Talking about cancer: Precarious neighborhoods and health trajectories

League Against Cancer – Call for Projects 2015 – Research in the Humanities and Social Sciences

The understanding of health as being influenced by geographical factors on the one hand and social conditions on the other is relatively recent in France (Leclerc et al. 2010). However, the general improvement in health indicators is related not only to individual conditions and behaviors but also to collective experiences.

Social inequalities in health (SIH) are documented in international comparisons (Mackenbach, Karanikolos, and McKee 2013). In France, they are now at the heart of health policy priorities (HCSP 2010) and specifically cancer policy (HCSP 2013). Reducing these inequalities is one of the missions of the ARS (Basset (DS.)
, 2008). With regard to cancer, inequalities affect not only causal chains, screening (ORS Alsace, 2013), prevalence, and mortality (Menvielle et al., 2008), but also care pathways. Within the same urban area, considerable differences in health levels appear between neighborhoods, even though the distances between them are sometimes small (Ross, Tremblay, and Graham 2004; Vigneron 2011). The issue of social and territorial health inequalities is particularly acute in sensitive urban areas (ZUS). Geographers refer to this as environmental justice (Jamie Pearce et al. 2007; Jamie R. Pearce et al. 2010). However, public health in these neighborhoods is less well documented in France and is less frequently the subject of remedial action (Chauvin and Parizot 2007).

These inner-city neighborhoods targeted by urban policy show high levels of social disadvantage (deprivation) and a combination of handicaps (ONZUS 2013). However, the poor health in these sensitive neighborhoods cannot be attributed solely to the individuals who live there: collective factors must also be taken into account (Ham et al. 2014). Nevertheless, the effects of territory on health and its community dimension have been little studied in France.

Some studies explore the effects of individual membership of a social group on the downward trajectory of perceived health (Barnay and Riccardis 2014), as well as the collective effects of territory on norms (Lapeyronnie 2008). These effects, which influence the mechanisms of health inequalities and have been explored in greater depth in the United States, are well known; Within territories, individuals establish symbolic boundaries that accentuate cultural mismatches between their tastes and dispositions, which are necessary for inclusion in their social and cultural group, and the integration of health norms (Small, Harding, and Lamont 2010). The effects of relegation and economic status crystallize into behavioral patterns which, in turn, reinforce the difficulty of integrating norms, particularly those promoting individual autonomy in health, for example (Duncan and Brooks-Gunn 1999). An initial effect of territorial concentration, this "culture of poverty" (Hoggart 1957) in turn produces adaptive effects in response to the situation of poverty. Health recommendations may appear to some groups as foreign or domineering norms (Sayad 1997). Life in areas of poverty has its own specific effects that cannot be reduced to individual variables: diminished cognitive skills, exposure to typical psychological states (resignation, fatalism, etc.).

However, there are variations and heterogeneity in the health behaviors of residents of working-class neighborhoods (Lamont 2009). When it comes to cancer, there is significant social differentiation in perceptions of both its causes and its effects (stigmatization) (Beck, Peretti-Watel, and Gautier 2006). This therefore represents a political and health challenge.

Despite sociological research in France on life trajectories with cancer (Ménoret 1999) and, more recently, on the impact of the cancer experience on returning to work (Tarantini, Gallardo, and Peretti-Watel 2014) from a biographical break perspective (Bury 1982), there has been little specific research on the health of foreigners (Berchet and Jusot 2012) or immigrants. And even less on cancer, whether from the point of view of prevention practices (Grillo, Soler, and Chauvin 2012) or disease trajectories (Pian 2012).

Today, pathway medicine is promoted, but little is known about the actual pathways of the most disadvantaged patients. This could lead to the mistaken belief that where medical care is required, social care should take a back seat (Birouste 2014). The culture of poverty can constitute a set of values, attitudes, and practices, but the patient narratives collected by researchers make it possible to individualize this social and cultural determination of behaviors and reveal the possibilities for individuals to take action on themselves.

Research on health in neighborhoods (Chaix et al. 2010; Turrell et al. 2013) or, more broadly, on social networks—in the sense of networks of friends, acquaintances, and neighbors (Christakis and Fowler 2013)—show how individuals' health can be understood in terms of the reference groups to which they belong and how social norms contribute to shaping each person's health (Visier 2011). The recent mobilization in France of the concept of empowerment and the imperatives of health democracy encourage us to consider patients, and the groups around them, as actors capable of playing an important role in the management of their illness.

Faced with a top-down approach, for which Parsons' functionalist sociology provides the theoretical model (Parsons 1951), a bottom-up approach is gaining ground. From a renewed ethical perspective, which has now reached international bodies, this approach would give a voice to the most disadvantaged communities (Ruano, Friedman, and Hill 2014) in the formulation of health needs. In the French context, this perspective leads to the conclusion that the professed universalism of healthcare coverage is not enough to eradicate social inequalities in health and that "nothing will be done without us" (Bacqué and Mechmache 2013).

Finally, a genuine commitment to patient-centered care must be reflected in the training of healthcare professionals (Compagnon 2014). This involves, in particular, working on the production of training materials for doctors and caregivers, which must be considered not only from an educational perspective but also from an ethical one (CCNE 2004).

In line with the shift that took place in the late 1990s with the États généraux des malades atteints de cancer (National Forum for Cancer Patients), patient testimonials can be considered in various forms as resources for both patients and professionals (Balez 2015; Kapikian 2015).