Book Reviews
Bodies at Risk: an Ethnography of Heart Disease
Elizabeth E Wheatley
ISBN: 0-7546 43-07-7 2006 136 pages Ashgate
Jeanne Daly
When I was sent this book for review my first response was, ‘Oh, no, this is the book I want to write!' That could have made me a prejudiced reviewer but, instead, it has given me an insight into the different ways in which a sociologist can study people recovering after a heart attack. In my own research, I was very much constrained by ethics regulation and allowed only limited access to clinical settings. Elizabeth Wheatley either experienced no such problem or was able to negotiate the difficulties better than I. Perhaps the United States is more respectful of the long sociological tradition of research by participant observation, a practice that is under threat in Australia.
Here is what Wheatley did. Instead of focusing on recuperation immediately following a heart attack as most researchers do, she used a range of strategies to gain a longer term view of the experience in a number of settings. In what we might call the cardiac ward of a hospital, Wheatley worked as a volunteer once a week, visiting patients, running errands for the nurses, making beds, setting up educational videos and so forth. She describes this experience as giving her a snapshot view of an acute illness experience. Wheatley's understanding of how people cope over time was gained from eighteen months working as an intern at two cardiac rehabilitation clinics. Here she developed an ongoing relationship with people learning to live with this chronic disease. Her participant observation was complemented by one-on-one interviews with patients in hospital or at home, including some follow-up interviews, and a series of focus groups which evolved into ongoing cardiac support groups.
Wheatley describes, in disturbing detail, how patients are stigmatised after having a heart attack, with questions asked about the risky behaviour which could have caused it. Her overall aim, however, was to collect people's stories of how they managed their bodies after these bodies had been stamped with the knowledge that they now had a disease which increased their risk of dying prematurely. People have to navigate a ‘long and winding road' in order to live with changed physical capacities, social identities and relationships. Here she draws on Anthony Giddens' analysis of risk and the risk culture. A heart attack is a life-threatening event, a ‘fateful moment', which forces people to confront their mortality head on. But there is also the need to confront the various, sometimes conflicting assessments of risk from hospitals, clinics, and a range of health professionals as well as the lifestyle industry. In managing their ongoing lives, people need to reskill.
In a very useful chapter two, Wheatley outlines the literature on how illness disrupts body, personal biographies, social identities and routines, with the need for interpretive effort to make the new state familiar. A central concept for Wheatley is reskilling, which she defines as ‘a process of re-learning physical and emotional features of embodiment in the wake of disruptions elicited by acute symptoms' (2006:11). Reskilling is ongoing and protracted but episodic to cope with signs of the disease as they arise in the now ‘suspicious body'. This excellent chapter draws on the focus group discussions, including some spirited exchanges as participants discuss their experiences and interpretation of heart disease. She gives a clear analysis, moving smoothly from individual account to group experience. It would provide a useful reference for lectures on the use of focus groups in health research.
Subsequent chapters follow a similar format, with analysis of the data supported by the relevant literature. Of particular interest to health researchers is persuasive argument that lifestyle choices are not merely an issue of personal commitment, but require ongoing negotiation. Wheatley shows that compromise and contestation are required to accommodate power relationships in the wake of the acquired stigma of heart disease. This is particularly relevant to the sometimes antagonistic negotiations about smoking and diet. Thus social contexts constrain or enable what health professionals see as necessary and individual changes to lifestyle.
In chapter four Wheatley gives a very useful account of the medicalisation of fitness in cardiac rehabilitation. The arguments mounted in this chapter are fully relevant to the health promotion emphasis on risk and lifestyle. The people she interviewed are, of course, vulnerable, as they suffer from a declared risk in addition to the risks that beset the rest of us. Wheatley shows how medically-identified risk promotes notions of fitness, creating market opportunities for preventive and rehabilitative industries. There is a startling account of the way ‘rehabilitation technicians' monitor bodies and slant understanding through what she calls ‘truth tricks': such as applying population-based data to the individual case in a risk profile. A footnote records Wheatley's discomfort when attending these sessions as an intern, and her lack of success at having social class introduced as a risk.
Wheatley's account does not fall into the trap of portraying the response to the overwhelming nature of a heart attack as being more or less the same for everyone. Here she draws on Foucault's technologies of the self to classify the various ways in which people go about the task of reskilling after a heart attack. Her ideal types of reskilling are not fixed or exclusive and are presented as a range of ethics that people draw on to make sense of their decisions. Here Wheatley draws on the full study to demonstrate what is involved in taking on an ethical stance that emphasises exactitude, resignation, playfulness, evasion, dispute, or experimentation. These represent the various ways people deal with the technologies of dominance they encounter in clinical and social settings.
Wheatley is no medical sceptic: she acknowledges the gain from medical and other health services. Her concern is with how notions of risk invade and distort recovery after a heart attack. As a result, this book is not just about heart disease but provides a great resource for researchers and teachers who analyse the social and other determinants of health. Perhaps it should also be compulsory reading for all hospital ethics committees.
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