Doctors, Democracy, and Disease:

The Political Transformations of American Medicine

Peter A. Swenson

Yale University

Medicine, as a social science, as the science of humans, has the duty to set . . . goals [for social, intellectual, and physical health] and attempt to establish scientifically how to realize them; the statesman . . . must find the means for their realization.

Rudolf Virchow (1848)[footnoteRef:1] [1: Rudolf Virchow, Mitteilungen über die in Oberschlesien herrschende Typhus-Epidemie (Berlin: Reimer, 1848), 22.]

1. INTRODUCTION

In 1954, President Dwight D. Eisenhower sized up the officialdom of the American Medical Association (AMA) as “a little group of reactionary men dead set against any change.”[footnoteRef:2] It would have been impolitic to utter such thoughts in public because the AMA wielded enormous political power. A New York Times reporter wrote that expert observers of Washington lobbying assert that it was “the only organization in the country that could marshal 140 votes in Congress between sundown Friday and noon on Monday.” According to a 1950 Consumer Reports editorial, it was “the nation’s No. 1 political lobby.”[footnoteRef:3] A large contingent of the nation’s doctors, about 65 percent, were members. Furthermore, the AMA’s power in medical affairs resided in its alliances with other conservative forces, including the U.S. Chamber of Commerce, the National Association of Manufacturers, and the American Farm Bureau. Its most important ally was the Pharmaceutical Manufacturers’ Association. While the AMA backed their agendas, they in turn aligned with it against its worst fear, compulsory national health insurance. [2: Stephen Ambrose, Eisenhower: The President (New York: Simon and Schuster, 1984), 199.] [3: Luther A. Huston, “AMA is Potent Force Among the Lawmakers,” NYT, June 15, 1952; Harold Aaron, “The Doctor in Politics,” Consumer Reports, February 1950, 75.]

To the AMA’s displeasure, Eisenhower was seeking a centrist solution to the problem of rising health costs and the inability of low-income and often medically needy citizens, especially retirees and the working poor, were unable to afford insurance--an electoral liability for Republicans. Eisenhower therefore proposed a modest fix, a federal trust fund to subsidize private insurance coverage for higher risk customers. He naively thought that his Health Reinsurance Bill, the fulfilment of a promise he had made in his second State of the Union address to Congress, would satisfy both his own and the medical establishment’s ideological predilections against “compulsion.” But the AMA saw red and lobbied successfully against the bill. It was “an entering wedge of socialized medicine,” a top AMA official and its future president warned Congress. Because of that, Eisenhower fumed, the AMA was “just plain stupid.”[footnoteRef:4] [4: David Blumenthal and James Morone The Heart of Power: Health and Politics in the Oval Office (Berkeley CA: University of California Press, 2010), 111-112; Joseph A. Loftus, “Ban on Health Plan a Defeat to People, Eisenhower Says,” New York Times, July 5, 1954.]

During the Eisenhower years, the AMA also mobilized to obstruct a federally funded expansion of medical schools advocated by the president to deal with a projected shortage of physicians. In 1952, the AMA prided itself for blocking a minor improvement in the Social Security system that would extend benefits to workers who became disabled and lost gainful employment before the official retirement age. It was a step toward socialized medicine, an AMA official told Congress, because the government would pay doctors to examine citizens to diagnose disabilities and steer them into a federal rehabilitation program if appropriate. The next year, fearing a socialist takeover of health care, causing damage to physicians’ clinical autonomy and therefore income, many AMA activists balked at supporting Eisenhower’s executive reorganization plan creating a new Department of Health, Education and Welfare. To head off its opposition, Eisenhower appeared at a special emergency session of the AMA House of Delegates in 1953 convened to defend it.[footnoteRef:5] [5: Huston, “AMA is Potent Force”; Congressional Record, May 19, 1952, 5472; “Introduction and Address of the President of the United States, Hon. Dwight D. Eisenhower,” JAMA 151:14 (April 4, 1953), 1200.]

In the following decade, the AMA allied with the pharmaceutical industry to battle legislation to require the pre-market testing of drugs in “adequate and well-controlled” clinical studies to establish clinical efficacy as well as safety. In 1962, a AMA chairman told Congress that doctors had no need for large-scale experimental science to guide their prescribing practices. The scientifically trained doctor, he said, “should not be deprived of the use of drugs that he believes are medically indicated . . . by a governmental ruling or decision.” The combined opposition of the AMA with the Pharmaceutical Manufacturers’ Association (PMA) probably explains President John F. Kennedy’s reluctance to promote the reform until after the Thalidomide related deaths and deformities of thousands of babies in Europe, as well as some in the U.S. whose mothers had been given experimental doses. Around the same time, the PMA joined forces with the AMA in agitating against Medicare for the retired elderly, in part out of fear that it would empower the federal government to regulate drug availability, pricing, and therefore profits.[footnoteRef:6] [6: Hugh H. Hussey, “Statement of the American Medical Association,” in U.S. Senate, Drug Industry Antitrust Act, Hearings before the Subcommittee on Antitrust and Monopoly of the Committee on the Judiciary, Part 2 (Washington: U.S. GPO, 1961), 998-1014, especially 1011-1023.]

The reactionary AMA of the 1950s was a far cry from the profoundly progressive organization that it once had been. A half-century earlier, organized medicine joined lay forces, especially consumer advocates led by women, in a crusade against the drug industry, not a friendly alliance with it. The result was the 1906 Pure Food and Drugs Act. The AMA also agitated unsuccessfully for creating a cabinet-level Department of Health for federal research on and public health measures against the spread of dread diseases. In 1912, AMA reformers welcomed President Theodore Roosevelt’s leadership of the short-lived “Bull Moose” Progressive Party, whose planks included a call for establishing a National Department of Health. Arthur Dean Bevan, an AMA leader who saw “medicine as a function of the state,” circulated a letter to every physician in his home state of Illinois praising the third party’s platform. The platform also endorsed compulsory health insurance, as did a significant number of AMA leaders, including Alexander Lambert, Roosevelt’s friend and physician—so long as it was sensibly designed to serve both society and profession well.[footnoteRef:7] [7: “The Campaign and Election of 1912,” ILMJ 22:12 (December 1912), 729-730.]

Clearly, at some point between the Roosevelt and Eisenhower eras there had been a radical and, as this book will show, quite sudden rupture in American medical politics. It was marked by a dramatic change in the kind of leaders given the helm. In 1914, the AMA had elected Victor C. Vaughan to its mostly honorific presidency, a pioneer among bacteriologists and physiologists—and, as a public health missionary, also something of a socialist. In his presidential address, Vaughan declared to the AMA House of Delegate that “too much stress has been laid on the sacredness of private property and too little on the duty of all to contribute to the welfare of the whole.” Indeed, “Preventive medicine is the most potent factor in the socialistic movement of the day with which every good man feels himself more or less in sympathy.”[footnoteRef:8] [8: Victor C. Vaughan, “The Service of Medicine to Civilization,” JAMA 57:26 (June 27, 1914), 2012.]

A reactionary turn began around a half dozen years after Vaughan’s address, although rebellious rumblings from below had begun a decade earlier. By 1924 the AMA was locked onto a new course. That year, the AMA’s House of Delegates elected William A. Pusey, an unabashed social Darwinist, for a year’s term as president. In his inaugural address, Pusey declared that all forms of “social cooperation” under government auspices were a force that would “break down individualism” and would “set aside the law of natural selection and . . . counteract Nature’s cruel but salutary process of eliminating the unfit.” It was not an aberrant view to be swept away with the discrediting of eugenicist thinking. In 1949, the New York State Journal of Medicine editorialized against compulsory health insurance with the argument that “What keeps the great majority of people well is the fact that they can’t afford to be ill.” It was, admittedly, “a harsh, stern dictum” that would mean that some cases of early tuberculosis and cancer would go undetected. However, the editorial asked, was it not better for a few to perish “rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor?” In short, it was time to “hoist Mr. Charles Darwin from his grave and blow life into his ashes,” and thereby revive “his tough but practical doctrine of the survival of the fittest.”[footnoteRef:9] [9: William Allen Pusey, “Some of the Social Problems of Medicine,” JAMA 82:24 (June 14, 1924), 1905-1906; “A Breeze from Down Under,” NYSJM 49:16 (August 15, 1949), 1905, and “License for Illness,” NYSJM 49:18 (September 15, 1949), 2130.]

This was the classic “rhetoric of reaction” that economist and political theorist Albert Hirschman describes in his exploration of conservative social thinking through the ages. According to Hirschman’s reactionaries, “perversity, futility, and jeopardy” thwart all political efforts at social betterment and justice, be it by overthrowing monarchies, expanding the electorate, or creating welfare states. Instead, according to each era’s reactionaries, radical reforms would bring only moral, economic, and—according to the New York medical journal—physical ruin.”[footnoteRef:10] Other reactionary rhetoric against “socialized medicine” wielded by organized medicine after the 1920s paraded what historian Richard Hofstadter calls the “paranoid style” in American politics. In 1939, for example, AMA journal editor Morris Fishbein warned that compulsory health insurance “will be the first step in the breakdown of American democracy . . . a beginning invasion by the state into the personal life of the individual, . . . a taking away of individual responsibility, a weakening of national caliber, a definite step toward either communism or totalitarianism.” Trying to head off Medicare in the early 1960s, the AMA enlisted conservative Republican Ronald Reagan, the future California governor and U.S. president, to declare that Medicare was the beginning of an invasion into “every area of freedom as we have known it in this country.” If Medicare passed, he warned, “one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.”[footnoteRef:11] [10: Albert O. Hirschman, The Rhetoric of Reaction: Perversity, Futility, Jeopardy (Cambridge MA: Harvard University Press, 1991).] [11: Richard Hofstadter, The Paranoid Style in American Politics and Other Essays (New York: Knopf, 1965); “The Platform of the American Medical Association,” JAMA 113:27 (December 30, 1939), 24-28; Ronald Reagan, “Ronald Reagan Speaks Out Against Socialized Medicine” [vinyl recording] (Chicago: American Medical Association, 1961), https://www.youtube.com/watch?v=z43NCL6Fxug. ]

As a later chapter will show, the ultra-conservative AMA leaders were not representative of the entire medical profession, just as progressive predecessors did not represent the perceived interests of the wider rank and file. Medical academics were among the most vocal detractors, lamentably divided from “the practicing profession,” according to an AMA president in 19xx. But the professors and scientists were passive bystanders, not actively rebellious medical politicians. According to one, it was rare for medical academics to be members, and it was “fashionable” and even “de rigeur to scoff or sneer at the AMA.” Looking back in 1974, this professor of medicine likened the AMA to “a great ocean liner that went full speed in reverse” since the 1930s.[footnoteRef:12] Bu then, around 1990, as the final chapter will show, the ship of medicine began slowly turning once again, though not quite making a full about-face. It was reacting to new winds of reform blowing from the outside world, and emboldening medicine’s internal critics to sound the calls for a new medical progressivism. Although the new medical progressivism emerged outside of the AMA and the rising medical specialty societies that had eclipsed it in many ways, organized medicine, even the AMA was pulled in its wake, and drifted in a progressive direction. The new political currents, aligning lay as well as medical forces, sought to enlist the medical profession’s organizational, cultural, and political power for larger things than its own economic interests. Those were, most importantly, more quality, equality, and economy in the financing, organization, and delivery of health care, even if the policy and institutional changes needed stepped on the toes of special medical interests. [12: John Gordon Freymann, “Leadership in American Medicine: A Matter of Personal Responsibility,” NEJM 270:14 (April 2, 1964), 711, 715; Freymann, “A Doctor Prescribes for the AMA,” Harper’s, August 1965, 76-77; Freymann, The American Health Care System: Its Genesis and Trajectory (New York: Medcom, 1974), 160.]

THE FIRST ERA OF MEDICAL PROGRESSIVISM

This book chronicles and explains the main course of American medical politics from the progressive 1870s into the ensuing conservative phase, and then into a new, if halting, partial, and chaotic, progressive turn. A common theme is the role of medicine’s changing lay alliances and the differences they made to the profession’s political power, successes, and failures. To do justice to the fascinating and largely unwritten history of medicine’s political phases, it relies on a great number of primary sources never before consulted, along with hundreds of books and other secondary publications. Because the full nature and scope of early 20th century medical progressivism is relatively unknown, most of the chapters will be about the role of the AMA as a force for reform before the 1920s. The AMA’s reactionary turn and more than a half century of conservativism afterward will be covered in the last three chapters, including the last, which delves into the new era of progressivism. The fact that the earlier AMA is often seen through the lens of its later conservatism justifies the greater focus on the progressive era. The relatively short discussion of the recent progressive turn will point in the direction of what the future might bring to medical politics and the America’s disordered health care system: internationally exceptional costs, surprisingly poor outcomes, and continuing unequal distribution.[footnoteRef:13] [13: Jeffrey Young, “The AMA Endorses Senate Healthcare Reform Bill,” The Hill (December 21, 2009).]

As the book will show, progressivism as a medico-political phenomenon began in the late in the nineteenth century. Although barely noticed in historical works on the Progressive era, its medical version dovetailed with those in many other social, economic, and political spheres of American life.[footnoteRef:14] Physician reformers saw their efforts as contributions to general societal, economic, political, and moral uplift and thus joined alliances that intersected professional, civic, philanthropic, commercial, and governmental lines of activity. Medicine’s reformers were animated by optimism about the role of both state and private voluntary action, guided by professional and scientific expertise, in governing a severely disordered capitalist society and polity. Professional redemption was a first step. On that, in loud cri de coeur addressed to the elite American Academy of Medicine, Leartus Connor summed up in 1898 many of what he and other reformers considered to be the “diseases of the medical profession.” They included “overcrowding; a vast number of incompetents; large numbers of moral degenerates; crowds of pure tradesmen; blatant demagogues; hospitals organized and conducted to the damage of both profession, patient and people; dispensaries and public clinics of the same character; . . . medical societies so conducted as to be a by-word among honest persons, and yet continued to advance the financial profit of their leaders; domination by commercial interests of drug manufacturers and proprietors of secret and proprietary medicines.”[footnoteRef:15] [14: Useful introductions to progressivism are Robert H. Wiebe, The Search for Order 1877-1920 (New York: Hill and Wang, 1967) and Arthur Stanley Link, Progressivism (Arlington Heights IL: Davidson, 1983). ] [15: Leartus Connor, “The Prevention of Diseases Now Preying on the Medical Profession,” BAAM 3:9 (October 1898), 4.]

Reformers like Connor, a prominent Michigan physician, medical scientist, educator, editor, and former president of the elite American Academy of Medicine, wanted medicine to heal itself. A first step in that direction was the medical licensure movement, which got off the ground in the 1870s, to turn the profession into the scientifically educated community it had so far unsuccessfully posed as, and to better equip it politically as well as intellectually for its key role in fighting, not just treating disease. A second step was to unify the sparsely and chaotically organized and therefore raucously conflictual profession. Doing so would redeem it from widespread societal ridicule, disdain, flight to alternative healers, and, not least, political impotence.

High on the invigorated AMA’s reform agenda, was getting political and philanthropic help in cleaning up rotten medical education that caused one prominent Illinois public health official to “blush for his country” because Europeans regarded American medical diplomas as contemptible.[footnoteRef:16] Thus great reform energies were spent at the state level to impose and improve the earlier licensure laws, and thus enlist the power of the state to control entry into medicine. Along with bad medical schools, doctor reformers saw the burgeoning pharmaceutical industry as one of the greatest causes of the American medical disorder. Again, shame drove the reformers. “In no other country has the standard and quality of drugs been left entirely to the manufacturers’ honor,” wrote AMA editor George Simmons in 1907, with the result that European manufacturers shipped their “unethical” products across the Atlantic Ocean.[footnoteRef:17] Doctors of all stripes, they knew, were dupes of and sometimes collaborators with a dishonest drug industry. They were duped in part by hundreds of cheap medical journals funded by the advertising of drugs of unknown composition with preposterous curative claims. [16: William G. Eggleston, “Our Medical Colleges,” JAMA 12:21 (May 25, 1889), 747.] [17: George H. Simmons, “The Commercial Domination of Therapeutics and the Movement for Reform,” JAMA 48:20 (May 18, 1907), 1645; George H. Simmons, “Proprietary Medicines: Some General Considerations,” JAMA 46:18 (May 5, 1906), 1336.]

Last but far from least, a supreme goal of the reformist medical elite was public health. On preventive political and civic action, the AMA shared with the medical intelligentsia of the age the philosophy and goals of the American Public Health Association (APHA). Indeed, the AMA was, according to the chief executive of the APHA, “in the vanguard of preventive medicine.” The two organizations’ shared vision, as summarized by C.-E. A. Winslow, one of the day’s premier public health experts, was to advance “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease.” If all that meant fewer visits to the doctor and swallowing of bogus medicines, all the better.[footnoteRef:18] A strong national health agency was needed, like those in Europe the reformers envied. As reported by George M. Kober, dean and professor of hygiene at Georgetown University, Munich, Vienna, Berlin, Zurich, Hamburg, Paris, and London all had lower death rates from typhoid fever, transmitted by human fecal matter in water supplies and elsewhere, than every major American city between 1902 and 1906.[footnoteRef:19] [18: William C. Woodward, “The American Medical Association and Its Relation to Public Health Work,” Journal of the American Public Health Association 1 (1911), 329; C.-E. A. Winslow, “The Untilled Fields of Public Health,” Science 51:1306 (January 9, 1920), 30; “The Overcrowded Medical Profession,” PhilMJ 6:17 (October 27, 1900), 765.] [19: KOBER]

The public health and other reform missions were interrelated. In the reformers’ minds, improved medical education and licensure would serve public health, not just remedy the competitive and therapeutic chaos. Needed, for example, were doctors who could competently diagnose and treat a case of diphtheria or typhoid fever—and report those and many other infectious diseases to public health authorities. Better educated doctors would be more impervious to drug makers’ bogus curative claims, and therefore become more interested in preventive medicine through private and public hygiene. But the AMA’s reformers did not address many burning problems, including some that the following medical regime also neglected. The top of the profession was dominated almost entirely by wealthy white Protestant males, like most of America’s interconnected social, economic, and political elites. The all-black National Medical Association formed in 1895 when, on a technicality, a district society of black doctors was refused recognition by the AMA. After the reorganization of 1901, medical apartheid was maintained in the AMA by virtue of the fact that its constituent societies turned them away, thus closing a door on national membership. Starting in 1906, the AMA began compiling the American Medical Directory of all licensed physicians in which black doctors were identified as “Col.”[footnoteRef:20] In 1906, the famous black sociologist, historian, and civil rights activist W. E. B. Du Bois reported on the tiny number of medical schools training black doctors—only five small ones—and only about 1,250 practitioners. By 1923, only about 50 blacks per year graduated from medical school to serve over ten million fellow citizens. That year the AMA journal published its first comment on the matter, a short editorial including a non-urgent appeal to philanthropists for financial aid to educate more black doctors. That it might be a problem so big and complicated that only the federal and state governments could handle it was not suggested. It was also the last such entry before a lone article in 1944 by Paul Cornely, a black professor of preventive medicine and public health at Howard University and civil rights leader of the 1950s, and then, in the 1960s, a handful of articles reacting to the black civil rights movement.[footnoteRef:21] [20: Robert B. Baker, “African American Physicians and Organized Medicine, 1846-1968,” JAMA 300:3 (July 16, 2008), 307; Baker “Creating a Segregated Medical Profession: African American Physicians and Organized Medicine,” JAMA 101:6 (June 2009), 501-510.] [21: W. E. Burghardt Du Bois, ed., The Health and Physique of the Negro American (Atlanta, GA: The Atlanta University Press, 1906), 95-97; “Education of the Negro Physician,” JAMA (April 28, 1923), 1244; Paul Cornely, “Distribution of Negro Physicians in the United States,” JAMA 124:13 (March 25, 1944), 826-830.]

Racism among doctors was more overt in the South. According to Victor Robinson, an outspoken progressive medical journalist, “the negrophobia of the mob is as much in evidence in the editorial pages of the Southern Medical Journal as in the novels of Mr. Thomas Dixon.” His 1916 article concluded, “There is a shameful chapter in the history of American medicine, and it is headed: The Negro.”[footnoteRef:22] Racism was not quite a regular feature of articles and editorials in the staider Journal of the American Medical Association, but only, it seems, because the health, lives, and even the basic humanity of blacks was of little concern. One, in 1906, reported with uncritical appreciation on Robert Bennett Bean’s racist conclusions he drew from his measurements of “the negro brain” that he published in the American Journal of Anatomy and a couple of lay magazines. Because of variations in the sizes and structures of various parts of the brain, he argued, blacks came up short “in the higher faculties” like “self-control, will power, ethical and esthetic senses and reason.” The journal did not call attention to the fact that Franklin P. Mall of Johns Hopkins, who had been Bean’s mentor, meticulously discredited Bean’s study published in the same anatomy journal three years later, which found no noteworthy differences in the weights and structures of brains of different races, even in what he called the “lower ones.”[footnoteRef:23] [22: Victor Robinson, “The Negro in American Medicine,” MRR 22:7 (July 1916), 481 and 484; “The Negro Brain,” JAMA 47:20 (November 17, 1906), 1660.] [23: “The Negro Brain,” JAMA 47:20 (November 17, 1906), 1660; Robert Bennett Bean, “Some Racial Peculiarities of the Negro Brain,” American Journal of Anatomy 5:9 (September 1906), 379; Franklin P. Mall, “On Several Anatomical Characters of the Human Brain,” American Journal of Anatomy 9:1 (January 1909), 1-32; Stephen Jay Gould, The Mismeasure of Man (xxxx: Norton, 1996), 111.]

In 1909, in discussing high tuberculosis rates among blacks, the journal asserted that while enslaved, blacks “lived a healthy out-door life” and if only because of “the commercial interests of their owners they were well fed, clothed and lodged.” Since then, however, they had gravitated to the cities, where there was no one to watch over their well-being. “Their happy-go-lucky disposition has led them to ignore all principles of sanitation—even if they had an opportunity of becoming acquainted with them.” The following year, the journal published an address to the AMA’s Section on Diseases of Children delivered by a Mississippi health official on “The Negro As a Health Problem” (not “The Health Problems of Negroes”). Full of degrading observations about blacks and their lapse back into their former “aboriginal conditions” and “African condition of irresponsibility,” it asserted smugly that “the darkey,” or at least those enslaved by “the better class of slave owner,” had had been blessed with a higher standard of health before emancipation. They had received the “very best treatment” because of their enslavers’ “humane motive,” not just “economic consideration” for their expensive pieces of property.[footnoteRef:24] [24: “The National Negro Antituberculosis League,” JAMA 52:12 (March 20, 1909), 969-970; H. M. Folkes, “The Negro as a Health Problem,” JAMA 55:15 (October 18, 1910), 426.]

That such literature passed muster as suitable reading for AMA members speaks of a wide dispersion of racist attitudes in the profession, in the North as well as South. To be sure, there was very little to learn from at the time in either medical, sociological, or anthropological literature on the powerful, mutually interactive effects of political oppression and economic, social, physical, and psychological environments on differential health rates of various classes of people. At least as regards race, victim blaming remained intellectually respectable in otherwise progressive medical reform circles. Circumstantial evidence of its acceptance of racist thinking lies in the AMA journal’s failure to mention Du Bois’s The Health and Physique of the Negro American, appearing in 1906. In it, Du Bois reprinted an article by the astute young sociologist Herbert A. Miller on the overlooked environmental and related psychological causes of observed differences between races. In spite of its frequent attention to the relations between hygiene and disease, the journal called no attention to the 1906 resolutions of a recent Atlanta University Conference for the Study of Negro Problems, which declared that racial differences in mortality were best explained by “conditions of life” and that there was “no adequate scientific warrant” for the assumption that blacks were inferior to other races in “vitality.” That medical wisdom came not out of the medical profession’s top scientists and statesmen but from laymen. The resolutions were drafted by Du Bois along with Richard R. Wright, the first black to receive a doctorate in sociology (from the University of Pennsylvania), and Franz Boas, “the founding father of American anthropology,” whose later writings would make him famous for, among other things, his arguments against prevailing scientific racism.[footnoteRef:25] [25: Herbert A. Miller, “Some Psychological Considerations of the Race Problem,” in W. E. Burghardt Du Bois, ed., The Health and Physique of the Negro American (Atlanta, GA: The Atlanta University Press, 1906), 95-104; S. Adolphus Knopf, “Tuberculosis a Social Disease,” JAMA xx:xx (June 16, 1906), 1815-1824; Du Bois, ed., Health and Physique of the Negro American, 110. On his views about life conditions versus “race traits,” see Du Bois, “Review of Race Traits and Tendencies of the American Negro, by Fredrick L. Hoffman,” Annals of the American Academy of Political and Social Science 9 (January 1897), 127-33. Hoffman’s argument, which Du Bois skewered, served his employer’s interest in heading off state laws against discrimination in the insurance business.]

Although women were treated with more gentlemanly restraint as men’s inferiors in published AMA material, if not in private discussions, they too were mostly obstructed from entry into the profession and its associational life. The AMA did not demand non-discrimination by local and state societies as a condition for their incorporation. That is not to say that there was no support for women in medicine among some of the progressive medical reformers. Among them, not surprisingly, was Abraham Jacobi, elected AMA president in 1914, whose wife, Mary Putnam Jacobi, daughter of the publisher George Putnam, was a physician, medical writer, suffragist, and founder and long-term president of the Association for the Advancement of the Medical Education of Women. She was a “bright particular star in the firmament in the profession,” thought the eminent William Osler.[footnoteRef:26] Inadvertently, the progressives’ expensive education reforms also reduced the already small number of badly funded women’s medical colleges, just as they had the black ones. State governments and wealthy philanthropists channeled money to medical schools that took in very few women. Nurses’ authority and responsibilities in hospital care were suppressed and nursing education constrained. Nurse midwives—often more capable (and cleaner) than licensed male doctors—were embattled by obstetricians seeking to displace them entirely. Consequently, many more babies and mothers died than necessary, given widespread neglect in medical schools of training in obstetrics.[footnoteRef:27] [26: Abraham Jacobi, “Women Physicians in America,” in William J. Robinson, ed., Collectanea Jacobi: Contributions to Pediatrics, Volume II (New York: Critic and Guide Company, 1909), 305-314; Rhoda Truax, The Doctors Jacobi (Boston: Little, Brown, 1952), 138, 143, 178, 242 (Osler quote).] [27: Mary Roth Walsh, “Doctors Wanted: No Women Need Apply”: Sexual Barriers in the Medical Profession 1835-1925 (New Haven CT: Yale University Press, 1977); Thomas Neville Bonner, To the Ends of the Earth: Women’s Search for Education in Medicine (Cambridge MA: Harvard University Press, 1992); Abraham Jacobi, “The Best Means of Combating Infant Mortality,” JAMA 58:23 (June 8, 1912), 1744; Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800-1950 (Oxford: Clarendon Press, 1992), 322-323; Janet Brickman, “Public Health, Midwives, and Nurses, 1880-1930,” in Ellen C. Lagermann ed., Nursing History: New Perspectives, New Possibilities (New York: xxx 1983), xxxx..]

Medical reformers took no outspoken stand against “eugenics,” at the time a respectable intellectual fashion, not least among progressives. Eugenics originated as the scientific study of inherited physical and mental pathologies and degenerated into the advocacy of questionable policy measures for “race betterment.” By that they meant, by and large, strengthening the already dominant race. Those aimed to reduce the numbers of “degenerates, delinquents, and defectives” with forced sterilization, restrictive marriage licensing, and immigration controls. America hosted both its intellectual originators and many states served as international vanguards with measures like mass sterilization of institutionalized populations. Progressive era medical leaders themselves were not impervious to the influence of eugenics. Surgeons Charles and William Mayo, who both served honorary stints as AMA presidents, privately welcomed its influence. But neither lent his name to the cause, unlike pioneering bacteriologist and medical educator William H. Welch, an AMA reformer of great repute. Of course we cannot infer from Welch’s involvement any agreement with extreme eugenicist views and policy recommendations. To its credit, the AMA journal treated eugenics with a mix of diffidence and caution in its scattering of editorials and book reviews. It put more stock in improving the environment of white people, not their genetic make-up. As an editorial in 1907 put it, “if the salvation of the race depends solely on the encouragement of multiplication among desirable citizens and the discouragement or prevention of procreation among others, important as these objects appear, it seems doubtful how far it will ever be attained.”[footnoteRef:28] [28: Link, Social Ideas of American Physicians, 181, 183, and 191; “The Science of Eugenics,” JAMA 49:20 (November 16, 1907), 1681.]

THE BREAK WITH PROGRESSIVISM

Interestingly, medical historians rarely detect a great break, if any, from the era of medical progressivism, perhaps seeing the distant past through the lens of the present or recent past. Medical historian George Rosen, in his important survey of the profession from the 1870s into the 1940s, finds no political discontinuity worthy of attention. Medical historian John C. Burnham notes the activism of isolated physicians in various progressive causes, but leaves the AMA and its leaders entirely out of the picture—even in an anthology on “building the organizational society.” In his extensive survey of American physicians as social thinkers, Eugene Perry Link mentions only one AMA leader, Abraham Jacobi, as notably humanitarian.[footnoteRef:29] [29: Friedman; Kessel; George Rosen, The Structure of American Medical Practice, 1875-1941 (Philadelphia: University of Pennsylvania Press, 1983); John C. Burnham, “Medical Specialists and Movements Toward Social Control in the Progressive Era,” in Jerry Israel, ed., Building the Organizational Society Essays on Associational Activities in Modern America (New York: Free Press, 1972); Eugene Perry Link, The Social Ideas of American Physicians, 1776-1976: Studies in the Humanitarian Tradition in Medicine (London: Associated University Presses, 1992).]

To the limited extent scholars think of the organized medicine’s turn of the century politics as progressive, they usually have no more than its efforts in medical school reform for professional uplift in mind. On that, books by medical historian Kenneth Ludmerer are essential, although he actually minimizes the role of the AMA as a major source of reform momentum, which, he points out, was picking up steam well before the AMA took on the cause. As valuable and illuminating as Ludmerer’s work is, it does not put education reform into perspective as of a piece with the rest of organized medicine’s larger progressive agenda.[footnoteRef:30] On drug reform, historians have devoted limited attention to the role of organized medicine in state and federal drug reform as opposed to their lay allies, especially muckraking journalists and pioneering consumer activists. Only one historian, James Harvey Young, has examined in any detail the AMA’s important and possibly decisive political efforts on the behalf of federal drug reform. But again, Young does so without linking organized medicine’s involvement to the rest of a much larger progressive agenda. Finally, a limited number of valuable and illuminating works, for example by John Duffy and George Rosen, also bring to light important knowledge about organized medicine’s reformers in the public health arena, especially in the losing battle to create a National Department of Health. However, again, they do not put that battle into the wider medical reform context.[footnoteRef:31] [30: Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (Baltimore, MD: Johns Hopkins University Press, 1985); Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (Oxford UK: Oxford University Press, 1999).] [31: James Harvey Young, Pure Food: Securing the Federal Food and Drugs Act of 1906 (Princeton NJ: Princeton University Press, 1989); John Duffy, The Sanitarians: A History of American Public Health (Urbana IL: University of Illinois Press, 1990); George Rosen, “The Committee of One Hundred on National Health and the Campaign for a National Health Department, 1906-1912,” AJPH 62:2 (February 1972).]

Historians of public health and related issues Gerald Markowitz and David Rosner explicitly reject the idea of a radical break. They maintain that “the basic conservatism and elitism” characterizing the medical profession into the 1970s not only evolved out of but were “inherent in the reform movement” dominating medicine until the 1920s. Adopting an entirely economistic perspective, they argue that the driver of reform was a crisis-level oversupply of doctors. The reformers displayed a “near obsession” with the glut of doctors and its depressive effect on their incomes. The ultimate weapon for resolving the crisis was the reform of medical education. Markowitz and Rosner thereby cast doubt on the idea that poverty among hypercompetitive doctors was particularly severe or that doctors with up to four years of training could earn only as much as a factory worker was at all problematic. That much of the working population could be duped into paying anything at all for worthless and even dangerous clinical interventions was, they therefore assume, not a problem. “Only the physician viewed the profession as ‘overcrowded,’ for only he suffered from the surplus of competitors.” The public’s main interest lay in keeping fees low. In sum, both the reform was “conservative in both intent and effect.”[footnoteRef:32] [32: Gerald Markowitz and David Rosner, “Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine,” American Quarterly 25:1 (March 1973), 84, 91, 107; Robert Wiebe, Businessmen and Reform: A Study of the Progressive Movement (Chicago: Ivan R. Dee, 1988).]

To Markowitz and Rosner, the progressives’ medical school reform efforts against chaotic and corrupt hospital management in the name of improved undergraduate and graduate bedside training was also conservative both in principle and effect because it “concentrated power in the hands of a small elite.” The reformers were, supposedly, “centered among those in the elite eastern university medical schools” who “no doubt exaggerated the defects” of the welter of profit medical schools throughout the country. Evidence of their conservativism comes from the fact that they had capitalist allies: “Rockefeller, Carnegie and other industrialists . . . who put all their resources, material and propagandistic, behind the centralization of power and decision-making in medicine and medical education.” But in fact, as later discussion shows, a large if not disproportionate share of the most fervent school reformers were Midwesterners and Southerners like Vaughan of Michigan and Joseph N. McCormack of Kentucky. Two of the main builders of Johns Hopkins in Baltimore, Maryland were John Shaw Billings of Ohio, and William Osler, a Canadian.

Especially problematic is Markowitz’s and Rosner’s’ argument that the reform leadership and the rank-and-file worked together on education reform because the capitalist-backed elites of the medical reform movement depended on support from “the more numerous private practitioners,” specifically “the general practitioner,” who stood to gain from choking off competition, for their “clout and power.”[footnoteRef:33] But the reformers, as the chapter on the reactionary turn will show, were not concerned about rank-and-file troubles with competition over their patients. And the lower ranks did not join in the educational reform movement. Afterward, having come from many of the schools slated for destruction, many were more aggrieved than relieved by the closure of their alma maters, which turned the certificates on their office walls into potential sources of embarrassment. [33: Markowitz and Rosner, “Doctors in Crisis,” 84, 87, 107.]

Thanks almost exclusively to one author, James G. Burrow, whose two books on the AMA touch on a range of its activities during the progressive era, scholars have at least some understanding of the scope of organized medicine’s progressive agenda, if not its radical break toward conservatism. But Burrow also fails to present an integrative understanding of medical progressivism and fails to place that reformism in a larger social and political context, especially by ignoring the role of organized medicine’s many societal allies. He focuses no attention on the character, collaborations, and contributions of the many key protagonists introduced here, choosing only Joseph N. McCormack, the AMA’s indefatigable organizer, as worthy of note. But he misses a crucial fact about McCormack: the Kentuckian was a dynamic, self-sacrificing, and inventive pioneer in his state’s public health affairs, and widely admired for that all over the country by doctors and laymen alike. Finally, Burrow’s books take no appreciable notice of, much less try to explain, the AMA’s abrupt break from progressivism, neglecting to mention a radical change either in ideology or leadership.[footnoteRef:34] [34: James G. Burrow, AMA: Voice of American Medicine (Baltimore MD: The Johns Hopkins Press, 1963); James G. Burrow, Organized Medicine in the Progressive Era: The Move Toward Monopoly (Baltimore MD: Johns Hopkins University Press, 1977). ]

Thomas Bonner is one among extremely few medical historians who try to explain the AMA’s break with progressivism, but his explanation is unsatisfying. American doctors, Bonner suggests, collectively swayed because of and therefore with the winds of nationwide political change first before and then after World War I. But even if the post-war conservative climate—marked by the presidencies of Calvin Coolidge, Warren Harding, and Herbert Hoover—did influence the profession on medical matters, it would fail to account for why the medical profession swung further and more resolutely to the right than the rest of the country. For, in fact, as historian Arthur Link points out, the country’s conservative turn was only partial and uneven, unlike the AMA’s violent hard-right turn.[footnoteRef:35] Furthermore, doctors did not fall in line a third time with the nation’s next political mood swing of the 1930s. Instead of responsiveness, organized medicine dug in its heels and bent resolutely against the New Deal decade’s resurging progressivism. Why the lability before but rigidity later? [35: Thomas Neville Bonner, Medicine in Chicago, 1850-1950: A Chapter in the Social Development of a City (Urbana IL: University of Chicago Press, 1991), 213-219; Arthur S. Link, “What Happened to the Progressive Movement in the 1920's?” The American Historical Review, 64:4 (July 1959), 833-851. Rosemary Stevens …… ]

Medical historian Ronald Numbers also refers, but only in passing, to a “conservative revolution” within the medical profession. On it, he dismisses Bonner’s argument about the external political environment as the reason for the back-bench revolt against the AMA leadership for its flirtation with compulsory insurance in the 1910s. Progressive AMA leaders had spoken favorably, shortly before the reactionary turn, on efforts spearheaded by lay social reformers in a handful of states to introduce health insurance along lines similar to reforms in Germany and Britain. They thought it best to collaborate with other progressives to make sure the reform served the profession’s as well as the public’s interests. Crucially, they saw great potential to advance their public health agenda with a well-designed reform. Numbers shows that the reaction of the lower ranks in county and state medical societies toward the reformers’ collaboration with lay progressives was widespread, swift, and fierce, arguing that its intensity was due to the economic and status threats that insurance seemed to pose, not primarily ideological convictions, although xenophobic rhetoric about Imperial Germany and Soviet Russia came in handy to make their point.[footnoteRef:36] [36: Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912-1920 (Baltimore MD: Johns Hopkins University Press, 1978).]

Numbers’ excellent narrative, focused only on the insurance controversy, should not be read as a full explanation of the reactionary turn. He in fact makes no such ambitious claim, and indeed does not even describe much less try to explain what happened a full four years after the issue was dropped. Because the progressive leaders’ retreat on the issue was so hasty and complete in 1920, the episode cannot adequately explain what followed four years later: their wholesale and permanent disappearance from the organization’s leadership ranks and the headlong rush into a conservatism that would endure for decades to come. For example, Alexander Lambert, Theodore Roosevelt’s friend and personal physician, who was the most energetic proponent of compulsory insurance, disappeared from the scene entirely. So did other AMA leaders not implicated in the health insurance episode. Former AMA president Victor Vaughan suffered a humiliating demotion in 1924 and followed Lambert’s exit from national medical politics, retreating into exclusively scientific, educational, public health, and clinical pursuits. Other reformers who focused on different issues disappeared as well.

MEDICAL POWER

The most influential study of American medical politics that portrays a seamless weave of developments from the progressive era into the following conservative phase is Paul Starr’s The Social Transformation of American Medicine. According to Starr, organized medicine’s overarching purpose was to establish “physician sovereignty” before the 1920s and subsequently defend it in the face of lay forces seeking to change how health care was financed, organized, and delivered. In his largely economistic analysis, Starr depicts the profession throughout as resolutely in pursuit of monopoly income, tight and inclusive organization, autonomous professional self-regulation, elevated social status from scientifically and therefore culturally legitimated authority, and political power. It was a grand unifying strategy of supreme dominion in health care. The varying objectives had interrelated and mutually reinforcing purposes. For example, “by augmenting demand and controlling supply,” Starr writes, doctors collectively parlayed scientifically legitimated professional authority into “control of markets, organizations, and governmental policy.” Thus from 1900 on, and by the 1920s, he maintains, the profession reorganized and installed the institutional pillars of a “medical system,” from licensure and medical schooling to hospital management, which conferred nearly uncontested professional sovereignty.[footnoteRef:37] [37: Starr, Social Transformation, 8-9, 24, and 232.]

To be sure, larger humanitarian purposes crop up here and there in Starr’s narrative, though only sporadically and without reflection on their relative importance. Economic motives dominate, as in his portrayal of the push for medical licensurea as part of a general anti-competitive movement in the late 19th century of “plumbers, barbers, horseshoers, pharmacists, embalmers and sundry other groups,” just as Friedman and Stigler do. Echoing Markowitz and Rosner on the doctor glut and medical school reform, Starr suggests that the reformers’ published reports about doctors struggling to survive on proletarian incomes were “self-serving” understatements of fee earnings. It was, he maintains, solely a desire to raise the doctor’s income and status in society that motivated closing cheap medical schools that accepted working class and lower-middle class “riff raff.” The reformers believed, Starr says, that medicine would never be a respected and therefore powerful profession “until it sloughed off its coarse and common elements.”[footnoteRef:38] [38: Starr, Social Transformation, 85, 103, 116-117.]

Likewise, on the AMA’s efforts to control drug labeling and advertising of thousands of useless and dangerous drugs, Starr declares that the “logic”—implying intent as well as effect—was to “withhold information from consumers and rechannel drug purchasing through physicians,” hence giving them “a larger share of the purchasing power of their patients.” Finally, neglected in Starr’s narrative is organized medicine’s efforts to remedy gross political and institutional failure in protecting public health. Despite the centrality of public health to the AMA’s reform mission, Starr mentions only in passing its efforts to promote a National Department of Health and generally gives short shrift to the reformers’ deep and wide concerns. Indeed, according to Starr, medical leaders addressed public health with ambivalence and sometimes even hostility toward the larger public health movement because of the threat to doctors’ incomes represented by a healthier population.[footnoteRef:39] In sum, the distinct impression Starr leaves is that the medical profession’s ends achieved after the 1920s break with progressivism with the help of cultural authority and economic control were the same as their purposes for seeking that power in the first place. Later chapters will show that the purposes as well as people seeking medical power in American society in fact differed drastically. [39: Starr, Social Transformation, 133-134, 180-197.]

To be sure, Starr’s book remains in many generalities and particulars an insightful and essential study of medical politics in America, especially during organized medicine’s conservative era and the subsequent “corporate” transformation. Doctors, he says, exercised power both through persuasive and coercive means through much of the 20th century. Their persuasive power, or “legitimacy” and “cultural authority,” flowed in large part from the scientific expertise that physicians professed to apply in clinical practice. In other words, organized medicine tapped into the deep and wide-ranging if not quite universal respect for the mainstream medical profession resting on a widespread perception that its practitioners had a monopoly on high quality and clinically useful scientific knowledge, and that the knowledge was evenly distributed and expertly applied across the licensed profession. The reputation was assiduously cultivated by extensive AMA public relations activity across the country. In 1949, as the president of the New York State Medical Society put it, the profession was enjoying, as never before, a “reservoir of good will and public esteem” that could be “utilized to win support” for its position against so-called socialized medicine. Echoing him in 1953 was AMA president Louis Bauer, who boasted that “we have never been as favorably received and as favorably considered, certainly in my recollection, as we are at the present time.” Because of that, the medical profession enjoyed a commanding “strategic position.”[footnoteRef:40] [40: “Preserving Values,” NYSJM 49:18 (September 15, 1949), 2129; Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic, 1982), 13-15; “Statement of President Louis H. Bauer,” JAMA 151:14 (April 4, 1953), 1204.]

Starr argues that because of their cultural authority, doctors were able to seize and maintain coercive economic power as gatekeepers, a cartel of middlemen at the intersections of medical commerce—i.e., between their patients and third-party payers and providers like corporations and governments in their roles as insurers, employers, hospital administrators, and not least drug makers. Power flowed from other institutions’ dependence on doctors to deliver those patients to them or their goods to patients. The power flowed additionally from patients’ dependency on legally licensed doctors and therefore exclusive purchasing agents who coordinated to suppress competition among themselves as well as with third parties over patients’ business. At the profession’s collective disposal, in other words, was “the purchasing power of its patients.” In short, because “the authority to prescribe is the power to destroy,” it was also the power to control medical commerce.[footnoteRef:41] [41: Starr, Social Transformation, 24-27.]

Starr’s analysis must be faulted, however, because his two ingredients of medical power in the conservative era—cultural authority and the economic power it conveyed—are far from the whole recipe. As a later chapter will show, a third source of external power was silence, and that required the internal exercise of power to suppress debate within the medical profession and external dialogue with the public about its endemic failures in quality, cost control, and coverage in order to forestall governmental efforts to remedy them. Silence helped generate and preserve cultural authority. Open inquiry about rising costs and how much benefit they brought, for example, threatened to bring laymen like economists together with non-clinicians like epidemiologists in the public health community, and thus instigation of corrective action by insurers and governments that undermined physician sovereignty. …..Organized medicine in the conservative era suppressed such interaction, imposing a kind of implicit social contract in which society handed over absolute sovereignty to the profession for managing medical licensing, specialty certification, medical school and hospital accreditation, and control of the drug industry. The understanding was that the profession would faithfully reciprocate with a uniformly high standard of scientifically validated practice in the millions of clinical encounters that took place every day.

Because there can in fact be no such guarantee, at least without systematic monitoring, measuring, and regulation, then part of the profession’s success in creating and preserving its sovereignty lay in deception: maintaining an illusion of rapidly diffusing scientific progress in therapeutics when evidentiary foundations for the work actually done were often sorely lacking. Conservative medical power politics thus involved extending and maintaining what bioethicist Jay Katz calls a “silent world of doctor and patient” from the microcosmic clinical encounter to the macro level, creating a larger silent world of profession and society. At the micro level, the concept of informed consent, Katz argued, was “an idea alien to the ethos of medicine” in the conservative age of uncontested physician sovereignty. When outsiders to the profession broached the subject, they were met with “passive-aggressive defensiveness, acrimony, and confusion.” At stake was the power of the individual doctors over infantilized patients. Tellingly, two historians of informed consent were able to find only nine articles in the American medical literature between 1930 and 1956 touching on the issue. More important from a social power standpoint was the heading off pressure for a kind of informed consent at the collective level in order to ensure that the social contract was being fulfilled. That involved hiding deficiencies and controversies in clinical knowledge from the public eye. One doctor who chose to go public about therapeutic disorder in 1965 told of his training by chaos that was the hospital internship. It was there he learned of an unspoken yet “enforced” code of secrecy surrounding the practice of medicine: “what the layman does not know is all to the good; the work that doctors do, the way they do it, the kind of men they are and the way they become doctors must be carefully hidden from public knowledge.” But fearing collegial censure, he chose to remain anonymous, as “Doctor X.”

The code of silence helped the profession maintain power by preserving what might be called “asymmetric ignorance”—when buyers know nothing about how little sellers themselves know about the quality of the merchandise, and the seller wants to keep it that way. The conservative uses of silence were different from the progressive ear profession’s strictures on the matter of communication with the public. The profession’s first code of silence, originating in the 18th and 19th centuries, concerned advertising for patients, criticizing competitors, and publicly boasting about one’s special clinical prowess. This book suggests that silence in the progressive era served a new, mostly political purpose: to quell furious internecine battles staged before the public, thus subjecting the profession to intense ridicule and hobbling reformers politically in their efforts to win over lay elites to reform. By contrast, during the conservative period, by which time the progressive mission of improving the profession’s cultural authority had been accomplished, the code of silence served an entirely new purpose: to stifle public debate about the profession’s increasingly expensive, often dangerous, often ineffective therapeutic practices. Relatedly, it meant keeping the profession’s unhealthy financial and political conflicts of interest with the drug industry in obscurity. Exposure would only empower lay critics with facts about deficits in quality and costs to support arguments for government remedies that might threaten professional sovereignty.

Another essential addition to Starr’s recipe for medical power indicated by the findings of this book is that that the collective power of doctors, numerically a small interest group in the democratic process, requires more than cultural authority and economic clout. A fourth crucial ingredient of medical power is socio-political alliances. One of the key findings is that progressive reformers before the 1920s and the dominant conservative element afterward relied greatly on outside support for their power over events. But that support was earned from lay allies to a far greater extent because of action on shared agendas. To the extent cultural authority helped cement alliances before the reactionary it turn it was based more on preventive than clinical science. The alliance for drug regulation was cemented by shared abhorrence of commercial fraud and death by drugs rather than implementation of pharmacotherapeutic certainties, which were exceedingly scarce.

In sum, why lay allies cooperated with medical progressives on their agenda no doubt depended on organized medicine’s vividly demonstrated public mindedness, not just clinical expertise based on scientific research. Indeed, that was still in exceedingly short supply. This book therefore suggests that the cultural legitimacy of the medical profession, which empowered the conservative leadership to pursue its protectionist economic agenda after the 1920s had already been won in good part for it by an intense altruistic minority on behalf of a largely silent and inert mass public. Those reformers earned public respect with the earnest and selfless public health activism and through bruising battles with the powerful drug industry. Their measures promised, if anything, to reduce, not increase the demand for physicians and thereby actually depress their incomes. In short, the post-1920s medical politicians inherited a reserve of cultural legitimacy accumulated by their predecessors that they could then harness on behalf of things those predecessors would never have agreed with.

SHIFTING ALLIANCES AND THE ARC OF CHANGE

After examining in detail the early 20th century era of medical progressivism, this book traces an arc of change ushered in by the reactionary insurgency of the 1920s into a half century of hard conservativism. The discussions in the last four chapters show that the progressive AMA’s reform efforts and alliances with outside lay forces helped sow internal division and fueled a massive insurgency and a break with the past. An elite element in the profession was deposed from power by reactionary forces that replaced it with leaders and goals more in alignment with the perceived economic interests of the lower and middling ranks of medicine. Just as the progressives did, the new medical conservatives relied on lay allies for their power and successes, especially the pharmaceutical industry, once the AMA’s sworn enemy. It was a profound socio-political realignment, and the new balance of medico-political power would prevail for decades to come.

Starting in the late 1960s, the medical profession began to suffer a decay in its scientific legitimacy, cultural authority, and political power. The AMA’s opposition to Medicare, passed in 1965 for the retired elderly population unable to afford private insurance, tarnished the profession’s altruistic veneer by denying to a large portion of the population access to its allegedly impressive and even wondrous scientifically based services. Many doctors, not just laymen, were appalled at what they regarded as organized medicine’s crass selfishness. The AMA’s paranoiac rhetoric against compulsory health insurance appeared ridiculous in light of the fact that universal health care in Europe had not resulted in socialist dictatorships and atrocious medical care. Then, in the 1970s, a series of scandalizing newspaper stories relying on purloined documents delivered to reporters from inside the AMA’s headquarters, did more severe damage to the AMA, some of them about executives’ tawdry financial dealings by executives. Even more damaging were exposures about its illicit relations with the pharmaceutical industry and, shockingly, even the tobacco and cigarette industries.

Ultimately more devastating to the conservative medical regime than the new era of medical muckraking was the rapid rise of health care costs, starting in the 1970s and continuing beyond. Because they were picking up a large share of their workers’ health care costs, America’s employers saw themselves as major losers, especially larger ones vulnerable to intensifying international competition. With that, the most powerful element in the conservative medical alliance would start to fall away, and major employers even began casting friendly glances at using compulsory health insurance to limit the shifting of costs of health care for the uninsured onto them by doctors, hospitals, and insurance companies. Then, AMA’s economic power took a crushing blow when the market deregulation movement of the 1970s led to a ruling by the U.S. Federal Trade Commission in 1979, upheld first by the Supreme Court and then Congress, which declared that the AMA had since the 1930s been engaged in a “national conspiracy in restraint of trade” in violation of the Sherman Anti-Trust Act. The ruling put to an end organized medicine’s blacklisting from membership, and with that, hospital privileges, of doctors who defied the AMA’s ethical strictures about working in the “corporate practice of medicine.” Combined with employers’ desire to corral their workers into corporate “managed care” arrangements that could play doctors and hospitals off against each other to lower fees and save money, the FTC decision delivered the conservative medical regime a brutal blow.

A third powerful factor added to the mix to hobble the conservative medical regime by severely hollowing out what Paul Starr calls the profession’s scientific legitimacy. Out of academic medicine and public health research came astonishing and disturbing findings that there was massive waste in the delivery of expensive health care services that could only be explained by the ignorance of clinicians about what constituted efficacious practices and therefore economically valuable care. Politicians worried about Medicare’s rising demands on the federal budget and corporations trying to get their own health care costs under control took note. The dam broke on the medical profession’s self-censorship, and large numbers of influential doctors joined the chorus of lay critics of their own profession. The code of silence about the faults of medicine was broken. A new medical progressivism was on the rise, but progress was not going to be fast and easy. Organized medicine, immobilized by division and, according to the profession’s own vocal critics, riddled with conflicts of interest as part of a vast “medical industrial complex,” would not take the lead.

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