Durham E-Theses The secret ring:: knowing asthma in Teeside's children Todd, Alison How to cite: Todd, Alison (2003) The secret ring:: knowing asthma in Teeside's children, Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/3085/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk THE SECRET IN THE RING: KNOWING ASTHMA IN TEESSIDE'S CHILDREN A copyright of this thesis rests with the author. No quotation from it should be published without his prior written consent and information derived from it should be acknowledged. Alison Todd Submitted for the degree of Doctor of Philosophy University of Durham Department of Anthropology Centre for Integrated Health Care Research, School for Health March 2003 1 2 DEC 2003 ---------- AJB§TRAC'f Alison Todd The Secret in the Ring: Knowing Asthma in Teesside's Children Submitted for the degree of Doctor of Philosophy, March 2003 Asthma in children in Teesside in the north east of England is the subject of my research. Asthma is the most commonly diagnosed chronic health problem of childhood in the United Kingdom and its prevalence has increased markedly in recent decades. Previous research has identified it as being a particular health concern of people in Teesside. 'What is asthma?' is my central research question, and I seek its answer in how people talk about asthma. My data is derived from semi-structured interviews with children with asthma and their families, observation of their consultations with health professionals in asthma clinics, and unstructured interviews within, and participant observation of, their local community. Asthma is presented as different modes of 'unhealth' -illness, disease, sickness and diagnosis, the last being a sub-category of, or the same as, sickness. Relationships are created between these different modes of asthma and other unhealths. Research focuses upon the contributions of biology, culture and history to asthma in Teesside' s children. I show how relationships between the self and the other, the individual and the population, and the local and wider worlds contribute to how asthma is known in them. Throughout, a contrast is drawn between asthma as a thing and asthma as a word. Central to my argument is that the contribution of things and words to asthma is variable, and uncertainty over their respective contributions gives asthma its potency. The dissertation is, however, also about researching asthma. Reflexivity guides my research and I discuss how my dual background in medicine and anthropology has influenced my approach to researching asthma and to writing about it. Disciplines, I argue, discipline the practice and presentation of research: what asthma was when I practised medicine is not what I have researched here as an anthropologist. DECLARATION The research cited on p.16 was submitted as part fulfilment of a Masters in Public Health in Developing Countries at the London School of Hygiene and Tropical Medicine in 1995. 11 STATEMENT OF COPYRIGHT "The copyright of this thesis rests with the author. No quotation from it should be published without their prior written consent and information derived from it should be acknowledged." lll ACKNOWLEDGEMENTS I wish to thank the following people. The patients who so rarely excluded me from their clinic consultations. The families I interviewed at home for making me feel so welcome. The people I talked to in the community part of the study for allowing me to interrupt their day. The health professionals and administrative staff at the asthma clinics whose assistance was a necessity, and whose company was a pleasure. My medical friends, especially Dr Stuart Watson, who filled in the gaps. The South Tees Local Research Ethics Committee for their constructive suggestions and advice, before and after submissions of my research project. The staff at Middlesbrough Public Library for being ever-helpful. Dr Margaret Bruce of the University of Aberdeen, for supervising my first research, and for her suppmt since. Dr Carolyn Stephens of the London School of Hygiene and Tropical Medicine who supervised the earliest version of this research, and was my last reason for stopping it. Dr Catherine Panter-Brick for giving me my first research opportunity in the University of Durham, and for maintaining my links with it until my return as a postgraduate. Professor Alan Bilsborough who was my initial contact for both my undergraduate and postgraduate studies at the University of Durham. Professor Michael Carrithers for his almost constant presence in postgraduate 'Work in Progress' meetings, Dr Simon Coleman as his most able temporary replacement, and postgraduate students in anthropology, especially Dr Rachel Bray (nee Baker), for their many stimulating comments. Dr Amar Amason for being another of the most significant of the above, and for his helpful comments on my first chapter. Professor David Byrne, Department of Sociology and Social Policy, for his excellent teaching, and for his key contributions at key moments. Other teachers and students, too numerous to mention, who have stimulated and sustained my interest in academia. & most of all, Dr Andrew Russell and Professor Pali Hungin for being all they should be as supervisors, and more. IV ACRONYM§ ADHD Attention defecit hyperactivity disorder AHR Airway hyperresponsiveness BTS British Thoracic Society DLA Disability Living Allowance EBM Evidence based medicine FEVI Forced expiratory volume in one second FVC Forced vital capacity GP General Practitioner HP Health professional ISAAC International Study of Asthma and Allergies in Childhood LFfs Lung function tests NAC National Asthma Campaign NHS National Health Service PE Physical education PEFR Peak expiratory flow rate RIU Research and Intelligence Unit SATS Standardized Assessment Tests SES Socioeconomic status SIGN Scottish Intercollegiate Guidelines Network THA Tees Health Authority UK United Kingdom WHO World Health Organization v CONTENT§ page ABSTRACT . DECLARATION 11 STATEMENT OF COPYRIGHT 111 ACKNOWLEDGMENTS IV ACRONYMS. v CONTENTS . VI Part 1 - Stages Chapter 1 INTRODUCING ASTHMA . 1 1.1 PRESENTING ASTHMA: BEGINNING AT THE END 2 1.2 RE-PRESENTING ASTHMA: BEGINNING AT THE BEGINNING 6 1.3 THE DISSERTATION . 18 Chapter 2 TRAVELS WITH ASTHMA. 19 2.1 THE MAP 20 2.2 PREPARING FOR ASTHMA 21 2.2.1 Literary Influences 21 2.2.2 Informal Influences 23 2.2.3 Formal Influences 25 2.3 DOING ASTHMA 30 2.3.1 Researching in the Clinic 30 2.3.2 Researching in the Home 31 2.3.2a Seeking subjects 32 2.3.2b Desperately seeking subjects . 33 2.3.2c Interviewing subjects . 34 2.3.3 Researching in the Community 39 2.3.4 Data Analysis . 40 2.3.5 Revisiting Research 42 2.4 MY DISSERTATION 46 VI Chapter 3 HERCULES'S MOOON 51 3.1 INTRODUCTION 52 3.2 THE CHILD HERCULES 53 3.3 THE ADULT HERCULES 62 3.4 MY HERCULES 67 3.5 CONCLUSION 72 Part 2 -Acts PRESENTING ASTHMA 74 Chapter 4 ASTHMA IN THE FAMILY . 76 4.1 INTRODUCTION 76 4.2 EXPERIENCING ASTHMA . 80 4.2.1 Atoms of Asthma 80 4.2.1a Cough. 80 4.2.1b Noisy breathing 81 4.2.1c Difficulty in breathing 81 4.2.ld Changes in colour 82 4.2.1e Chest pain 82 4.2.1f Tiredness 83 4.2.1g Reluctance to eat 84 4.2.1h Not themselves 84 4.2.li Fear 85 4.2.2 Distinguishing Asthma's Biogra:ghers 88 4.2.3 Distinguishing Asthma's Biogra:ghies 88 4.2.4 Asthma's Other Biogra:ghies . 90 4.2.5 Asthma's Analogous Biogra:ghies 93 4.2.6 Asthma as Meta:ghor 94 4.2.7 Asthma in Performance 96 4.3 LIVING WITH ASTHMA 98 4.3.1 Agents of Asthma 98 4.3.1a Asthma in time 98 4.3.1b Asthma in space 100 4.3.2 Ex:ganding Asthma 103 4.3.3 Restricting Asthma 105 4.3.3a Asthma's material management 105 4.3.3b Asthma's psychosocial management . 111 4.3.3c Managing families with asthma 113 4.3.4 Living with Other Asthmas 114 4.4 BEYOND ASTHMA . 120 4.5 CONCLUSION 125 Vll PRESENTING ASTHMAS 126 Chapter 5 ASTHMA IN THE FREE GARDEN 128 5.1 INTRODUCTION 128 5.2 DETECTING ASTHMA 131 5.2.1 Symptoms 132 5.2.1a Cough. 132 5.2.1b Wheeze 138 5.2.1c Dyspnoea 142 5.2.1d Colour changes 143 5.2.1e Chest tightness 143 5.2.1f Rest of asthma 143 5.2.2 Stimuli 144 5.2.3 Family History 146 5.2.4 Signs 146 5.2.5 Investigations . 149 5.2.6 Pathology 150 5.2.7 Pathophysiology 152 5.2.8 Asthma in Clinical Context 155 5.3 DISCOURSES ON ASTHMA 156 5.3.1 Definitions 156 5.3.2 Classifications 159 5.3.3 Severity 162 5.3.3a Acute severity. 162 5.3.3b Chronic severity 164 5.3.3c Assessing severity 165 5.3.4 Asthma in Medical Context 169 5.4 RESTORYING ASTHMA 175 5.4.1 Naming Asthma 175 5.4.2 Knowing Asthma 178 5.4.3 Managing Asthma 181 5.4.3a Managing asthma from the inside 181 5.4.3a(i) Drugs .