Untangling Neoliberalism's Gordian Knot

319 Pages·2017·9.19 MB·English

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Theses and Dissertations--Sociology Sociology
2013
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George F. Bills
University of Kentucky, [email protected]
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Bills, George F., "Untangling Neoliberalism’s Gordian Knot: Cancer Prevention and Control Services for
Rural Appalachian Populations" (2013). Theses and Dissertations--Sociology. 12.
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The document mentioned above has been reviewed and accepted by the student’s advisor, on
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George F. Bills, Student
Dwight Billings, Major Professor
Keiko Tanaka, Director of Graduate Studies
UNTANGLING NEOLIBERALISM’S GORDIAN KNOT: CANCER PREVENTION
AND CONTROL SERVICES FOR RURAL APPALACHIAN POPULATIONS

______________________________

DISSERTATION
______________________________

By
George F. Bills
Lexington, Kentucky

A dissertation submitted in partial fulfillment of the
requirements of the degree of Doctor of Philosophy in the
College of Arts and Sciences
at the University of Kentucky

Director: Dr. Dwight Billings, Professor of Sociology

Lexington, Kentucky

2013

Copyright @George F. Bills 2013
Abstract of Dissertation

Untangling Neoliberalism’s Gordian Knot: Cancer Prevention and Control Services for
Rural Appalachian Populations

In eastern Kentucky, as in much of central Appalachia, current local storylines narrate the
frictions and contradictions involved in the structural transition from a post-WWII
Fordist industrial economy and a Keynesian welfare state to a Post-Fordist service
economy and Neoliberal hollow state, starving for energy to sustain consumer indulgence
(Jessop, 1993; Harvey, 2003; 2005). Neoliberalism is the ideological force redefining the
“societal infrastructure of language” that legitimates this transition, in part by redefining
the key terms of democracy and citizenship, as well as valorizing the market, the
individual, and technocratic innovation (Chouliaraki & Fairclough, 1999; Harvey, 2005).
This project develops a perspective that understands cancer prevention and control in
Appalachia as part of the structural transition that is realigning community social ties in
relation to ideological forces deployed as “commonsense” storylines that “lubricate”
frictions that complicates the transition.

Keywords: cancer prevention and control, Appalachia, Neoliberalism, social networks,
discourse
Untangling Neoliberalism’s Gordian Knot: Cancer Prevention and Control Services for
Rural Appalachian Populations

By

George F. Bills

_______________________
Director of Thesis

_______________________
Director of Graduate Studies

______________________
Date
(To Sheilla and Denver – You have been my anchor)
ACKNOWLEDGMENTS

The following thesis, while an individual work, benefited from the insights and direction
of several people. First, my Dissertation Chair, Dwight Billings, exemplifies the high
quality scholarship to which I aspire. In addition, Cynthia Cole started me looking into
community-based projects as a research focus, encouraged me to pursue National Cancer
Institute Funding for this project, as well as being my biggest fan. Next, I wish to thank
the complete Dissertation Committee: Shaunna Scott, Rosalind Harris, Chike
Anyaebunam, and Kristen H. Perry. Each individual provided insights that guided and
challenged my thinking, substantially improving the finished product.

In addition to the technical and instrumental assistance above, I received equally
important assistance from family and friends. My partner, Sheilla Wallace, provided on-
going support throughout the thesis process. My son, Denver Bills, has made me want to
be a better father as well as better man. The rest of my family has believed in me and
made me want to finish this project so they would be proud of me. Finally, I wish to
thank the respondents of my study (who remain anonymous for confidentiality purposes).
Their comments and insights created an informative and interesting project with
opportunities for future work.

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Table of Contents

Acknowledgements………………………………………………………………..…….iii

Chapter One: Opening Thoughts
Untangling Knots in Communicative Sociation……………………………..…..…...1
Research Questions……………………………………………………………....…...5
Methodology…………………………………………………..………………..…….6
Cancer Prevention in the Context of Regional Development…………................…...7
Observing the Lay of the Land: Chapter Summaries………………..…..…………...9

Chapter Two: Constructing Cancer Prevention, Constructing Appalachia
The Problem of Knowledge………………………………………………...…….…16
Family Well-Being and the Lifeworld………………………………….…………...19
Family Empowerment and Knowledge Interest………………………..……….......22
Challenges to Family Empowerment around Cancer Prevention…………….……..24
Two Personal Recollections on Culture and Growing Up in Appalachia.…………..28
Recollection One………………………………………………………………....28
Key Factors That Shape the Public Health Context…………………….…………..35
From New Social Movements to Communication Infrastructures………….…...41
Recollection Two…………………………………………………….…………..46

Chapter Three: Roll the Stone – Cancer Prevention as Ritual
Cancer Prevention Rituals in the Neoliberal Service Economy…………………53
From Rituals to Institutions…………………………………….….….................56
Regionalization and Routinization as Ordering Principles……………………..…..59
Network Embeddedness, Self-Interaction, and Commitment in Social
Movements.................................................................................................................63
The Tri-County Cancer Coalition…………………………………………………...69
Historical Background…………………………………………………………...71
Cancer Rates in the Sixteen Counties……………………………………………77
Coalition Goal Setting……………………………………………………………79
Composition……………………………………………………………………...83
Structure………………………………………………………………………….82
The Impact Mining on Regional Health and Inaction in the Face of Injustice……..89
Summary……………………………………………………………………………95

Chapter Four: Cancer Prevention as a Regional Social Problem
Cancer as a Social Problem………………………………………………….……97
“Pink Ribbon” Culture at Center Stage: The Public Face of Cancer Prevention…104
Summarizing the Rebuttals………………………………………………………...107
“Health Disparity” as Backstage…………………………………………………..110
Public Health, Coalitions, and the Spatial Division of Labor……………………...114
Regionalized Action and the Shape of Sustained Participation in Coalition
Activities…………………………………………………………………………...122
How Network Structure Impacts Coalitions as Vehicle for Democracy………...125
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Chapter Five: Colorectal Cancer Screening Among 49 Appalachian Eastern Kentucky
Primary Care Practices: Controlling for Structural Aspects of Space*
Introduction………………………………………………………………………...129
Colorectal Cancer Screening in Appalachian Kentucky…………………………...130
Conceptualizing Screening Recommendations in Terms of Closeness Centrality...132
Study Sample and Data……………………………………………….………….134
Methodology……………………………………………………………………….136
Results……………………………………………………………………………..141
Discussion and Conclusions………………………………………………………144

Chapter Six: Using Critical Discourse Analysis to Explore Media Discourse Around
Cancer in Eastern Kentucky
“Sensitive Issues” in Local Health Care Social Circles in Harlan County, KY…...148
Social Worlds and “What” and “Who” in Local Social Circles…………………...152
The Dialogic View in CDA………………………………………………………..154
Methods and Data………………………………………………………………….159
Story Similarities……………………………………………………………….150
Orders of Discourse and Core Action Types Related to Cancer Screening and Coal
Mining………………………………………………………………………….152
An Example From the Environmental Stories…………………….……………177
Cliques and the Basis of Social Worlds………………………….……………..180
Intertextual Positioning and Cliques in the Two Cultures of Action………………183
Health Organization Cliques as Further Specification of Social World
Segmentation……………………………………………………………………186
Environmental Organization Cliques…………………………………………...191
Interpretation and Conclusions…………………………………………………….193
The Early Detection and Cancer Screening Activism COA…………..…………...195

Chapter Seven: Newspapers, Power, and the Representation of Local Healthcare Social
Worlds
Political Power: Cultural Recognition, or Coalitional Politics?...............................198
Who is Visible and Why? Local Cultures of Action and the Colonization of the
Lifeworld through Newspaper Stories……………………………………………..205
Methods and Data………………………………………………………………….209
Cancer Awareness Themes………………………………………………………...211
Social Motivations Considered Rational, Self-controlled and Autonomic…….211
Social Relationships Considered Open, Trusting and Honorable………………215
Social Institutions Considered Rule Regulated, Contractual and Equal………..218
Story Lines, Modal Verbs, and Speaker’s Commitment to Claims Made in Texts..225
The Breast Cancer Awareness Cluster and the Modal Verb “Can”…………….225
The Mining Accident Cluster and the Modal Verb “Will”……………………...230
Conclusion…………………………………………………………………………234

Chapter Eight: Appalachian Identity and Cancer Prevention in Eastern Kentucky
Introduction………………………………………………………………………..238
v
Mapping Appalachian Identities as Part of a Mythic System……………………..240
Emotional Bonding via “Class-as-Lifestyle”……………………………….……..243
Consumer Myths Concerning Healthcare Consumption…………………………..252
The Contrasts of Myths Underlying Alternative Healthcare Consumption……….256
Divine Tool/Maternal Power……………………………………………………259
Technological Liberation/Revenge-of-Nature………………………………….260
Stories as “Metaphysical Terrain”…………………………………………………264
Raw-Cooked-Rotten……………………………………………………………….268
In Closing………………………………………………………………………….272

Chapter Nine: Closing Thoughts
What I Set Out to Do……………….……………………………………………...278
Summarizing the Chapters…………….…………………………………………..280
Experts, Cancer Prevention and Knowledge Gaps………………………………..281
So What? Is There a Recommendation Here?.........................................................283
In Closing………………………………………………………………………….285
Dissertation Bibliography…………………………………………………………….286

Vita…………………………………………………….………………………….……305

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