The second sickness: contradictions of capitalist health care. - book reviews

Howard Waitzkin dedicates this book to his grandfather, house painter and union organizer, who died from a form of liver cancer caused by the toxic solvents used in paint thinner--his union had been unsuccessfully requesting government monitoring of these chemicals. The "second sickness" of the title comes from Norman Bethune, surgeon to the liberation forces of China, and refers to the sickness and suffering generated by social causes--the lung cancers of asbestos workers, the chronic back injuries of farm workers, the premature deaths of infants whose mothers have no prenatal care. Much of the power of this book stems from the fact that its author is a physician who has directly experienced the contradictions of capitalist health care in his clinical work--with the programs of the Black Panther Party in Boston, the United Farm Workers' Union in rural California, and La clinica de la Raza in Oakland, California. It is a impassioned work; as the author states: "There is purportedly a fine line between committed scholarship and polemic. Personally, I have not found this distinction helpful."

Much of Waitzkin's work addresses the deficiencies in the current organization of medical practice in the United States. Unlike many radical critics--most notably, Ivan Illich in Medical Nemesis--he does not simply blame physicians for the current mess, nor does he see medicine as only, or even primarily, a mechanism of social control. He does provide a critique of the ideological functions of medicine and attacks the tendency to medicalize (and thus individualize) social problems, but he allows room for the popular perception of medical care as a social good. Medicine is not, he says, a major determinant of the health status of large populations--being much less significant than working and living conditions, nutrition, sanitation, and socioeconomic development--but it does undeniably have positive effects on subpopulations, especially those without prior access to services. A redistribution of services could thus achieve definite improvements in health, especially in infant mortalityf the simplest and most basic medical services would have the greatest measurable effect.

If this is the case, and there is much evidence to suggest that it is, we are now spending the vast majority of our social resources on the least effective forms of medical intervention, thus explaining why spiraling medical costs seem to bring such minimal returns in terms of improved health. The billion of dollars spent on medical goods and services have created a healthier medical industry, but not necessarily a healthier population.

Why do we make such poor use of our medical resources? In his first two chapters, Waitzkin provides a general analytic framework for understanding how the contradictions in medicine are produced by the contradictions within capitalist society, showing, for example, how the maldistribution of medical care can be understood in terms of the uneven development of the economy as a whole. Here the issues of corporate involvement in the promotion of medical technology, drugs, and even primary health services are briefly introduced, as are the ways in which these lead to escalating costs and profits--themes that are more fully addressed in later chapters.

In seeking to understand the social origins of illness, Waitzkin turns to three analysts who have received little attention in American medical literature--Friedrich Engles, Rudolf virchow, and Salvador Allende. His chapter on their work should be sufficient reminder that concern with the social etiology of disease in hardly novel, and that there is a long history of research and analysis needing to be recovered--and developed--by those currently concerned with health policy. (An English translation of Allende's La Realidad Medico-Social Chilena would be most helpful in making this work more accessible to many North Americans.) One would have liked to have had considerably more attention paid to the social production of disease and illness in the United States, but perhaps this will be the subject of another book.

In the second part of this volume. Waitzkin returns to his main subject: contradictions in the organization of medical services.

An excellent chapter on medical technology is devoted to a detailed examination of the development of coronary care units during the 1960s--an example of the overselling of many new technologies marketed before there was any real evidence of their effectiveness. Coronary care units (CCUs) provide continuous electronic monitoring of the heart's rhythm and are supposed to reduce morbidity and mortality from heart attacks. In the late 1960s and early 1970s. CCUs were sold to hospitals across the country on the basis of this claim, despite the fact that no controlled studies had been done on their effectiveness.

U.S. corporations participated in every stage of CCU research, development, promotion, and proliferation: they funded academic cardiologists who promoted CCU's in the medical and cardiological literature, helped design CCU systems, and introduced them for clinical use. One example among many: Hewlett-Packard (H-P) was one of the first corporations to jump into the coronary care market. The W.R. Hewlett Foundation, established by H-P's chief executive officer, earmarked large annual grants to Stanford University, where researchers helped design and develop the product. Stanford University, after "an undoubtedly fierce competitive examination of alternatives," chose H-P equipment for its CCU and other intensive care facilities. On the basis of this research, the American Heart Association encouraged even small and local hospitals to establish CCUs; AHA's officers were cardiologists, corporate executives, and bankers. In their 1973 Annual Report, Hewlett-Packard stressed thd close relationship between corporations and medical researchers and their collaboration in shaping the health care system (pp. 18-19):

Health care expenditures, worldwide, will continue to increase significantly in the years ahead, and a growing portion of these funds will be allocated for medical electronic equipment. Interestingly, this growth trend offers the company--working in close collaboration with researchers, clinicians, and other hospital personnel--the unique opportunity to help shape the future of health care delivery.

There was much financial support in the United States for CCU development, but no funds to support careful studies of their effectiveness. In Britain, controlled trials suggested that for many conditions, CCUs were no more effective than rest at home--but CCUs did have a dramatic effect in skyrocketing the costs of medical care.

Those involved in medical policy now recognize uncontrolled inflation of medical costs as a central problem in the United States.

But while CCUs and similar technologies proliferate, health and welfare programs for women and children, the poor, minorities, and the aged have faced determined fiscal attacks. Cuts in food stamps, nutritional programs for women and children, and the closing of community clinics hurt the poor, leaving corporate profits intact. Cuts in Medicare and Medicaid coverage are to be followed by cuts in employer-funded insurance packages. The glamor of intensive-care technology contrasts with the realities of community medicine, where services of the simplest kind often remain inaccessible.

Waitzkin devotes considerable attention to the contradition between the expansion of private medicine and the contraction of public services. Public financing is increasingly being channeled into private institutions, while public programs go begging. Across the country, public hospitals are being closed or transferred to private management: the hospital able to turn a profit is likely to be considered "efficient." Private hospitals engaged in "patient dumping" (sending "undesirable," i.e., uninsured, patients across town to public facilities) will soon have nowhere left to dump their unwanted patients, as even the streets fill with the homeless.

In the current situation, the community clinics started with such enthusiasm in the 1960s are struggling for survival. Hurt by cutbacks, and with many uninsured or uninsurable patients, they are dependent on external funding, and remain isolated and vulnerable. At the same time, those that survive remain a vital point of contact with community medicine and represent the possibility of a system of medical services oriented to people's needs rather than to corporate profits.

Moving from the larger structures of medical care to the micropolitics of the doctor-patient relationship, Waitzkin demonstrates the ways in which larger social contradictions penetrate even the intimacy of professional-client interactions. Three tape-recorded medical encounters are analyzed in rather devastating detail, showing the ways in which ideological messages about work, leisure, and family relations are unconsciously transmitted to patients. These analyses show the need to link medical services to social activism so that social contradictions are not simply internalized in the patient's mind and body, but can again be externalized in the struggle for social change.

In his final chapters, Waitzkin discusses potentail solutions to the problems he has analyzed. One chapter is devoted to "Lessons from Chile to Cuba" and another to struggles within the United States. The analyses of Chilean and Cuban medical reforms are useful, if only to expand our vision of the possible, but they seem far removed from the realities of life under Reaganomics. Both chapters lean heavily on the distinction between reformist reforms and nonreformist reforms: reformist reforms are defined as those that "have intact current political and economic structures, while providing small material improvements that may reduce social discontent"; nonreformist reforms "achieve true changes in power and finance and, by increasing political tension and activism, create the potential for wider political action."

Unfortunately, Waitzkin tends to use the distinction between reformist and nonreformist reforms as though any specific reform could be designated a priori as belonging to one or the otehr category. In reality, the same social intervention can in one social context or historical moment appear as a reformist reform and in another social context or historical moment as a nonreformist reform--those involved in a reform effort may themselves not know, or may incorrectly assess, its long-term implications. Because we cannot decide a priori whether a particular reform falls into the "reformist" or "nonreformist" category (at least as expressed in a linear either/or form), this distinction is unlikely to be very helpful as a guide to political action. Despite this caveat, Waitzkin's discussion of such issues as health maintenance organizations, alternative clinics, national health insurance, and national health service, does provide a useful guide to some of the major issues debated by the health left over the last decade.

Waitzkin addresses the central issues of health care policy today and provides a Marxist framework for understanding such problems as the inflation of medical costs and cutbacks in medical services, the domination of private and corporate interests, and the closing of public hospitals and clinics. He brings the analysis down to the interpersonal politics of the doctor-patient relationship, and then back to the larger necessity for political activism and social change. Throughout, the book is permeated by a clinician's concern for the individual suffering of those who have to bear the costs of social injustice as well as by a political commitment to structural transformation. Several chapters of this book previously published in the Annals of Internal Medicine, the International Journal of Health Services, and the American Journal of Public Health have excited considerable interest and controversy; their availability and expansion in book form should make them accessible to a wider audience interested in understanding the contradictions of our medical economy, and thus provide an important theoretical tool for health and community activists.

COPYRIGHT 1984 Monthly Review Foundation, Inc.
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