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Response to Review of Remaking the American Patient: How Madison Avenue and Modern Medicine turned Patients into Consumers

Let me start with a thank you to Martin Gorsky for writing such a perceptive review of my book and to Reviews in History for giving me an opportunity to reply. Encouraging this kind of exchange is yet another way that online, open source journals benefit the historical profession.

In my view, Professor Gorsky’s commentary is a model of what good reviewing should be: an accurate summary of the author’s main arguments along with intelligent criticisms of them. I share his assessment of where the book feel short. So, this response will not be a querulous rebuttal but rather an attempt to explain further why I made the choices I did, especially as they bear on the ‘idiosyncratic’ aspects of the American story.

Professor Gorsky quite correctly points out that Remaking the American Patient does not engage much with the theoretical debates about why health care systems differ, debates that Professor Gorsky does a nice job of laying out in the mid-part of the review. I am in fact quite interested in those debates and hope to contribute more directly to them in the future. But as Professor Gorsky observes, I had a different agenda in writing this book. In recent years, historians have been urged to step outside of their academic comfort zones and try to communicate their findings to a broader audience. In my case, I wanted to craft a narrative overview of the 20th-century medicinal profession that would simultaneously connect medicine’s evolution to larger themes in American history (consumer culture, the shift to a post-industrial service economy) while also addressing contemporary issues of concern to doctors and patients. Rather than write a trade book, which would have required a drastic shortening of the text and elimination of the footnotes and bibliography, I went with a good university press that allowed me to produce a ‘doorstopper’, as my editor called it – a very long book with lots of footnotes. I hoped to find the sweet spot: to write a work that historians would find substantial while also appealing to non-academic readers. In the process, I did slight the extensive theoretical and historiographical debates that have bear on the differential development of modern health care systems.

That said, Remaking the American Patient did attempt to make a modest contribution to contemporary policy discussions in the United States (as distinct from academic debates) in ways that might not be so apparent to historian readers. In this country, health care policy is heavily dominated by economists whose models of how the health care system should be ‘fixed’ depend heavily on mechanisms of patient-consumer choice. I became intrigued with those models while participating in the Robert Wood Johnson Foundation’s investigator award program, which brought me into regular contact with economists, political scientists, and sociologists studying the American health care. Listening in on those discussions, I was amazed at how under-historicized the roles of patients as economic actors were. Despite the growing policy weight placed on ‘educating’ Americans to make ‘better’ choices as a corrective to the system’s many dysfunctions, economic as well as therapeutic, there was surprisingly little work on the impact of consumerism as a historical phenomenon. I hoped by historicizing the ‘patient-as-consumer’ that I might in some small way contribute to a more realistic approach to health care reform. That was a na├»ve hope on my part; as the latest effort to repeal the Affordable Care Act shows, thoughtful policy debate has no place in the current politics of American health care. But I do not regret making the attempt, even if it felt much like bashing my head against a brick wall.

Those policy interests also influenced my efforts to locate medicine within the larger context of American culture. Much excellent historical work has been done in the past few decades on the evolution of basic institutions (medical schools, hospitals, medical specialties, pharmaceutical firms), on patient experiences with specific diseases and processes (tuberculosis, cancer, diabetes, mental illness, pregnancy, reproductive health), and on the powerful role that class, race, gender, and region play in shaping those experiences. Rather than replicate that work, I decided to look at the other end of the funnel, so to speak, and study the doctor’s office and the drugstore, two sites of care that have received very little historical attention. That pairing also reflected my interest in locating medicine within the larger context of American consumer culture, advertising, and consumerism. There has been a huge literature on those subjects in recent years, little of which directly considered medicine and health. By looking at the doctor’s office and the drugstore, I wanted to explore the interplay between the dynamics of modern consumer culture and the contours of modern biomedicine.

Those choices of emphasis did tilt my history toward the consumerism practiced by white educated middle-class patients. That problem bothered me throughout the writing of the book; had I more energy and another 200 pages available to me, I would have done more to move beyond the focus on the articulate and affluent. It was certainly not my intent to ‘underplay the extent of inequality’. But I thought there was no need of another book demonstrating that the American system fails to care for the poor, recent immigrants, people of color, and other vulnerable groups. We have a mountain of historical, social scientific, and clinical studies attesting to that fact. What is less apparent is how badly the health care system has served even the entitled people who are ‘supposed’ to be doing well within it. Current American health care policy works from the assumption that if only they ‘choose wisely’, the system works reasonably well for discerning people blessed with good insurance. That assumption drives the efforts to ‘fix’ the system primarily by making it more accessible to everybody else. I wanted to question the idea that expanding access alone was going to solve the system’s problems, and to push back against the rampant patient-blaming that has become endemic to political discussions in this country. At the same time, I did not want to dismiss the grassroots struggles of the past or present as useless or meaningless. This conundrum made for a difficult interpretive task. Simultaneously to criticize and defend the concept of critical consumerism.

As to the representative or idiosyncratic question, I have no sense yet of how relevant or useful historians outside the United States will find my study. I had so much trouble figuring out what was going on in the US that I rarely extended my gaze to other places. When I did, it was chiefly to describe how American critics invoked comparisons to other countries to benchmark American deficiencies. One of the pleasures of finishing a book that took 15 years to write is that I now have the luxury of discussing it with my colleagues. Frank Huisman has invited me to come to the Descartes Centre at Utrecht University this summer to start that conversation; we have plans for a future conference to which we can invite Professor Gorsky and other historians to think more about the comparative history of health care systems. I look forward to that opportunity.

As one final point, I want to explain that putting all the illustrations together was a cost savings measure. I was fortunate that the University of Carolina Press was willing to take a chance on publishing such a very long book (over 500 pages), which is a rarity in academic publishing today. But to keep the cost down, we did have to economize on issues such as the placement of the illustrations.