26 results
Acknowledgements
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Index
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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4 - Biosensing in Old Age
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
Remote care or care at a distance for older people has been developing in discursive contexts that tap into the dual tropes of ageing as a social problem or burden resulting in a ‘care crisis’ (Matthews-King, 2018), and older people as intrinsically at risk (Pickard, 2009). Yet, older people are not necessarily sick, or not sick enough, for the ageing body to be brought into the clinic. The professionally adopted shift from chronological to functional definitions of ageing and the notion of the life course have come to underpin the character and organisation of care for older people, who are increasingly subject to ‘techniques of measurement, standardisation and intervention’ (Marshall and Katz, 2016: 146). With population ageing often framed as an economic burden, older people considered to be frail find themselves in a preclinical space, a kind of waiting room serviced by sensors and systems of monitoring. It is in this waiting room that we have observed forms of telecare playing a role, or attempting to facilitate ‘care’ rather than medicine.
Sensor-based home monitoring, or ‘telecare’ as it is often termed, differs, on the face of it, from the examples of biosensing that we have so far examined in this book. Within this field, there is, of course, a spectrum of domestic monitoring systems and devices that fall broadly into health-related and care-oriented modes. In the health/medical mode, ‘telehealth’ systems aim to improve ‘patient activation’ or self-care, providing users with readings of vital signs and facilitating the uploading or transmitting of data about their bodies for consideration by professionals. In contrast, the ‘care’ mode includes automated movement and home environment sensors that send signals to remote monitoring centres and usually trigger a phone call back to the ‘user’; these are most usually referred to as ‘telecare’ rather than ‘telehealth’. While many sensor-based devices collect data from the body for interpretation, in home telecare, there is less emphasis on the active self-tracking of health and more on the preservation of an existing state or ‘safety’, the maintenance of a kind of waiting, seen in many examples of monitoring systems generating automated messages about (it is claimed) bodily states.
References
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Conclusion: What Might Biosensing Do?
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
In 2018, two of us moved to the Australian National University, and in a flurry of new academic encounters, were invited to the inaugural lecture of a Vice-Chancellor's Entrepreneurial Professorial Fellow. Adrian attended and wrote the following field note in Box C.1.
Box C.1: Biosensing futures
By Adrian Mackenzie
The auditorium stacks to the back rows, health ministers, local politicians and university dignitaries to the front, and a university audience behind. We sit back to hear about micro-wearables, nano-technology biosensors engineered to ‘functionally interface’ with the skin. The Entrepreneurial Professorial Fellow's startup will engineer devices that ‘gain access to the skin for all manner of signals.’ He shows photographs of a small square patch stuck on a forearm like a plaster and a video of an ECG (electrocardiogram) signal, pulsing smoothly. The signal is ‘clean’ because nano-sized sensor spikes probe interstitial fluids without puncturing cell walls, without needles for blood or vials for urine. In a planned ‘biotech skunkworks,’ innovation will slalom past pharmaceutical or medical device manufacturers with their fifteen year product pipelines. It will be like Google, he claims, because the biosensor field is moving too fast for the regulatory regimes of medicine. Micro-wearable biosensing, we hear, is more like contemporary cars than clinical observations: 200– 2000 continuous signals can be recorded. The data will not only feed into population-level data collection but into profiles of individual variability. In the crowded lobby afterwards, white-aproned waiters pour glasses of local wines and neaten up trays of canapés for the guests. Despite the biotech skunkworks – an interdisciplinary incubator for high-tech – and the vaulting ambitions to change clinical practice in global North and South, the microwearables, should they reach a market, do not figure in the talk or in the chorus of talk in the lobby as elements of a platform. The devices might combine science, engineering and medicine, and they might ‘break through the silos between global science, technology and people,’ but their alignments with biosensing and its platforms are not mentioned.
Appendix
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
Scenario: the Browns from Preston: an ‘ordinary family’
Theresa, grandmother died at 75 with Alzheimer's disease
John, 65, Theresa's son, becoming forgetful Cath, 60, John's wife, concerned about her husband and son
Ben, 32, John and Cath's son, single, uses genetic testing kit from 23andMe, found to have an ‘increased risk of Alzheimer's disease’
Louise, 36, John and Cath's daughter, married, infertility issues, uses ovulation microscope
Yusef, 30, Louise's husband, infertility issues
Act 1: making sense of genetic data
Ben is a single man with a good job working in a small engineering company. He likes computers and his smartphone and enjoys downloading films and surfing the web. One of his recent favourite websites is called 23andMe. This is a company based in the US that sells genetic testing kits directly to the public. A friend at work had read about 23andMe in the magazine Wired and mentioned it over lunch one day. He had been quite excited about it.
Three months ago, Ben sent off for a genetic testing kit from 23andMe's website, and when it arrived, he followed the instructions as pictured in the package. He registered the kit on the website and filled in the online form with his name, gender and date of birth. It also asked him if he wanted to take online surveys and be part of 23andMe's research studies. He read through the consent document and ticked the box: ‘Yes, I’d like to participate in making new genetic discoveries with 23andMe Research’. He took out the small ‘spittoon’ that came with the box, spat into the tube and sealed it according to the instructions. His favourite part of the kit was the biohazard logo on the plastic bag that came with the tube.
Five weeks later, he got an email from 23andMe saying that his results were ready and that they would tell him all about his ‘personal genome’, about the patterns in his DNA and what they mean for his health, the way his body works, and even his family history running back centuries. Ben is healthy, and did not expect any bad news. His main reason for having the test was curiosity. He read through his results, which said all kinds of things, such as that he was unlikely to be a sprinter and that his earwax type was wet.
3 - Platform Biosensing and Post-Genomic Relatedness
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
The biosensing practice concerning us in this chapter bears different names: DNA genotyping, genetic tests or personal genomics. But it targets a single macro-molecule shared by all living things, DNA. DNA genotyping begins with a tissue sample, usually taken from saliva. Where it ends is difficult to say. Since 2007, DNA genotyping has been available ‘direct’ to ‘consumers’. In this context, ‘direct’ means without recourse to a medical clinic or medical pathology services. The tests, sometimes called ‘direct-to-consumer’ (DTC) genetic tests, are direct in the sense that people submit their saliva and payment from home rather than at a doctor's clinic or medical facility, and results come back to them rather than to a physician. In many respects, the tests are indirect. They depend on social network platforms, they leverage publicly funded scientific research and they struggle to comprehend and capitalise on test results whose significance snakes around plural variations of patterns of DNA. They are steeped in practices and patterns of biomedical and Internet platformisation that precede and expand beyond them. The genotyping platforms, with their devices – for example, DNA chips or microarrays – and scientific entourage (genome-wide association studies [GWAS], DNA genotyping data and literature databases, and so on) – build on wider transformations in biology, life sciences and biomedicine. They are rooted in the exigencies of institutional health care, online platforms and the changing relations of states to their citizens. DNA genotyping platforms – our preferred term for the biosensing dimension of DTC genetic tests – display all the messy entanglements of selfhood, relatedness, regulation, health, science, technology, platform capitalism and collective sense-making visible in biosensing more widely.
This chapter describes some key aspects of the burgeoning of DNA biosensing, bringing into focus its attachment to Internet platforms, ambivalence towards clinical expertise, speculation on future scientific knowledge and embrace of ‘data citizenship’. In terms of biosensing practices and the life course, DNA genotyping ostensibly concerns the problem of future risks or susceptibilities (for example, of Alzheimer's disease or macular degeneration), some or many of which endure beyond the course of an individual life. However, as we will suggest, DNA biosensing stretches above and beyond risk calculations or predictions of individual health outcomes.
Living Data
- Making Sense of Health Biosensing
- Celia Roberts, Adrian Mackenzie, Maggie Mort
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This book critiques the popular claim that 'more information' equates to 'better health' and explores the potential challenges related to people's changing relationships with traditional health systems as access to, and control over, data shifts.
2 - Biosensing Stress
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
Since the 1970s, adult citizens of the Global North have been encouraged to learn to notice when they are physiologically stressed, and to hone skills to alleviate stress in the name of improving their mental and physical health, their social relationships, and their productivity at work. Today, many technology companies offer devices and/or apps to assist users to develop such knowledge and skills. These range from apps to teach stress recognition and relaxation techniques (such as Fitbit's and Apple Watch's breathing apps), through to worn heart-rate variability or skin conductivity sensors, and saliva and blood sampling kits to send off to laboratories to measure levels of so-called ‘stress hormones’. ‘Stress’, although remaining complex and elusive as a scientific phenomenon and experience, is rapidly becoming rearticulated through biosensing devices and platforms in ways that could have serious repercussions for how we live, including, importantly, how adults and children are monitored and assessed by remote others, such as employers, parents, teachers, social and corrective services officials, and health insurance companies.
The assessment of stress via biosensing blends culturally and historically specific experiences of, ideas about and practices to ameliorate physical and psychological discomfort. Knowledges and practices developed in Eastern traditions, including yoga, meditation and mindfulness, are blended with a body of Western scientific work that dates back more than 100 years. Developed most notably by Hungarian-Canadian scientist Hans Selye (1907– 82) from the 1930s to the 1970s, this scientific work elaborated the late 19th-/early 20th-century notions of ‘internal chemical environments’ and ‘homeostasis’ posited by French physiologist Claude Bernard (1818– 78) and North American Walter Cannon (1871– 1945). As detailed later, from the 1970s, Selye's theories about the role of hormones in maintaining homeostasis, and his notions of ‘good’ and ‘bad’ stress, widely infiltrated public and clinical discourse with a narrative of ‘balance’ that can be disrupted by external stimuli such as overwork, interpersonal difficulties and major life events. This narrative also has important resonance with Chinese and other Eastern understandings of physical and mental health that were widely promulgated in the US, UK and Europe in the 1980s (Franklin et al, 2000; Jackson, 2013: 258).
Contents
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Introduction: What Does Biosensing Do?
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
You would think that it would be obvious, but it is not: what is a biosensor? Biosensors have been defined by Intel anthropologist Dawn Nafus (2016a: xiii) as devices that ‘indicate something about the body or the physical environment’, and biosensing as a practice that ‘uses information technology to understand something about bodies or the environment in which they live, whether the technology is at the cutting edge or not’. Standing at the intersection of everyday experience, scientific, medical and technical knowledges, media-platform economies, transformations in the biopolitics of health care, and cultural-material imaginaries of digital health, it is hardly surprising that biosensors are lively assemblages. They increasingly form a stage – a platform – on which problems of childhood, puberty, sexualities, reproduction, wellness, fitness, disease, ageing, medical expertise, health-care provision, economic productivity and citizenship, among others, play out.
Questions teem around these broad, pragmatic definitions of biosensors and biosensing. Are biosensors really concerned with ‘the body’ or ‘the physical environment’, or are they an outgrowth of the fitness and health-lifestyle industries? (Given that things seem to get inside us, do bodies live in an environment anyway?) Do the ideas of ‘indicating’ and ‘understanding’ accommodate what people do with biosensors? What else do they do with them? Do biosensors and biosensing challenge or extend traditional medical authority? Does biosensing increase people's control over their health, as is often claimed? What is the connection between more data and health? Who is biosensing who? What is the relation between biosensing and people's anxiety about their health? How do people subvert or reinvent biosensors to assure themselves of health? How does biosensing participate in making certain forms of selfhood and group viable? What socio-material networks do biosensing practices produce and rely on? Who is profiting from biosensing and who is not, and how? What new forms of work and care are produced in biosensing? How does the dream of continuous monitoring animate biosensing? How might collectives or communities thrive through biosensing? What, if any, policy framework might meet public concerns about health biosensors?
In this book, we offer some ways of responding to this panoply of questions and perhaps framing some new ones.
Frontmatter
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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1 - Fertility Biosensing
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
Bodies constantly sense and humans frequently notice their bodies in order to promote or protect health. Lying at the heart of human life, reproduction has long been entwined with both kinds of sensing. Contemporary fertility biosensing blends techniques of body awareness and related forms of recording (such as diaries and charts) with modern forms of scientific and biomedical knowledge, high-tech gadgets and biodigital platforms. Recent studies show that people who menstruate and/or have ovaries and a uterus use a wide variety of technologies – from paper-based diaries, through mobile phone apps, to wearable biosensing devices – to track and record fertility or sex hormone-related events such as menstruation, ovulation, unprotected heterosexual intercourse and other acts of insemination (Lupton, 2015; Wilkinson et al, 2015; Epstein et al, 2017).
Fertility biosensors articulate bodies that menstruate and/or ovulate through codifications of cycles, relying on an organisation of time across days, notably, the notion of a regular 28-day cycle and ‘peak fertile times’. Fertility biosensors are only relevant for a certain portion of one's life: the so-called ‘reproductive years’ (which can, of course, constitute many decades). Menstrual apps marketed to young women and those oriented towards tracking the (peri-)menopause help to constitute the beginnings and ends of this period of time, as well as shaping its contemporary unfolding as a biomedical phenomenon. In this sense, they directly participate in the figuring (that is, both the discursive formation and the lived experience) of women's (and potentially men's and others’) life courses more broadly. As the so-called new reproductive technologies did before them (Franklin, 2013), fertility biosensors, in other words, remake what it means to be sexed/gendered, to reproduce and, thus, to be human.
Reasons for monitoring fertility and associated flows of sex hormones are diverse, ranging from curiosity, through strong desires to avoid or achieve pregnancy, to medical concerns about gynaecological or reproductive health (endometriosis, polycystic ovary syndrome and other conditions), and the tracking of processes of gender transition. In this chapter, we explore practices of fertility and sex hormone biosensing, asking how they are changing enactments of contemporary bodies, sex/gender, reproductive relations and associated notions of ‘the reproductive years’.
Preface
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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Summary
In October 2010, Celia, Adrian and Maggie met in the Sociology Department coffee room at Lancaster University to discuss what to do after Celia had received a rather unusual email. The message was from ‘Intel Labs’, not an organisation that we had heard of, although, of course, we knew about the Intel Corporation. It contained a call for proposals for a three-year research programme called ‘Biosensors in Everyday Life’; it seemed that Intel Labs wanted to know more about the possible uses and usabilities of what appeared to be a revolutionary new trend in the approach of ‘middle-class users’ to acquiring health-related knowledge about their bodies.
None of us had ever had research funding from a commercial technology company before and the programme was intriguing for us as researchers in the Science and Technology Studies field. Celia and Maggie had just finished working on a European study of ‘remote-care’ technologies and Adrian had been working on the data-intensive transformations of genomics. Celia's background in feminist studies of reproduction, sexuality and biomedicine, Adrian's in philosophy of technology and software studies, and Maggie's in technological change in health care and forms of public engagement and participation, all seemed to tell us that we should make a response to the approach from Intel Labs.
We decided to propose a project that would push at what seemed to be Intel's primary interest in middle-class users by opening up questions around two areas of contemporary social concern – infertility/conception and personal genetic testing – for which we offered to supervise two doctoral studies. To this, we added a third element: a parallel cross-cutting initiative to try to understand the public's (in addition to middle-class users’) views about these developments. We thought that if the proposal gained favour with Intel Labs, then the research would be worthwhile and, we hoped, socially useful. If not, little would be lost.
In the event, we formed a productive and educative relationship with Intel Labs, and discovered that it employed talented and critical anthropologists with whom we went on to have great discussions. Our initial fears about corporate influence over our work proved unfounded, and at Lancaster, we decided to form the Living Data Research Group (see: www.livingdata. wordpress.com/about-us/) as our group expanded to include Mette Kragh-Furbo and Joann Wilkinson undertaking their PhD studies.
List of Tables, Figures and Boxes
- Celia Roberts, Lancaster University, Adrian Mackenzie, Lancaster University, Maggie Mort, Lancaster University
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18 - Placing the Flood Recovery Process
- Edited by Ian Convery, Gerard Corsane, Peter Davis
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- Displaced Heritage
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Summary
Contrarily, and without apparent irony, the preferred story in a natural disaster is one of good news: miraculous rescues and escapes; acts of heroism and bravery; selfless rescue workers from Rotherham; sniffer dogs from Barking; saintly surgeons from Surbiton. As the hope of more wide-eyed victims being plucked from the grave diminishes, as the disaster medics wrap up their kit and go, so too do the 24-hour rolling news teams. This is very expensive stuff, and nobody has the budget or the audience for the grim, dull depression of resurrection. (Gill 2010)
The writer A A Gill’s heartbreaking portrait of the aftermath of the Haitian earthquake of January 2010, in which up to 230,000 people died and more than 1 million were made homeless, raises the question of what it means to recover from a disaster. In the immediate aftermath of an event like Haiti, there is inevitably a focus on physical action and progress – the rubble is moved, survivors treated, fed and clothed – all of which corresponds to what emergency planners term the ‘response’ phase of the emergency. And yet what Gill is hinting at, beautifully captured in the notion of resurrection, amounts to something else entirely: the idea of recovery as a spiritual, physical and emotional process that is deeply hard to achieve and much less visible than the usual metrics applied to such situations would suggest (How many people are back in their homes? How many businesses are open for trading? What aspects of key infrastructure have been reopened?).
This chapter argues that, if we want to understand the recovery process then it is essential to think about just exactly what it is that is being recovered. Our case study is a qualitative, longitudinal study of people’s recovery from the floods of June 2007 in Kingston-upon-Hull, UK, in which over 8600 households were affected and one man died (Coulthard et al 2007). The aim of the research was to discover what the long-term disaster recovery process was like for people as they struggled to get their lives and homes back on track. The project, which is described extensively elsewhere (Whittle et al 2010), used in-depth qualitative methods that had been previously used to investigate people’s recovery from the 2001 Foot and Mouth Disease (FMD) disaster in Cumbria (Mort et al 2004).
2 - The research
- Marian Barnes, University of Brighton, Stephen Harrison, The University of Manchester, Maggie Mort, Lancaster University, Polly Shardlow
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- Unequal Partners
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- 10 February 1999, pp 9-16
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Summary
Introduction
As noted in Chapter 1, users of health and social care services have become increasingly organised, and within this, increasingly self-organised. Although there are signs that this process is spreading to other sectors of care, including acute medicine, it is in the fields of mental health problems, learning difficulties and physical disability that it has been most long-standing; these are the roots of the user movement. We sought to take advantage of this relative maturity as a means to understanding the implications of user self-organisation for developing concepts of citizenship. The research was therefore confined to these sectors, and a comparison of mental health and physical disability was chosen as one which provided a potentially useful contrast between a sector largely concerned with personal services (mental health) and one with a much wider focus, including services but also the environment and the social origins of ‘disability’. We did not, however, start out by identifying particular user groups for study: we describe below how they were identified.
Research objectives
Our research objectives were both policy-related and conceptual; the former centred on the relationship of user group activity to new forms of agency management, and the latter on notions of consumerism and citizenship as a means of understanding the significance of user groups. The separate perspectives of user groups and actors within the statutory agencies (whom we term ‘officials’) were also to be addressed. In summary, our objectives were to use a purposive sample of user groups in each of the two specified service sectors to analyse
• (from the perspective of the user groups) the topics on which influence was sought, the strategies employed, and their resulting influence within the system of local governance;
• (from the perspective of officials) the legitimacy accorded to groups and their specific activities, the strategies adopted for dealing with them, and the place accorded to them within the wider context of official activity.
Overall, our objectives were to examine this activity in the context of contemporary notions of consumerism and citizenship.
Selecting the user groups
The research adopted a case study design. Our starting point was user self-organisation rather than official ‘user involvement’ strategies. As intended, we studied three mental health groups and three disabled people’s groups. Following meetings with national umbrella organisations, local groups were selected to enable exploration of different strategies for achieving influence.
1 - The policy context
- Marian Barnes, University of Brighton, Stephen Harrison, The University of Manchester, Maggie Mort, Lancaster University, Polly Shardlow
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- Unequal Partners
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Introduction
The study reported here concerns the constitution and activity of what we refer to as ‘user groups’ in the fields of state provision of services for people with mental health problems and with physical disabilities. Although one purpose is to report in some detail on one example of a group operating in each of these fields (in Chapters 3 and 4 respectively), our conclusions also draw on evidence from our research into four other groups (Barnes et al, 1996), and a second purpose is to offer a more general analysis of the relationship of this kind of group to present and future policy options. In this chapter, we outline the context for the report. This can conveniently be divided into two elements, each the subject of a section below: the larger macro-social context forpolicy and the narrower context provided by policy itself, though it is not suggested that these are theoretically or causally unrelated. A third section of this chapter introduces the elements of the ‘user movement’.
The context for policy
Much of the thrust of our analysis hinges upon some concept of citizenship, a concept which is far from static. Historically, it has been conceived as carrying a complex cluster of meanings: defined legal or social status; means of signifying political identity; a focus of loyalty; a requirement to perform duties; expectations of rights; and a yardstick of good social behaviour (Heater, 1990, p 163). At different historical moments particular elements of this cluster have been emphasised. Thus, for much of the present century until, say, 1980, citizenship has been predominantly discussed from a liberal perspective, that is as a set of rights that enables the individual to “function relatively equally in private life or in exchange in civil society” (Meehan, 1993, p 177). T. H. Marshall’s (1950) influential analysis of the development over time of, respectively, civil, political and social rights, all counterposed against social class, is the classic text of this genre, which remains at the heart of recent, more sophisticated, sociological accounts such as those of Twine (1994) and Roche (1992).
Over the last two decades, however, the emphasis of discussion has changed in several ways, not all of which are consistent with each other.
References
- Marian Barnes, University of Brighton, Stephen Harrison, The University of Manchester, Maggie Mort, Lancaster University, Polly Shardlow
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- Unequal Partners
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4 - Implementing the social model of disability – after the honeymoon
- Marian Barnes, University of Brighton, Stephen Harrison, The University of Manchester, Maggie Mort, Lancaster University, Polly Shardlow
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- Unequal Partners
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- 10 February 1999, pp 47-80
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Summary
Movements with objectives for social change may have to face up to the dilemmas of success as well as the need to adapt to changing circumstances. If a movement is built on opposition what happens when the ideas it seeks to promote start to become accepted into mainstream thinking? Feminists working in the Women’s Refuge Movement, for example, had to make decisions about their preparedness to work within State institutions once the reality of male violence had been accepted as a legitimate focus for action by local authorities (Lovenduski and Randall, 1993). But they also had to address the fact that ideas themselves can undergo change in the process.
The disability movement can claim considerable success in shifting thinking about the nature of disablement. Disability rights legislation is now on the statute book and the media are scrutinising images of disabled people for their tendencies to portray ‘tragic heroes’ or ‘objects of pity’. Disabled people are more visible within public spaces because those public spaces are more accessible to them. While disability activists would rightly claim that they are far from fully achieving the objectives of the movement, many would also acknowledge that they face new dilemmas as a result of the opportunities to enter into more formal relationships with powerful decision makers (eg Barnes and Oliver, 1995).
The disabled people’s organisation which is the subject of this chapter is the longest established coalition in the country. Members include activists who have contributed substantially to the thinking of the movement nationally and internationally, and it is based within a local authority area which prides itself on its radical equal opportunities policies. Yet interviews revealed that some members of the Coalition were not optimistic about its future role vis-à-vis local health and social services agencies. In this chapter, as well as describing the nature and objectives of the group from the perspectives of those active within it, we will consider the nature of changes which have taken place within the Coalition’s relationship with statutory agencies from the perspectives of both ‘sides’. Such changes need to be understood by reference to particular characteristics of the local situation, but also to the substantial changes which have taken place in the ideology and structure of welfare discussed in Chapter 1.