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Book Reviews

Who Is Indoctrinating Whom?

The New Shorter Oxford English Dictionary defines tendentious as "composed with the intent of promoting a particular cause or viewpoint." Tendentious is what PC, M.D. is. The cause or viewpoint is clearly conservative, as befits a W.H. Brady Fellow at the American Enterprise Institute. Author Sally Satel, a practicing psychiatrist, is articulate, literate, and a clever polemicist; that is, she is skilled at highlighting overreaching claims and foolish statements made by those she wishes to skewer. In the process, she diverts attention from the extent and the severity of the social problems those claims and statements address. Is it true that "the quest for social justice" reflects "a global ideology to manipulate the way people think about disease and its remedies"? Balderdash!

Even on positions with which I strongly agree, her voice is so shrill as to obscure important underlying issues. Satel forthrightly decries, as I do, "therapeutic touch," a treatment based on a bizarre notion of a "human energy field" that practitioners allegedly recognize by waving their hands just above a patient’s body (not actually touching it) to resolve energy "blockages." The theory is scientific nonsense; there is no credible evidence for its effectiveness. It is embarrassing to me as an academic that prestigious university hospitals provide it as a "consumer option" (I presume because it is a profitable cost center). So far we agree. But then Satel conflates therapeutic touch with women’s studies in nursing schools to dismiss legitimate grievances nurses have about lack of status, income, and respect in the health care system.

Satel scathingly and deservedly derides the virtual epidemic of traumatic stress disorders attributed to repressed memories of childhood sexual abuse. "Therapists" claim to "recover" memories of abuse from the very first year of life, even though memory cannot be encoded in words before the development of language. In this folie-à-deux, patients learn to generate "multiple personality" disorders. That such irrationalities (which peaked in the early 1990s) were tolerated was and is a disgrace to the mental health field. But Satel segues from a critique of victim therapy to laments about multicultural counseling and "oppression obsessions." No doubt about it, outlandish claims for multiculturalism reinforce ethnic stereotyping. Nonetheless, it remains the case that insensitivity to, and ignorance of, cultural differences handicap the provision of comprehensive health care.

I do not for a moment believe that racial and ethnic congruence between doctor and patient either is necessary for, or assures, good care. If it is, minorities in the United States will be in trouble for a long time. Minority practitioners not only are disproportionately few, but they are being recruited into professional schools at lower rates than the percentage of minorities in the population. Thus, it is essential that majority practitioners increase their knowledge and skills across faults of class and culture, and that is what training for cultural competence aims to do.

Satel disparages affirmative action in medical school admissions (and belittles minority students in the process). What she doesn’t tell the reader is why those policies were widely adopted in the 1970s. In the academic year 1968–69, black students made up 2.7 percent of the total enrollment in all U.S. medical schools.¹ That way of putting it, while factually accurate, understates the magnitude of the disparity. Half of those black students attended Howard or Meharry, the two traditionally black medical schools. Enrollment at all other U.S. medical schools came to 1.4 percent (in a year when blacks were about 11 percent of the U.S. population); Native Americans, Mexican Americans, and mainland Puerto Ricans, barely on the map in those days, added up to a grand total of twenty-six students. The reason was no mystery: an unabashed commitment to legacy admissions for doctors’ sons and affirmative action for white, Anglo-Saxon, Protestant males (Jews and Catholics didn’t fare very well in those days, either). There were, after all, no women at all at Harvard Medical School until 1945; women made up only 5 percent of national enrollment.²

As one important result of the struggle for civil rights and women’s rights, the number of women admitted to medical schools increased more than sixfold during the past thirty years (from 1,256 in 1970–71 to 7,725 in 1999–2000, from 11 percent to 46 percent of entering classes).³ What was afoot? Had there been a mutation in the "MD" locus on the long arm of the X chromosome? Or had all of those talented women been there all the time, awaiting an opportunity? The admissions process, not the female sex, had mutated. Women of Satel’s generation were (and properly so) the beneficiaries of affirmative action. They had a much fairer shot at becoming physicians than did the generation that preceded them. As more women were admitted into one year’s class, still more women applied to the next one. Indeed, the influx of women rescued medicine from impending disaster in the late 1980s. The number of male applicants had declined so sharply between 1974 and 1988 that there were not enough men, qualified or unqualified, to fill the first-year class.⁴

Satel claims that "a cadre of academics have put themselves in the business of condemning ‘competitive meritocracy,’ opposing the free market system, supporting affirmative action and derailing welfare reform—all in the name of health." In contrast to these "one-sided interpretations," she argues for "free enterprise, accountability and opportunities to be creative on the job" that might relieve the stress that comes "from being stymied when one wants to do a good job." Readers can decide for themselves which thesis they prefer, but it is clear that there is "indoctrinology" on both sides of the ideological spectrum. What matters are the data, which demonstrate, overwhelmingly, the existence of health disparities associated with class and race that should outrage every American. Blacks have an average life expectancy that is six years shorter than whites’.⁵ How much is class? How much is race? We don’t know, but the world over, rates of disease and death go up as income declines.

Part of that difference stems from lack of access to medical care. A RAND/University of California, Los Angeles (UCLA) study provides unequivocal evidence that highly active antiretroviral therapy for adults with human immunodeficiency virus (HIV) infection not only is effective but reduces overall costs; the same data reveal that disadvantaged groups (women, blacks, intravenous drug users, and patients covered by Medicaid) have much less access to high-quality care.⁶

Access per se will not obliterate all of the disparities; they persist in countries with universal coverage. John Lynch and his colleagues have shown that mortality rates in U.S. metropolitan areas are greater in areas where income inequalities are greater; the excess deaths equal the loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide, and homicide.⁷ Indeed, Satel herself cites these authors to chastise them for concluding that a less stratified society would be a healthier one.

Satel’s view of medicine is uncoupled from the most deeply held historic commitments to equity and justice in the practice of medicine. Concern for the setting within which disease occurs has been central since the inception of Western medicine in ancient Greece. It is evident in the Hippocratic treatise "Airs, Waters, Places," in which the writer enjoins physicians who "wish to pursue properly the science of medicine" to attend not only to the properties of the seasons, soil, winds, and waters but also to "the mode of life of the inhabitants," including diet, exercise, and drinking habits. Rudolf Virchow, the great German pathologist, investigated an uncontrollable epidemic of relapsing fever among miners in 1847. Its causes, he asserted, were as much social (bad housing and malnutrition) as they were medical. In his words, "If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life."⁸ Who can deny that proposition in view of the epidemics of typhus among Rwandan refugees, of HIV in Africa and Asia, of multiple-drug-resistant tuberculosis in Russia, and of higher mortality among disadvantaged populations in countries like ours?

Leon Eisenberg

Editor's Notes

 
Leon Eisenberg is Maude and Lillian Presley Professor of Social Medicine and professor of psychiatry, emeritus, Harvard Medical School. He recently coedited The Implications of Genetics for Health Professional Education (Macy Foundation, 1999); and Bridging Disciplines in the Brain, Behavioral, and Clinical Sciences (National Academy Press, 2000).

NOTES

1. Association of American Medical Colleges, United States Medical School Enrollment, 1970–71 (Washington: Office of Minority Affairs, 1976).
2. D.R. Bennett, "Women at HMS," Harvard Medical School Alumni/ae Bulletin 55 (1981) 44–45; and D.G. Johnson, Physicians in the Making: Personal, Academic, and Socioeconomic Characteristics of Medical Students from 1950 to 2000 (San Francisco: Jossey-Bass, 1983).
3. B. Barzansky, H.S. Jonas, and S.I. Etzel, "Educational Program in U.S. Medical Schools, 1999–2000," Journal of the American Medical Association 284, no. 9 (2000): 1114–1120.[Abstract/Free Full Text]
4. C. Eisenberg, "Medicine Is No Longer a Man’s Profession, or, When the Men’s Club Goes Coed It’s Time to Change the Regs," New England Journal of Medicine 321, no. 22 (1989): 1542–1544.[Medline]
5. National Center for Health Statistics, Health, United States, 2000 (Hyattsville, Md.: NCHS, 1998).
6. S.A. Bozzette et al., "Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy," New England Journal of Medicine 344, no. 11 (2001): 817–822.[Abstract/Free Full Text]
7. J.W. Lynch et al., "Income Inequality and Mortality in Metropolitan Areas of the United States," American Journal of Public Health 88, no. 7 (1998): 1074–1080.[Abstract/Free Full Text]
8. G. Rosen, "What Is Social Medicine?" Bulletin of the History of Medicine 21, no. 5 (1947): 674–733.[Medline]

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