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Th e Politic s o f Medicin e

John McKnight

Attempts to reform health services in the U.S. have not resulted in better health — they have furthered the dependence of people on experts, and served to perpetuate the myth that technology can cure all problems. Good health cannot be achieved until the practice of medicine is divorced from the political function of the medical empire.

The United States was once known as a consumer society because of our predilection for defining life as the use of goods and services. But during the past decade v/e have become a society that lives by consuming crises. We have ingested such unpalatables as civil rights, overpopulation, Watergate, energy shortages, inflation and recession. The popular impression is that in the face of crisis we will digest — i f not overcome. There is, however, one crisis that has been with us for a generation, and we still cannot seem to get i t down. I t is popularly known as the 'health care crisis'.

There is something refreshing about a nonconsumable crisis. I t demonstrates the limits of American ingenuity and ensures some continuity in American life. Grandparents, parents and children can join in common cause as they reflect upon and complain about their continuing health care problems.

There are compelling reasons why the 'health care' crisis has not been consumed. The principal reason is that its consumption would contribute to a revolutionary crisis in American politics. The applicability of this proposition may be peculiarly American. I f i t applies to other developed societies of the capitalist or socialist world, invidious comparisons are left to the reader.

Prescriptions for Reform

The chronic American 'health care crisis' has created an impressive array of palliative reforms. Each ineffective remedy has produced a new prescription. At least six therapies have been administered:

1. The effort to ensure equal access to medical care. The government has outlawed racial discrimination, supported all manner of programs to increase the number of 'health workers', created incentives for doctors to practice in underdoctored areas and supported regulatory systems to allocate hospital beds in relationship to 'medical need'. 112

2. The focus on improving the quality of health care. Increased professionalization and professional review processes have received the support of the state and of many modernized medical practitioners.

3. An attempt to deal with costs. Comprehensive prepaid systems, health maintenance organizations, Medicare, Medicaid and the proposal for a National Health Insurance program represent efforts to conquer the medical system's growing capacity to consume the gross national product.

4. The effort to involve 'health consumers' in the system. Here, the government and the medical industry are gradually enabling non-professionals to participate in the decision-making processes of the system. Laypeople are given seats in medical congresses where they may vote on the future policies of the system.

5. The increasing concern over ethical issues posed by modern medicine. Organ transplants, abortion, and life-extension technologies provide new crises and new public and professional policies.

6. The preventive health care movement. This reform provides policy alternatives designed to 'get at the root of the problem.' I t calls for continuing checkups, computerized screening systems and medical outreach plans tied to public education programs that will enable more people to use the system.

Although these reform efforts have consumed the resources and energies of Americans for more than a generation, the work of Dubos, Fuchs, Illich et al. demonstrates that the recent growth of modern medicine has had very little positive effect upon the health of the American people, insofar as health is measured by morbidity and mortality rates. In the face of the mounting evidence that modernized medicine is irrelevant as a determinant of health, we have responded with phenomenal new investments in medicine. Since 1965, the growth rate for total medical care expenditures has averaged more than 10 per cent a year. The nation's medical care bill has increased from $30 billion in 1965 to $94 billion in 1973 — a figure representing 7.7 per cent of the gross national product.

Medicine's Hegemony

Since these soaring investments in medicine appear to have so little effect upon our health, the basic question is not 'How can we reform medicine?' but 'Why do we invest so heavily in its reform?' The answer may lie in the very fact that the reform increases the hegemony of the therapeutic ideology.

Consider the predictably hegemonic outcomes of the six American reforms.

1. Achieving equal access serves to confirm the value of medicine by broadening the clientele and establishing the legal premise that the right to consume medical service is the central 'health' issue. 'Progressive' litigation seeks to establish 'the right to treatment.'

2. The guarantee of quality care serves to intensify popular belief that health-care professionals know what care is. The critical issue is to force or entice the professionals to produce 'it' . 3. Cost-control ensures not our health but a rationalized guarantee of the medical system's income. The central issue is how to extend the system while lowering or stabilizing the price.

4. Consumer participation co-opts potentially disruptive citizens by providing participation in medicine as a substitute for political action that might affect the critical determinants of physiological il l health.

5. Ethical 'reform' could limit medical hegemony by concluding that such issues as abortion and life extension are not medical prerogatives. However, medical professionals have co-opted theologians and clergy by expanding their trade and becoming the guiding counselors for appropriate decisions regarding these problems. 1

6. 'Preventive' medical care systems can make every person a client each day of his life. Medicalized prevention tells us that we need the medical system precisely because we do not perceive a need.

Each reform, therefore, represents a new opportunity for the medical system to expand its influence, scale and control. I t is no wonder that the reform efforts are often generated by medical interests. Indeed, should the American people come to believe that health is basically a political affair and abandon the medicalized reform efforts, the medical system would deflate like a great balloon pricked by the common sense of citizens. The system needs the hot air of reform i f i t is to continue to inflate.

The System's Political Functions

Despite the utility of reform as an essential process to promote the growth of medicine, i t would be totally inaccurate to suggest that medical reform is basically a self-serving mechanism of the medical industry. Its 'nonmedical', political effects are now its most important function. Indeed, the reason the 'health care crisis' is so nonconsumable is that we cannot afford to digest i t because its functions are so critical to the maintenance of the status quo. The political functions of the system are numerous:

First, in any economy that becomes capital-intensive, means of distributing income are needed in order to create new markets and to forestall disruptive unemployment. 'Service' systems rationalize alternative means of income distribution. The expansion of the medical system is, in most modernized societies, a primary means of providing income and markets disguised as help.

Second, expanding medical systems require the manufacture of need. As each new need is created, citizens have an increased sense of deficiency and dependence. Indeed, an essential function of professional medical training is to increase the capacity of the trainee to define his or her neighbor as deficient while reducing the capacity of the neighbor to cope.

Third, as physiological health remains stable or diminishes while medical resources increase, political energies are increasingly consumed in the effort to reform the medical system. Next to inflation and recession, 'health' insurance is still the major domestic issue on the U.S. political agenda. The consumption of politics through medical reform is a central function of the 'crisis'. New Ecologist No. 4 July/Aug 1978

Fourth, in many countries current research demonstrates that increasing numbers of people use the medical system for reasons that doctors say are not physiologically based. In the U.S., well over half the 'patients' are classified by doctors as not having physiological problems. When doctors are asked why these people visit them, they identify a series of cultural, social and economic problems. Therefore, their medical 'care' is, by the doctor's own definition, a placebo for that action that could address the cultural, social, economic and political causes of the malady.

Fifth, the growth of medical hegemony provides the training ground for popular acceptance of expertise. As public belief in the need for medically defined service expands, the people act less as citizens. They are more accurately defined as clients. Clients are people who believe that they are going to be better because someone else knows better. In the U.S. this training in 'clientage' contributed to support for the Vietnam war. Having been trained by professional servicers to believe in professional expertise, American clients waged war by putting their faith in 'systems analysts', 'international relations experts' and 'management authorities'. They were given prescriptions for the problem coded in terms of body counts, minilistening devices, herbicides and missions. Prepared for professional dependence, they accepted the diagnosis and prescription of a new breed of war-making professionals.

Sixth, the growth-oriented medical system trains people to accept inequity as the price of progress. Indeed, issues of equity and justice can be most effectively co-opted by the belief that the next professionaltechnological breakthrough will bring health to everyone i f we will only invest our resources in professional 'help'. This 'research and development' argument has been a magnificent mechanism to ensure regressive use of efficacious medical resources while preparing people to accept the generalized proposition that inequity is the price of progress.

Seventh, the most important political role of a growth-oriented medical system is its capacity to obliterate any remnant cultural sense of the limits of a technological society. Communicating its commitment to the death of death, the medical system, by its growth, affirms a world view that places ultimate value in development, exploitation and conquest. In a society that is decaying because of the unlimited growth of technology and technique, medicine's primary political function is to obscure the cause of our dying.

Reasserting the Possibility of Politics

Viewed in these terms, the essential function of medicine is the medicalization of politics through the propagation of a therapeutic ideology. This ideology, stripped of its mystifying symbols, is a simple triadic credo: (1) The basic problem is you, (2) the resolution of your problem is my professional control, and (3) my control is your help. The essence of the medical ideology is its capacity to hide control behind the magic cloak of therapeutic help. The power of this mystification is so great that the therapeutic ideology is being