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. Read more
Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.
If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.
~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.
“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable. Read more
Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.
The social determinants of health
Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.
The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment. Read more
It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.
Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.
Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)
Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are. Read more
I’m still on “sabbatical.” Mostly reading. Thinking about what I most want to write about. I know what my interests are — the problem is, I have too many. Meanwhile, here are some blogs I enjoy reading.
Thought Broadcast by Dr. Steve Balt
Psychiatry is a controversial topic these days. We (speaking for myself, anyway) love to criticize the overprescription of psychopharmaceuticals, the medicalization of the slightest deviation from “normal,” and those psychiatrists who are eager to take “gifts” from the drug companies whose products they subsequently prescribe and promote.
I suspect people relate to psychiatry more readily than to the science of medicine. We’ve all known moments of slippage along the spectrum of mental health. We’d all like to understand ourselves better, something psychiatry used to promise before it tried to reduce us to the chemical interactions inside our brains.
Dr. Balt writes about all of this. What I especially like about his blog is his compassion for patients and his honest assessment of the psychiatric profession. His writing has a quality like Gawande’s: He maintains a strong personal presence without straying too far into the overtly personal.
To get a sense of Thought Broadcast, read Dr. Balt’s My Philosophy page. A recent post I’d recommend: How to Retire at Age 27. It’s on psychiatric qualification for disability. His point is that labeling (and medicating) someone as disabled does nothing to solve underlying social problems. It concludes:
Psychiatry should not be a tool for social justice. … Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest. More importantly, it harms the very souls we have pledged an oath to protect.
The high rate of cosmetic surgery in Asia has been widely discussed, including an article in The New York Times. What caught my attention in this more recent piece was the postmodern/feminist spin.
Susan Feiner, a feminist economist, offers these comments: (emphasis added)
Parents are caught between a traditional world view and a postmodernist world view. On the traditional side especially, your daughter is your property and potential to social advancement. … On the postmodern side you have this idea that western beauty, this imported beauty ideal, is really a sign of your family’s openness to the future. So those two impulses – a very traditional impulse and the more modern neo-liberalism impulse come together at the moment of submitting your own daughter to the knife. …
On one hand we have all of this acceptance and even approval for women to become doctors and lawyers and political leaders and at the same time what’s been held up to women is this Walt Disney notion of our lives. That really even if you are a doctor or a lawyer or a political leader the best you can really do is to be beautiful and get some wealthy rich man to take care of you, so the best possible outcome for any women is to be both hugely successful professionally and be knock-down beautiful.
Why so much willingness to reshape the body?
What drives the popularity of cosmetic surgery? As bioethicist Carl Elliott notes in one of my favorite books, Better Than Well, medical enhancements, along with body size, are part of the logic of consumer culture: “You cannot simply opt out of the system and expect nobody to notice how much you weigh.” Read more
My abiding life philosophy is plain: In our appearance-centric society, beauty is a huge factor in everyone’s professional and emotional success—for good or ill, it’s the way things are; accept it or go live under a rock.
But Rivers is a TV star. TV and movie stars have always utilized the miracles of cosmetic surgery to look good in the two-dimensional spaces they inhabit. How did the rest of us learn to desire a perfectly plastic body? How did ordinary women and men with ordinary lives and ordinary bodies learn that they need plastic? The answer: the plastic ideological complex, a set of cultural texts that are both highly contested and yet tightly on message. It is itself so ubiquitous that it might even be described as hegemonic. In other words, the “need” for cosmetic procedures is impossible to avoid. Through advertising and TV shows, movies and magazines, we learn to want cosmetic intervention in our aging faces and imperfect bodies. This need is now so firmly implanted in our cultural psyche that it has become “common sense” to embrace cosmetic procedures. Why wouldn’t we want to look more beautiful, younger, thinner, more feminine, better? The question is no longer will you have plastic surgery, but when.
Accept plastic beauty or go live under a rock. Rivers isn’t just joking; she’s also doing the serious work of enacting the ideology of plastic, an ideology that we can no longer avoid. Even if we did live under a rock, whenever we crawled out from underneath it, we would be assaulted by images of perfectly plastic beauty on billboards and the sides of buses and on TV and in movies and even the nightly news. And then there are those damn magazine racks, an unavoidable gauntlet of Dos! and Don’ts! that must be passed through each and every time we buy our food.
Medicine is a profession. Economically, it’s sufficiently different from other marketplace transactions that it shouldn’t be run as a for-profit business. When I made that argument in a recent post, I mentioned: “The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.”
That may still be true of brain surgery, but it’s obviously not true of plastic surgery. Here’s an excerpt from a recent press release:
Though the recession is slowly lifting, desired cosmetic surgery is still out of reach for some. And with winter almost over, time is running short for those who want to receive plastic surgery in time for summer. That’s why Dr. Lapuerta of the Plastic Surgery Institute of Southeast Texas, sympathetic to both his patients’ time and finances, is offering a very special offer of $500 off the very popular surgery, tummy tucks.
Just to make sure you understand how sympathetic Dr. Lapuerta is, the release continues:
With cosmetic procedures slowly but surely on the rise, Dr. Lapuerta wants to ensure that those who desire the procedures are more able to attain it. He appreciates the present circumstances stating, “I know that a tummy tuck or any cosmetic surgery can seem out of reach of many. Even though the procedures are on a rise, a lot of people who want the surgery are unable to get it because of finances. I hope that offering this special deal will help.”
Popular uprisings in the Middle East and North Africa are happening in countries with youthful populations. The percentages of residents under age 25 are, in descending order:
55.3% in Syria
52.3% in Egypt
50.8% in Saudi Arabia
47.4% in Libya
43.9% in Bahrain
42.1% in Tunisia.
(The percentage in the US is 34%.) The inability of these countries to employ so many young people, including the college educated, contributes to dissatisfaction and unrest.
It’s not surprising then that Colonel Muammar Gaddafi of Libya would want to maintain a youthful appearance. His Brazilian plastic surgeon, Dr. Liacyr Ribeiro, has just released the details. Ribeiro – who has also performed cosmetic surgery on Italian Prime Minister Silvio Berlusconi — told a Brazillian weekly that he operated on Gaddafi in 1995. According to Ribeiro:
He [Gaddafi] said he had been in power for several years and that he didn’t want young people to see him as old.
What about doctor/patient confidentiality, Dr. Ribeiro? The surgeon decided to reveal Gaddafi’s secret in order to “contribute to understanding this historic figure around whom there is much speculation but little information.”
The surgery removed fat from Gaddafi’s abdomen and injected it into his cheeks to remove wrinkles. The Libyan ruler also received surgery on his eyelids (presumably blepharoplasty), and a scar on the right side of his forehead received attention. Dr. Ribeiro was accompanied on his trip to Libya by a Brazilian colleague, Fabio Nakkash, a specialist in hair implants. Read more
Well, one reason is that primary care physicians are being financially squeezed out of practicing their profession. There’s a good post at KevinMD on how physicians are responding, along with an acknowledgment of this sad truth in the comments. The post is called “Primary care physicians are rebelling against the system.”
Here’s one comment that explains why more doctors are doing cosmetic surgery:
Great article, I agree this is a quiet and insidious rebellion. I found myself dropping one insurance after another, adding more and more cash based ancillaries, until my practice is now 99% cosmetic (botox, laser, etc.) and 1% internal medicine. My next decision is whether to bother spending the time and money to recertify in internal medicine this year. I probably will not. Sad situation for medicine in America, but the reality for most of us.
Frequently asked questions about Neuticles, testicular implants for dogs, cats, horses, or “any pet which is neutered.” The logic: “Would he know if his foot was cut off?”
Why not? The 207 year-old traditional form of altering used on family pets includes the permanent removal of the pet’s testicles. Many caring pet owners hesitate or even to [sic] refuse to neuter their pets because of this. Neuticles eliminates ‘neuter-hesitant’ concerns – as a ‘Neuticled’ pet looks exactly the same after surgery. With Neuticles its [sic] like nothing ever changed!
What’s the difference between NeuticlesOriginal, NeuticlesNatural and NeuticlesUltraPlus and NeuticlesUltraPLUS with Epididymis?
NeuticlesOriginals are crafted from FDA medically approved polypropylene homopolymere which is nonporous and rigid in firmness. NeuticlesNatural are solid silicone – not gel filled or saline filled but a solid rubber-like material that replicates the pet’s testicle in firmness once implanted. Neuticles UltraPLUS is the latest in solid silicone technology and feels almost like its’ [sic] liquid filled – but is still solid silicone. In addition, the UltraPLUS features a special ‘textured exterior’ which eliminates the risk of scar tissue development. Neuticles UltraPLUS with Epididymis restores pets to anatomical preciseness. It is for pet owners who wish to have their previously neutered, monorchid or cryptorchid pets restored to anatomical preciseness.
A less pithy title – and what I really mean – would be “Imagine a future where aesthetic cosmetic surgery wasn’t motivated by the images of celebrities/advertising/porn and by the dissatisfaction with normal bodies that these images create.”
In the concluding chapter of her new book, American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection, Laurie Essig suggests we might try using reality-check groups before going under the knife. We could weigh our decision, benefit from the input of friends, then opt for lipo if we were still determined to pursue perfect beauty relentlessly at any cost.
The purpose of such groups would not be to dissuade members from getting cosmetic surgery. It would simply introduce some objectivity. You might decide you really should get that facelift or breast augmentation, but “you will at least be making a far more informed and realistic choice than if you sit at home alone and watch plastic surgery shows while you try to pay your bills and fantasize that if only you looked better you’d have more money because your career would suddenly take off or Prince Charming would finally show up, haul you up onto the back of his horse, and ride off with you.”
The beauty solution
As part of her research for the book, Essig attended a number of conferences for plastic surgeons. One of them was in East Berlin, a meeting of the International Confederation for Plastic, Reconstructive, and Aesthetic Surgery.
The secretary-general of that organization, Dr. Eisenmann-Klein, delivered a speech on the future of cosmetic surgery. She quoted William Mayo (of Mayo Clinic fame) on “the divine right of man to look human.” She cited scientific studies that show the brain is hardwired for the “survival of the prettiest.” Currently 87.5% of cosmetic surgery clients are female, but – according to the good doctor – “the good news is that men in industrialized countries were becoming less satisfied with their bodies.” Read more
One of the things that surprised me is how out of control the cosmetic surgeons themselves felt in all this. I felt a lot of sympathy for the cosmetic surgeons, even when they were telling me that I needed a facelift. Cosmetic surgeons are primarily men, well over 90 percent. They’d gone to medical school and they came out with huge amounts of debt themselves, often well over $200,000. They meant to be reconstructive surgeons, they meant to fix people after horrific accidents or cancer, and they started doing some boob jobs on the side and it started to eat up more and more of their practice because it was so lucrative. They want to send their kids to nice schools, they have mortgages, they have family, and you could see that they felt a little bit helpless as well. It wasn’t what they meant to do.
They seemed just as much products of the system as the middle-aged women going in for a facelift or boob job. They were hoping for a better future. Of course, they create the desire — they advertise, people come into their office and they tell them what they need — but I think that if they hadn’t graduated from school with so much debt, most of them would be selling cosmetic procedures a lot less than they are.
I am not a blogger. I know what Andrew Sullivan and the Huffington Post people say about how one should blog: Think of it as a conversation and just write what you would say to a friend. I can do that in a comment, but not in a post. It doesn’t suit my “personality” – and personality is a topic in this post.
[T]here is a personality or psychological need within some people that drives them to have plastic surgery to fill a hole inside them. I think people who seek fame and want to go into the entertainment industry, like Wang Bei, by and large have a certain personality type. And it is largely based on a need for constantly being in the spotlight, and a need for constant applause or approval. The roots of these needs would be many and complex, but could include genetics and parenting style.
In my customized Google news, I have a category for cosmetic surgery. Most items that turn up are self-serving PR announcements, but recently there was lengthy coverage of the death during cosmetic surgery of aspiring Chinese pop star Wang Bei.
The details are tragic: She was only 24. Ironic: She was already beautiful. And dramatic: Her mother was having the same procedure at the exact same time. So her mother woke up to discover her daughter was dead. Or perhaps not. According to conflicting reports, her mother was told nothing until the next day. The news reports out of China do not strike me as especially reliable.
For example, Wang Bei’s death was first reported as an anaesthetic accident, but the majority of stories describe the cause of death as bleeding from the jaw. Wang was having facial bone-grinding surgery “to make her jaw line fashionably narrow and her face smaller.” (Chinese women are said to prefer an oval face shaped like a ”goose egg.”)
The blood from Wang’s jaw drained into her windpipe, and she suffocated. Is that an “anaesthetic accident?” Wang’s surgeon claims the operation was a success and that Wang died of an unexpected heart problem several hours after the procedure. Read more
The young Afghan woman on the cover of Time (see last post) is beautiful, as all the photographic cues imply she should be. Except … she doesn’t have a nose. The contrast between the sumptuousness of the photo and the missing nose increases the shock value of the image.
For many in the wealthy West, what this image undoubtedly brings to mind is the thought: “She could get that fixed.”
Sure enough, Time managing editor Richard Stengel tells us:
Aisha will head to the U.S. for reconstructive surgery sponsored by the Grossman Burn Foundation, a humanitarian organization in California.
If we didn’t know the surgery had already been arranged, any number of wealthy individuals or organizations would undoubtedly have stepped forward with an offer. In fact, the organization Women for Afghan Womenreports that, in response to their outreach efforts for Bibi Aisha,
the response has been tremendous. We have had several offers from doctors and medical professionals in the United States for free travel to the United States, surgery and care for Bibi Aisha. There have also been Kabul-based doctors who have offered to do her surgery for free. The generous outpouring of offers of help has been moving for all of us, particularly for Aisha.