The practice of western medicine remained virtually unchanged from the time of the ancient Greeks to the mid-19th century. This is a testament to medicine’s basically conservative nature: Let’s not risk human life with something brand new.
Dramatic changes occurred, however, once medicine became a science. By the mid-20th century, medicine was experiencing a Golden Age: Life-saving drugs, miraculous medical breakthroughs, new diagnostic technologies, and a profession held in high public regard.
By the 1970s the Golden Age had ended. Medicine, along with other professions and institutions, fell victim to the anti-establishment sentiments of the 1960s. It was criticized harshly by consumers, journalists, and scholars. Medicine — it was alleged — was no longer concerned with the needs of patients, but with the ambitions of doctors.
The advent of Medicare and Medicaid in the 1960s not only brought government into the health care equation. The American Medical Association’s strenuous opposition to this legislation led the public to associate doctors with small businessmen — avaricious and probably dishonest. The practice of medicine changed from a healing relationship between doctor and patient to a profit-driven business enterprise.
Robert Crawford on personal responsibility for health
Among the many strands that explain how and why medicine began to change in the 1970s, I’m particularly interested in new attitudes towards health. An author I’ve found especially helpful on this subject is Robert Crawford.
Writing initially in the late 1970s, Crawford was extremely insightful, identifying changing perceptions of health at the time they were happening. He also saw how these changes — in particular, the emphasis on personal responsibility for health — related to the emerging political climate of neoliberalism (privatization, free market solutions for public problems, an emphasis on individual responsibility rather than the common good).
In a 2006 article, “Health as a meaningful social practice,” Crawford looked back on his initial assessments with 30 years of hindsight. In retrospect he’s even more convinced that the attitude towards health that developed in the seventies and eighties fueled the success of conservative political ideas. (emphasis added in the following quotations from Crawford)
The success of privatized, market solutions to public problems cannot be grasped without a clear understanding of how personal responsibility triumphed over a political morality premised on collective responsibility for economic and social well-being. Ideologically, the period (roughly 1975–85) was a crucial turning point. Although other events were also at work (the first shock waves of the new economy, the beginning of a radical decline in the power of organized labor, a political realignment toward the right that exploited the politics of race, gender, sexuality, drugs, crime, taxes, family and nation), individual responsibility for health played a decisive role.
The new health consciousness and politics
In the seventies, the problem of health was redefined as the individual’s obligation to practice a correct lifestyle, including diet, exercise, fitness, and the avoidance of unhealthy habits. The solution to the problem of health could then be defined simply as personal responsibility.
Significantly, what Crawford calls “the new health consciousness” provided a broader model for individual responsibility – or for the lack of responsibility if one failed to get with the program. Just as personal responsibility for health accounted for a healthy body, taking individual responsibility for one’s economic well-being accounted for economic success in life. Or accounted for poverty if one failed to take responsibility.
Health consciousness embodied the spirit and goals of the new political climate.
The new health consciousness, … [a]s ideology, … simplified the world: one either smoked and got lung cancer or did not smoke and avoided cancer. One either changed diet and exercised and thereby avoided heart disease and fatness or not.
As Margaret Thatcher said, “There is no such thing as society.” There are only individuals.
The ideal of a healthy lifestyle provided cover for the political goal of deregulation.
By the 1990s, smoking and obesity emerged as visible expressions of responsibility-laced images of race and class. By relocating the task of health protection to the sphere of lifestyle, health practice in the 1970s provided cover for corporate and political strategies aimed at eviscerating the regulatory regime.
The diversion argument, however, must be stated cautiously. One should not assume a zero-sum game. In retrospect, it is clear that concerns about environmental health threats did not disappear. Crucially, however, public attention did shift to lifestyle hazards and individual solutions – in other words, to an arena in which health became a problem one ‘could do something about’. Politics receded – even if the identification of environmental hazards, the distrust of corporations and government and a growing sense of a hazardous world had not.
Political solutions recede; choice remains political
One can find contemporary remnants of this non-zero-sum game in discussions of the Dartmouth Atlas. Twenty-plus years of research on Medicare statistics allow a geographic comparison of medical expenses with patient health. The Dartmouth Atlas data consistently find areas of the country where expenses are exceptionally high, but the health outcomes for patients are no better — and sometimes worse — than areas that spend less.
One interpretation of the data is that health care costs are driven by supply. In areas where there are more hospital beds, those beds get filled. In areas where there are more high-cost specialists, there are more visits and revisits to specialists. Any potential patient benefits of more care are outweighed by the increased risks of more care — medical errors, hospital-acquired infections. The Dartmouth Atlas research also claims that the majority of geographical differences – more than 70% — are not due to variations in levels of poverty.
All this may be true, but what gets overlooked is the geographic differences in environmental factors and the “biologic variations” that promote disease. Dr. Brad Spellberg – author of the recent book Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them — points this out in a recent letter to the editor of the The New England Journal of Medicine.
A significant proportion of the geographic variance in Medicare spending … may be explained by regional, biologic variations in disease-promoting factors. A noncomprehensive list of such potential biologic factors includes population ethnicity and genetics, lifestyle (e.g., diet, smoking status, alcohol and drug use, and activity level), endemic pathogens, and pollution levels. …
Research in health economics will have the optimal effect on policy when it considers not just total costs but also the effects that biologic causes of disease have on costs. We should focus first on understanding the fundamental mechanisms leading to disease, second on which interventions are effective in preventing or treating those diseases, and only then on how much those interventions cost.
Ultimately, decisions about a country’s health are not a matter of science, medicine, research, or scholarship. They are essentially political choices. When the US leans right, the solution to the health care crisis is to emphasize personal responsibility (aka prevention through healthy lifestyles). When the country leans left, there’s increased interest in the “negative externalities” of advanced market capitalism (pollution, climate change, ethnic inequities).
Neither one is exclusively right or wrong. But when the political climate puts the spotlight on patients who are guilty of unhealthy lifestyles, the focus goes dim on those “fundamental mechanisms leading to disease” that have nothing to do with lifestyle. We lose sight of the genuine solutions that an increased focus on those mechanisms could provide.
Image source: Wellness Consumer Builders
Robert Crawford, Health as a meaningful social practice, health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, October 2006 vol. 10 no. 4 pp 401-420