Even If Obama Passed Single Payer, Primary Care Doctors Still Wouldn’t Get It

“No, you should not sleep with your baby, you might roll over and kill her,” our primary care physician, Dr. Z, scolded us a while back. “She needs her own room, not a family bed.”

Dr. Z passed out a flyer from Michigan’s Ingham County Health Department which said as much. 1

On nighttime breastfeeding Dr. Z was equally as tart.

“It’s OK that your child screams in the night sometimes. She’s learning to be independent. You cannot always be there for her in life. She’ll learn that.”

Having read the work of anthropologist James McKenna (no immediate relation), we firmly rejected Dr. Z’s nostrums. McKenna directs Notre Dame’s Mother-Baby Behavioral Sleep Lab and has spent a lifetime as an applied anthropologist challenging biomedical orthodoxy on this issue. He’s appeared on major media outlets as a learned scientist pointing out co-sleeping’s enormous benefits to both mother and child.

McKenna presents evidence, for example, that sleeping alone may actually increase Sudden Infant Death Syndrome (SIDS), while co-sleeping may help protect against it. The title of one of his articles captures his advocacy approach: “Goodnight Nobody? 100 Years of Medical Misrepresentations of Healthy Infant Sleep Behavior and Arrangements: Why We Never Asked, Is It Safe For Infants To Sleep Alone (McKenna 2000).

“Did you know that co-sleeping is preferred across the world?” I told Dr. Z.

“Mr. McKenna,” Dr. Z stared sternly at me, “When will you join America??

What sector of America do we join?

America is coming apart at the seams. Michigan, where I live, has an official unemployment rate of 15.1%, the highest in the nation. Many of Dr. Z’s doctor colleagues have already voted against Michigan’s version of America with their feet. Today Michigan is a physician “export state” because a great many freshly minted medical students choose to relocate to “states with stronger economies and better climates (Farquhar, L. J. 2007).”

Sociologist Zygmunt Bauman has recently written a series of books that describes our “Liquid Life” and “Liquid Times.” By liquid he elaborates Marx’s idea that under capitalism, “all that is solid melts into air.” Bauman describes our current culture as moving from a solid to liquid phase in which social forms can no longer keep their shape for long, leaving us unable to keep up with change. This is made worse by the “gradual yet consistent withdrawal or curtailment of communal, state-endorsed insurance against individual failure and ill fortune [which] deprives collective action of much of its past attraction and saps the social foundations of social solidarity.” According to Bauman, “this promotes division, not unity; it puts a premium on competitive attitudes, while degrading. . .team work to the rank of temporary strategems that need to be. . .terminated the moment their benefits have been used up (Bauman 2007:2-3).”

Simply put, we are in need of communal care now more than ever.

Doctors call themselves primary caregivers. Are they fitting the bill?

Liquid Doctors are Drowning Us

Let’s be frank. The primary causes of preventable illness, injury and disease – capitalist social relations – need to become the “primary cares” of medicine. The Alma Ata Declaration of 1978, for all its imperfections, came close to implying as much.

As David Sanders, MD, argued long ago, the fundamental causes of ill health are out of the control of [the biomedical profession], and “indeed, any open recognition of the real causes would call into question the very system that allows [medical professionals] to own and market their commodity (Sanders p. 117).”

The family bed/breastfeeding tale, above, is one of three powerful vignettes that challenge “primary care” doctoring. Below are two more. I gathered these tales during my six year ethnography of medical education in Michigan.

Food is an essential element of all three stories. That is as it should be. David Hollister, the former Mayor of Lansing, told Michigan State University’s medical school officials and students that they practiced “cookbook medicine” at a public forum. “You produce social workers with prescription pads,” he said. In fact the doctor-cooks are mostly influenced by natural scientists like biologists (that’s why they call it biomedicine) not social scientists like anthropologists. The resulting food concoctions are usually not very nutritious.

Psst. . . .Don’t Tell my Doctor!

As an anthropologist investigating community health problems, I was unprepared for the stories of suffering that often be fell local folk.

Sitting on an examination table in a ruffled blue sweater, Carol Neal complained of a backache that kept her in constant pain. The harsh rural Midwestern winter had been rough on the elderly widow. During one long snowy stretch she did not venture out to the grocery store for six weeks. This alarmed her doctor who expressed concern about her poor diet and deteriorating case of diabetes. But it was not the diabetes that concerned Neal as much as her loneliness.

“Neal’s the norm,” her physician later informed me, “most patients here present with multiple chronic conditions.” As part of her treatment, the doctor, an osteopath, gave Neal some drugs including a hypertension medication and Tylenol-3 with codeine, marketing samples from a pharmaceutical company. These were much appreciated by Neal, whose health insurance, Medicare, did not cover prescriptions. The physician also gave Neal an educational brochure on diabetes, prescribing a 2,100 calorie per day diet. The doctor had a gentle manner but, under time constraints, soon hurried off to her next 15-minute clinic encounter, grateful that I would be spending time with her patient.

After the doctor left, Neal “confessed” that her “sweet tooth” prevented her from follow ing the recommended diet. Almost as proof, she invited me over for some homemade mince pie.

Neal seemed eager to have someone listen to her troubles and welcomed the chance to share details of her life story. Her story was indeed one of suffering. Years ago her husband had lost both arms in a chain saw accident and he had recently died. She had lost a middle-aged son to can cer and a brother to a tractor accident. “He was pulling up stumps for firewood and the wheels ran over him.” Neal’s three other children had long ago left for distant parts of the country. In 1979, the wiring company where she worked moved south to Missis sippi. In the ensuing months she had sought mental health counseling but found that she could not afford it. She had been unemployed since then. Her husband, near the end of his life, had “found the Lord” but Neal found his proselytizing difficult to handle. “I’d rather he’d have been an alcoholic,” she said.

Neal told none this to her physician. But behind the clinical constructions of “presenting complaints” was a world of struggle that went unelicited, unattended, and untreated.

Triple Shift Work as a Primary Caregiver. . .for Pennies on the Dollar!

It was 8:30 on a summer morning and Mrs. Beck had been waiting in the clinic for nearly an hour to be seen. When I opened the door, she jumped off the examining table and ex claimed, “Are my lights on?”

“What?” I said.

“My car, are my lights on? I’ve been in here so long and if I left my lights on my battery will be dead.”

She asked a nurse if it was OK, then scurried out into the parking lot. When she returned we talked. She was there for a diabetes check and a hypertension check. A nurse’s aide entered briefly for testing and discovered that Mrs. Beck had high blood pres sure and very high sugar levels.

I asked Mrs. Beck about her work and family. She told me that she was a nursing home caregiver and educator and had just, within the hour, completed a double shift of 16 hours. She boasted that she had 27 grandkids and said that seven of them lived with her since her own children could not afford to take care of them all. She was in a hurry to get home to make them breakfast. She had come in for treat ment, she said, because she was planning to travel to Denver to be with another grand child for her one-week vacation. She told me, proudly, that she had never been a Medi caid recipient. “I’ve always paid my own way.”

The primary care provider, a third-year osteopathic student learning the trade, entered, took a brief history, left, consulted with her preceptors in an adjacent room, and then returned and gave Mrs. Beck some scripts and verbal instructions about diet and exercise. “I always try to do the preventive piece,” she said, “But I don’t always know if they’re listening. When she returns, we’ll probably do a stress test on her.”

After speaking with Mrs. Beck, I had a better appreciation for why she felt her lights were on and feared her battery was dead. If her story was true, her lights were working overtime and her battery needed recharging. You see, from a cultural perspective, it wasn’t the doctors doing primary care medicine so much as Mrs. Beck herself. She was a primary caregiver par excellence, 24 hours per day, attending to the elderly and her kin.

In this barren biomedical context, it was not a surprise that Mrs. Beck, echoing the dominant discourse of microbiology and self-responsibility, told me that she wanted desperately to improve her diet but that good food was one of her only indul gences. Just like Mrs. Neal.

Change Your Lifestyle or Die: It’s Your Fault, Anyway

Medical doctors tell us to change the things we can and so inculcate a besieged population to become engrossed in lowering their weight, spotting the 7 warning signs of cancer, lowing high blood pressure and high cholesterol, practicing safe sex and so on. But while important, these are largely displacements which are “largely unconnected to the genuine source of anxiety (Bauman 2007:12).” And yet the constant worry about these bodily concerns, reinforced by the medical establishment, propels the already fear-obsessed culture to intolerable ends.

In all honesty, how enduring is a doctor’s so-called “primary care?” The areas where Mrs. Neal and Beck live are still classified as physician shortage areas. Mrs. Neal and Mrs. Beck were left behind. Do we also isolate our infants to wail alone in a distant night room? Are these two dynamics related?

In this context we need a radical rethinking of “primary care.” Deeper, we need a medical revolution that replaces biomedicine with a new form of critical social medicine, a movement still in its birth throws. That movement demands the end of capitalism.

One tactic in this long-term battle is to take back the referent “primary care” from the medical-industrial complex.

The Original “Primary Care”

In fact, mothers have been the primary caregivers since the dawn of our species. There is a straight line linking the co-sleepers and infant milk drinkers from our mammalian/primate ancestors 60 million years ago through the Australopithecines and up to Homo Sapiens today. Sharing and communal living are biocultural imperatives.

A new book “Finding our Tongues,” (2009) by anthropologist Dean Falk underscores the historical importance of the primary relationship between mother and child. Falk argues that “Motherese,” or baby talk likely was the basis for human language itself. He posits that baby talk developed as a way to reassure babies that everything was fine as their mothers were occupied nearby. In other words, if ancient proto-allopathic doctors had gained hegemony earlier in our species history, we might never have learned to talk!

Another new book reinforces the significance of the family meal. In Catching Fire: How Cooking Made us Human (2009), anthropologist Richard Wrangham argues that the shift from raw to cooked food was the decisive factor in human evolution. He makes a case that cooking became a basis for pair bonding and marriage as time formerly spent chewing raw food could now be used to tend camp. In other words, the family meal fostered the cementing of social ties and primary care relationships in our species.

Bauman argues that “in a liquid, fast-flowing and unpredictable setting we need firm and reliable ties of friendship and mutual trust more than ever (Bauman 2005:108).”

Co-sleeping and the slow food movement, embodied in the daily family meal, are two modes to build this trust. As such, they are important forms of cultural resistance.

That means that Mrs. Neal needs societal help providing the infrastructure to share meals (and her mince pie) with others on a daily basis. Similarly, Mrs. Beck needs assistance with meal preparation for her grandkids. Moreover Beck needs a thirty hour work week with substantial pay (on par with professionals) and humane benefits. And the culture needs to reward mothers (and fathers) with their essential duties of primary caregiving by releasing them of formal work obligations for a year or more after giving birth (as in some European countries). Pay the real (the most important) primary caregivers. This drive towards social sanity and equality will create a healthier world.

The family bed and its corollary, the family meal, send very important cultural messages. We’re all in this together. I’ll always be there for you. I give you my heart.

That’s something you can’t get from a doctor’s cookbook.

BRIAN McKENNA lives in Michigan. He can be reached at: mckenna193@aol.com

Endnote 1. I later worked for that same health department and whistleblew against them for their environmental health falsehoods and deceptions, see McKenna: PEER 2001.


Bauman Zygmunt (2001) The Individualized Society. Oxford:Blackwell.
—- (2005) Liquid Life. Cambridge:Polity.
—- (2007) Liquid Times, Living in an Age of Uncertainty. Cambridge:Polity.

Falk, Dean (2009) Finding our Tongues, Mothers, Infants, and the Origins of Language. Boulder:Perseus.

Farquhar, L. J. (2007) Michigan’s Physician Shortfall and Resulting Advocacy Efforts. Institute for Health Care Studies, MSU: East Lansing.

McKenna, Brian (1998) Articulations and Contests between Biomedicine and Community in a University-Based Primary Health Care Education Project in a Midwestern U.S. State. Ph.D. Thesis. Michigan State University.
—- (2001) Ingham County, MI, A Story of Suppression: The Story of Water Resources at Work. Public Employees for Environmental Responsibility, Washington DC.

See: http://www.peer.org/docs/mi/Ingham_co_water.pdf

McKenna, James (2000) Goodnight Nobody? 100 Years of Medical Misrepresentations of Healthy Infant Sleep Behavior and Arrangements: Why We Never Asked, Is It Safe For Infants To Sleep Alone. See: http://www.nd.edu/~jmckenn1/lab/articles/Goodnight%20Nobody.rtf

See also the Mother-Baby Sleep Behavior Laboratory website at: http://www.nd.edu/~jmckenn1/lab/

Sanders, David (1985) The Struggle for Health. London: MacMillan.

Wrangham, Richard (2009) Catching Fire: How Cooking Made us Human. Boulder:Perseus.

Note: A version of this article was published in the Society for Applied Anthropology Newsletter, November 2009 edition, Tim Wallace, Editor. See: http://www.sfaa.net/newsletter/nov09nl.pdf

Brian McKenna is an anthropologist who teaches at the University of Michigan-Dearborn and can be reached at mckenna193@aol.com