A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.
How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?
At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.
Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water.
Looking for clues in the questions we fail to ask
One of the books I read this past year was Our Present Complaint: American Medicine, Then and Now, by medical historian Charles Rosenberg. I was very struck by his comments on the ‘invisibility of contingency.’ (This is just a fancy way of saying that we assume our present situation must have been inevitable and don’t stop to acknowledge the arbitrariness — and thus malleability — of the way things are.) I referred to this in a post on healthism:
Our financially and professionally entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo. Part of the power of our biomedical culture, however, is that its contingency – the very real possibility that it could be different — is ordinarily invisible to us. What would it take to imagine a widely shared understanding of health that valued not only the quality and availability of health care, but daily living conditions that are conducive to everyone’s health? This is the question I hope an examination of healthism will provoke.
Healthism was what started me blogging in 2008. It seemed like a clue to something I wanted to understand. What I realize now is that the clue I discovered in healthism is yet one more thing that unites my interests, as I’ll try to explain below.
Embracing the abnormal
The six categories I’ve discussed in these posts are not simply a collection of abstract intellectual interests. They have a strong personal resonance for me. That’s probably why I was so reluctant last year to limit myself to any one topic.
My interest in the social determinants of health may stem from my slightly unusual family of origin. It combined elements of both the working and middle classes (father an uneducated factory worker, mother a stay-at-home college-educated library user). Something about this confused me as a child, and I ended up feeling different. Thanks to wonderful high school teachers, scholarships, and an era of generous financial aid from the federal government, I was able to attend elite post-secondary schools. My family and my class-conscious educational environment may account for my interest in social disparities.
Feeling different, it’s perhaps not surprising that I developed an interest in deviance, conformity, and what it means to be ‘normal.’ I was fortunate to come across a set of ideas — the sociology of knowledge — that allowed me to embrace the abnormal (see my post The problem is you).
I referred to those ideas in one of my first posts:
I was struck by the concepts of the taken-for-granted nature of the world, the stock of knowledge we inherit, the limitations imposed on our conceptions and even our perceptions by the very language we speak, as well as by the time and culture into which we’re born. These ideas resonated with me at a very deep level. They seemed to offer a means to wake up and escape from the unquestioned dream of life.
Waking up includes the recognition that what’s ‘normal’ changes over time and serves economic, political, professional, and/or cultural (as in ‘culture war’) interests.
When Charles Rosenberg refers to the invisibility of contingency, he’s talking about the taken-for-granted nature of the world. When we are told that people who are overweight or who suffer from poor health have only themselves to blame because their lifestyles have been insufficiently healthy, that reasoning is superficial. If we look deeper we discover multiple motivations for the ‘personal responsibility’ message that have nothing to do with lifestyles. We don’t suspect those motivations if we take it for granted that the ‘healthy lifestyles’ mantra is the only explanation we need to account for the inequitable distribution of disease and mortality.
I was initially attracted to the subject of healthism because I felt I’d been taken in by health messaging. But I also suspected there was something worth waking up to here. I now see that what lies beneath the taken-for-granted – the questions that don’t get asked in media coverage of health issues or in the health policies of governments — unites my blogging topics and makes them personally meaningful.
In whose interest is neoliberalism? Medicalization? Conformity? Non-holistic medicine? The commercialization of health? Healthism? More often than not the answer is that none of these are in my interest. Nor are they in the interests of a society I would want to live in. When an entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo, and when that status quo is no longer in our collective interest, it becomes necessary and important to challenge the new normal.
I’d like to thank all the interesting and helpful people I’ve met on Twitter during my year of being on ‘sabbatical.’ They have broadened and sustained my interests and deepened my understanding in so many ways. Twitter turned out to be a wonderful place to indulge all those interests I haven’t even mentioned here. I’d especially like to thank Dr. Jonathan Tomlinson, who writes movingly about the plight of patients in a neoliberal world, and Pierre Fraser, whose writings on health as a social value and the export of American individualism have influenced my thinking. Finally, I am deeply grateful to Deborah Lupton, Carl Elliott, and Robert Crawford for everything they have ever written.
Charles Rosenberg, Our Present Complaint: American Medicine, Then and Now (2007)
Peter L. Berger and Thomas Luckmann, The Social Construction of Reality: A Treatise in the Sociology of Knowledge (1967)
Deborah Lupton, The Imperative of Health: Public Health and the Regulated Body (1995)
Carl Elliott, Better Than Well: American Medicine Meets the American Dream (2004)
Robert Crawford, Healthism and the medicalization of everyday life, International Journal of Health Services, 1980, 10(3), pp 365-88