgery complaining of illness and doctors offered diagnosis and treatment, care and concern, within the limits of their own abilities and those imposed by medical science and health service resources. Over the past decade, general practice has shifted to a more pro-active approach, inviting patients to attend for health checks and screening procedures and adopting a more interventionist role in relation to lifestyle issues, such as smoking and drinking, diet and exercise. Instead of serving their patients’ needs, GPs now serve the demands of government policy—and the dictates of government-imposed health promotion performance targets. New procedures, such as the routine check-up and the lifestyle questionnaire, allowing the systematic recording (now in a readily accessible computerised form) of intimate knowledge of the patient, have become a familiar feature of the doctor-patient relationship. Having taken on a major role in health promotion, the government has worked with the established organisations of the medical profession—the various royal colleges, the BMA and others—to push forward initiatives like the Health of the Nation campaigns of the early 1990s. It has also recognised the limitations of these traditionally conservative and inflexible bodies and has encouraged the development of a range of institutions to play a more dynamic role. An early example of this approach was the establishment of the Health Education Council in 1968; this was transformed into the Health Education Authority in the heat of the Aids crisis twenty years later and was finally wound up in 2000 as its functions were subsumed by New Labour’s Health Development Agency and other public health initiatives. The internal controversies 68 SCREENING of this body— and its well publicised tensions with government— reflect some of the difficulties involved in developing a novel health promotion approach (Farrant, Russell 1986). The anti-smoking campaign ASH, formed in 1971 with funding from the Department of Health, provided a model for numerous health-oriented voluntary organisations and pressure groups which flourished from the 1980s onwards, popularising health promotion messages. The big Aids charities—notably the Terrence Higgins Trust and the National Aids Trust—both heavily reliant on government funding, played a major role in the safe sex crusade. As we have seen, the big cancer charities have complemented the activities of the national screening agencies in encouraging women to have smears and mammograms. Together with new health organisations and campaigns came a new corps of health professionals, skilled in the techniques appropriate to the advance of health promotion. Some of these were doctors, many more were nurses, only too keen to adapt their traditional skills to the requirements of the new discipline. While campaigning groups oriented towards politicians and the media required organisers, fund-raisers and journalists, those engaging with the public required skills in counselling in general, often combined with more specific expertise, required for example to give advice about diet, sexual behaviour or ‘smoking cessation’. The exercise cult has provided employment for numerous personal trainers, aerobics instructors and others, who are now likely to have received basic health promotion training. The fact that activities once proscribed as sinful—gluttony, sloth, lust—are now regulated in the name of health has led numerous commentators to draw parallels between the ascendancy of health promotion over lifestyle today and the rule of religion in the past. The common features are indeed striking: the devotion to the cause of fitness displayed by the faithful, the spirit of self-denial required to sanctify the body, the zealotry of the newly converted, the dogmatism of the clergy. It appears that health provides some compensation for the decline of traditional religion, both as a focus of individual aspiration and as a secular moral framework for society.

Alcoholism provides the model of a disease defined by uncontrollable behaviour which can readily be adapted to other activities deemed to be compulsive proven 100mg viagra jelly erectile dysfunction filthy frank. The American critic of addiction Stanton Peele observes that ‘there are an awful lot of things that 107 THE EXPANSION OF HEALTH people do that they know they shouldn’t or that they regret doing more of than they want to’ purchase viagra jelly 100 mg otc erectile dysfunction treatment in bangkok. However, ‘once this pattern has been defined as a disease, almost anything can be treated as a medical problem’ (Peele 1995:117). Whereas the struggle to medicalise alcoholism raged for more than a century, the extension of the disease model of addiction, first from alcohol to heroin and tobacco, and then to gambling, shopping and sex has taken place over only a few years. Though there were attempts to advance a disease theory of alcoholism from the end of the eighteenth century, the medical model made little headway against the powerful forces of religion and temperance until after the Second World War (Murphy 1996). During this period the conception of excessive drinking as a moral problem, as a vice demanding punishment, remained ascendant over the notion of alcoholism as a disease requiring treatment. It was not until the 1950s and 1960s, as the influence of religion declined and that of medicine increased, that the ‘disease concept of alcoholism’ gradually gained acceptance (Jellinek 1960). In 1977 the World Health Organisation adopted the term ‘alcohol dependence syndrome’, reflecting the new emphasis on ‘chemical dependency’ as the underlying pathology. By the 1980s, programmes of ‘detoxification’ and ‘rehabilitation’ under the control of the medical and psychiatric professions became the established forms of treating the problems of alcoholism. The establishment of medical jurisdiction over opiate, specifically heroin, addiction was more straightforward, for a number of reasons (Berridge 1999). First, until the 1960s, it was a marginal problem: according to one account, ‘there were so few heroin addicts in Britain that nearly all of them were known personally to the Home Office Drugs Branch Inspectorate’ (BMA 1997:7). Second, most of these were ‘anxious middle aged professional people’ (indeed many were doctors or nurses) who were not regarded as a threat to society. Third, heroin, a synthetic opiate first introduced (for its non- addictive qualities! In 1926 the Rolleston Report firmly defined heroin addiction as a disease and inaugurated the ‘British system’ of medical supervision. In the USA a more prohibitionist approach continued to criminalise heroin, with the effect, as in the sphere of alcohol, of encouraging illicit supply networks (Berridge 1979). It was not until the 1970s and 1980s, that heroin abuse became identified as a significant social problem, now associated with an 108 THE EXPANSION OF HEALTH ‘underclass’ of alienated and marginalised youth. This resulted in some tension between the medical profession and the criminal justice system as the civil authorities insisted on tighter methods of regulation, as well as imposing harsher penalties on users and dealers. As we have seen, the penal and medical approaches subsequently converged in the extensive methadone maintenance programmes of the 1990s. The drug which has played a key role in the recent popularisation of the concept of addiction is one which was not considered addictive at all before the 1980s—tobacco. Nicotine: from bad habit to chemical dependency Most smokers do not continue to smoke out of choice, but because they are addicted to nicotine. Whereas earlier editions had characterised smoking as a bad habit, the February 2000 version, bluntly titled Nicotine Addiction in Britain, claims that smokers are in the grip of a chemical dependency. According to the RCP report, its recognition of the addictive character of nicotine was a result of new researches in psychopharmacology, involving biochemical and behavioural studies in animals in humans. It seems probable that a greater influence was the growing popularity of notions of addiction in society generally. The RCP report conducted a detailed comparison of nicotine with heroin, cocaine, alcohol, caffeine, and concluded that nicotine was a ‘highly addictive drug’, by some criteria more so than some of these notorious drugs of abuse (RCP 2000:100). Though this comparison was designed to reinforce the pernicious character of nicotine, it also implicitly undermined the wider concept of addiction: after all, if millions of people have managed to quit smoking and overcome the demon nicotine, perhaps the grip of heroin and cocaine is not quite the overwhelming compulsion it is often made out to be. For the anti-smoking campaign, labelling nicotine as addictive is crucial to its challenge to the tobacco industry’s insistence on 109 THE EXPANSION OF HEALTH ‘consumer sovereignty’, on the freedom of the individual to choose whether or not to buy cigarettes. As the RCP put it, ‘if smoking and nicotine are addictive, the argument that the individual adult consumer has the right to choose to purchase and use tobacco products, and that the tobacco industry has the right to continue to supply them, is difficult to sustain’ (RCP 2000:101). If the smoker is the victim of a chemical dependency, and cigarettes are delivery systems for this chemical, then the government should regulate the supply and distribution of cigarettes as it would any other dangerous drug. Though the anti-smoking lobby plays up its offensive against the tobacco industry (whose executives are now despised and demonised as though they were war criminals or child abusers) its real threat is to the status of the individual and to civil liberties. If people who smoke—more than a quarter of the adult population— are defined as being in a state of drug addiction and are considered as a result to be incapable of making rational decisions, then the state is justified in taking ever greater control over their behaviour.

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That’s actually my biggest fear—if I fell out here on the pavement and I fractured a hip cheap viagra jelly 100 mg otc erectile dysfunction 23. If I fall cheap 100mg viagra jelly amex erectile dysfunction statistics worldwide, I’m going to be a hell of a lot worse off than losing a little vanity. Ambulation aids can give a greater sense of security and 188 mbulation Aids help prevent falls (Tinetti and Speechley 1989; Tinetti et al. I don’t use it in the house to do things, but the minute I go out, I use it, and I feel very secure with it. At risk of being shoved or tripped in a crowd, people wel- come the explicit symbolism of the ambulation aid. That’s why I walk with a cane when I’m on the street, when I travel on the public transportation. Each car has seats marked with the wheelchair logo for disabled passengers, and Lester believes that carry- ing a cane validates his claim to the designated seats. Ron Einstein, a primary care physician, has trouble getting his patients to use a cane. She says, “I will not be seen dead with a cane, and I will not leave my house. You’d think older people would be more comfortable with themselves, but they’re still em- barrassed. If ambulation aids can help, using them seems logical, but people aren’t always logical. Einstein is genuinely concerned about his mother’s safety and comfort but feels powerless. He risks sounding paternalistic, condescending, or disrespectful by constantly urging his mother to use Ambulation Aids / 189 something she fervently wishes to avoid—even if it could spare her a nasty fall, ease her pain, or speed her way. Unless people themselves choose to use an ambulation aid—or at least give it a solid try—they often won’t use it properly and get little benefit, confirming their original objections. Some people agree to carry the ambu- lation aid but won’t let it touch the floor, defeating the purpose. The phys- ical therapist Gary McNamara finds, Until they’ve taken a first step and realize that it’s going to take change to create change, you can’t do anything. You go to some- one’s home and they say, “Yeah, I’ve fallen and my doctor told you to come. They’re convinced that they’re stuck in this rut and there’s nothing they can do. There’s a lot of preconceived notions in their head about assistive devices and what they mean. The psychologist Rhonda Olkin (1999, 285) argues that acceptance of assistive technologies, such as mobility aids, requires that they “be per- ceived as enablers of activities and functions that would otherwise be diffi- cult or impossible. Since mobility aids are visible, family members often hold strong opin- ions, and long-established familial dynamics come into play. Sometimes “a family might resist the implications of an AT and insist that the family member rely on his or her own limited facilities, despite the drain on per- sonal energy and emotional resources” (Olkin 1999, 291). I heard this from younger women whose husbands became deeply disturbed when their wives used mobility aids. The husbands do not outright forbid it, recogniz- ing their wives’ needs. Nevertheless, the husbands are terrified by the im- plications—presumed permanent debility and inevitable downward spiral. Other times, family members are persistent advocates, and physicians en- list their help to persuade patients. They try to get patients to use the device, but they don’t always succeed. Johnny Baker navigates delicate terrain between his patients and their family members. Although family members want his professional opinion to validate their positions, Dr. Baker simply doesn’t know exactly what is right: after all, little scientific evidence exists to guide decisions about ambulation aids. Frequently there’s a family member who says, “Mom does fine here in your examining room, but she totters around at home and I’m concerned about her. Then I try to redirect things to the patient: “How do you respond to what your daughter’s saying?

This will help you in only not­ ing the details relevant for your task cheap viagra jelly 100mg without a prescription erectile dysfunction pills walgreens, rather than spending time in writing a précis of the whole article or chapter quality viagra jelly 100mg erectile dysfunction no xplode. This includes dates, names, references to further reading, quotes and defini­ tions. However, in written material it may be quicker to photocopy reference lists and de­ tailed illustrations. Start to compile a bibliography by recording the books and articles you have used for your notes. Record the information either manually us­ ing a card index or electronically on a computer database. Notes can be quickly scribbled down as you browse through the shelves at the library. However, if you need to compile a reference list, then a data­ base is the preferred method. See Chapter 17, ‘Getting the Best Out of Your Personal Computer’, for more information on databases. Make sure you record all the information required to fulfil your institu- tion’s guidelines on writing references. See Chapter 12, ‘Dissertations’, for more information about writing references. For books: ° title ° author(s) (including first names) ° year of publication ° edition ° publisher ° place of publication ° library and classification number NOTE-TAKING 163 ° précis of content ° personal notes on usefulness, readability. For articles: ° title ° author(s) (including first names) ° year of publication ° journal title ° journal volume/issue number ° pages containing article ° library and shelf number or topic code. Practical demonstrations Keep note-taking to a minimum in any sort of practical demonstration. The emphasis will be on showing you what is happening, and in some cases on you joining in and having a go yourself. It is difficult to combine this sort of practical experience with note-taking. If you do get a chance to jot something down, then follow these rules: 1. Record any information you think you are unlikely to find in a textbook or lecture. Organising your notes Sort and file your notes immediately, otherwise they will build up into a mound of paperwork that will be frustrating and of little use to your stud­ ies. The sys­ tem you choose must be flexible, allow easy retrieval of information and be practical to use. The most common and probably the best method is to file loose-leaf sheets in A4 size ring binders. These binders allow you to insert additional 164 WRITING SKILLS IN PRACTICE notes where you want them, as well as having the capacity to hold a large amount of paper. If you lack the space or funds for a set of shelves, a cheap alternative is to use card­ board boxes from your local supermarket. Place the box on its side so that the ring binders can be filed in an upright position. The box is easily car­ ried by the precut handgrips for storage out of the way in a cupboard. Your system needs to be log­ ical, adaptable and easy to cross-reference. Avoid having to access several different files to get the required information. You may want to separate theoretical modules from clinical experience, or you may want to integrate the two. Choose a cate­ gorisation system that allows you to quickly locate the information you need to prepare for essays and revise for assessments. You will need to devise a cataloguing system as soon as you start your note-taking. Journals, newspapers cuttings and other resource materials are best stored in box files. Make a note of any cross-references between your resource materials and your filed notes.

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