“If the structure does not permit dialogue the structure must be changed.”
— Paulo Freire
I begin by sharing an excerpt from a stunning speech by Leon Eisenberg, MD, in which he spoke truth to power before approximately 300 medical students, educators and administrators at Michigan State University. Here is Eisenberg:
“Like the ancient Greeks there will soon be two types of doctors, slave doctors and free doctors. Which will it be for you?”
Slave doctors are those who dutifully marched to the orders of bean counters and bureaucrats, practicing “cookbook medicine,” seeing 40 patients a day, Eisenberg said. Free doctors placed people’s humanity front and center. He explained they fully understood the dictum that, “medicine is a social science, politics by other means, and politics nothing but medicine on a grand scale,” a phrase uttered by the 19th century socialist, Dr. Rudolph Virchow, he said.
Eisenberg cited Virchow as one of his medical heroes, and then, echoing his hero, delivered a lecture that accused the medical profession of fostering a “hidden curriculum” which socialized students to keep quiet in the face of unethical behavior.
The audience, and I, sat there frozen.
“Four out of five medical students witness unethical practices among their peers, but most find themselves afraid to challenge behavior which they privately deplored,” he told us. Eisenberg described biomedical education as a system of “cultural indoctrination” in which “the first year student is reluctant [to speak out],” against injustice while the third year student does not even hear [about] it.” He said that this socialization experience helps to create conservative medical providers. “Courage and morality,” he said, “atrophy with misuse.”
I recorded Eisenberg’s words in the final months of my ethnography (1992-1998) of medical education at MSU (McKenna, 1998, 2010). It was the first time in five years of research that I’d heard anyone in my fieldwork mention Virchow’s name, a name I knew very well. So rare were the truths he spoke that day, so unexpected, that they deserve close scrutiny. In fact, my anthropological study of medical education, presented below, corroborates the essence of his statements, and more. As I was to discover, sustained critical dialogue about social problems and the politics of medicine is seldom permitted in medical “education” curricula.
One might think that such a spectacular project would have had quite an impact on the medical schools (there were two medical schools at MSU, an allopathic and an osteopathic). But today if you ask around the campus, it’s as though the $6 million C/UHP never existed!
A great many of the culture’s brightest young people, desperate for secure futures while wanting to do good, are turning to medicine. What is going on in that “black box” of medical schooling?
The “Unbecoming Hubris” of Medical Education
Medical education has not changed much since Abraham Flexner’s Report to the Rockefeller Foundation in 1910. Flexner’s work resulted in the growth of so-called scientific medicine in the model of John Hopkins University. Since then there have arisen many movements to challenge its dominance. One, the 1978 Alma Ata movement, can be viewed as “a rejuvenation of the concerns of social theorists of the last Century (Virchow et al.) that were undermined both by political forces and by the bacteriological emphasis of the late nineteenth and early twentieth centuries (Heggenhougen, 1993:214).”
In 1961, Dr. Kerr White initiated a form of medicine in this tradition. White adopted a population-based, ecological perspective on primary care practice. He argued that it was the social responsibility of medical education to reorient itself to the actual and perceived health needs of a given population. White called for “the full range of cultural and social diversity” in the academy. He included the disciplines of epidemiology, economics, demography, statistics, cultural anthropology, sociology, and social psychology (White, 1991:970).
But 30 years later, in 1991, White concluded that medical educators had essentially failed in this mission (White, 1991), with physicians “providing little insight into the nature of needed changes” (White, 1991:968). “Too often,” White said, “[medical academics] are mired in unhelpful rhetoric, unbecoming hubris, and reliance on an outmoded biomedical paradigm that ignores social, environmental, and psychological influences on health and health care.”
It was at this point, in 1992 that I joined Michigan’s $6 million Community/University Health Partnerships (C/UHP) project as a medical education evaluator. It was part of a larger $47.5 million effort, underwritten by the W. K. Kellogg Foundation, called Community Partnerships in Health Professions Education (CP/HPE). It took place in seven U.S. states (Massachusetts, West Virginia, Georgia, Texas, Tennessee, Hawaii, and Michigan). Each of the seven projects received about $6 million. Our site project, was based at Michigan State University and three associated communities in Saginaw, Houghton Lake/Alpena/Roscommon and Muskegon.
On paper the project was quite radical. The mission was to create community-oriented primary care professionals who courageously challenged biomedicine’s orientation towards specialization, curative care, professional rivalry, and hospital-based medical education. Remarkably, local communities were to be empowered to shape and create the medical curriculum.
From an international perspective, the demand for community participation in health was not new. By the 1950s government administrators across the world came to the conclusion that the hospital approach to health care had largely failed (Coreil and Mull, 1990). By the late 1970s, Mull (1990:30) reports that “health leaders were ready for an entirely new approach, and were galvanized by the social justice ethic implicit in the drive for ‘Health for all by the Year 2000.’” As a result, in 1978, an international assembly of representatives from over 130 WHO member countries and 60 international agencies met in the Soviet Union to codify this new understanding in a document called the Alma Ata Declaration, named after the location of the conference. The Alma Ata Accord was approved unanimously.
Among its eight essential planks were: education concerning prevailing health problems and the measures of preventing and controlling them; provision of adequate food supply and proper nutrition and community participation in health. The authors of the declaration drew inspiration from China, Cuba, Tanzania, and the Kerala State in India in order to indicate that high levels of health and social development could be accomplished by a strong political commitment to policies based not on economic growth but on equity (Asthana, 1994:182). The Alma Ata document said that community participation was an important index of “political will” because the program challenged governments to involve common citizens in assessing their locally felt health needs, defining problems, setting priorities, and helping to implement and evaluate the success of health programs (Coreil and Mull, 1990; Asthana, 1994).
However, calls for community participation in health and development contained an inherent potential for stimulating radical political transformation among the rural poor. Heggenhougen states that “in any hierarchical and non-egalitarian society PHC efforts . . . will be repressed when they begin to succeed, since success of necessity implies an attack on existing socio-political and economic structures” (Heggenhougen, 1984:217). The Guatemalan government’s response to the Alma Ata community participation program was to murder some of the health workers (Heggenhougen, 1984; Green, 1989).
So, what happened in Michigan?
Can Doctors Heal Themselves?
One way that the medical schools and university dealt with the Kellogg Foundation challenge was to use stall and delay tactics. They argued that accreditation standards prevented them from being interdisciplinary or listening to citizens. They said that it was too difficult to implement because no one had ever done anything like this before. So slow was C/UHP development that Kellogg was rumored to have privately threatened to withhold money from MSU in September 1994. The MSU project then hired its fifth project director to get things in order. The medical schools were pressured to establish more community boards and hire independent “regional managers” in the three distant communities to run them.
Soon after she was hired one regional manager said, “We saw that the universities would not implement one zillionth of a change. They were satisfied with just didactic education; we wanted multi-professional clinical education as well. I said that if you’re going to spend $6 million dollars, it’s not enough to change just two percent of the curriculum.” When the regional managers began acting, all hell broke loose.
Without warning, two years into the project, 21 allopathic medical students signed a petition to protest their “forced” participation in the C/UHP program. They viewed the program as an “add on” that would interfere with their “real education.” In their petition, students quoted lines from their student handbook that apparently gave them the right to refuse participation in any program that would interfere with their education.
“We’ve had all this before, in the first two years of medical education,” one student told me. “The community is not my client,” another angrily charged. “The client is my client. That’s public health, not us; that’s social work, not us. The Kellogg Foundation project is a waste of my time. We’ve been told that the money’s been sopped up by administrators and deans. Don’t waste our time with this, give us scribe notes.”
The students had received no orientation by their college and were under a number of misconceptions about the project. Regional managers believed that students were required to participate in the program, as the grant indicated. The allopathic college conceded to student demands, permitting them leave the program if they so desired. Eleven chose to do so.
As a process evaluator, I carefully informed the regional managers (who had formed an alliance) about the relevant work of Paulo Freire and John McKnight (discussed below) and suggested they find a way to implement them in their work. This was to have telling consequences.
Disguise the Community Curriculum?
Soon afterwards, in an unusual move, the fifth C/UHP project director visited the regional managers as they were forging an “ad hoc community curriculum.” He indicated that he thought their efforts were inadvisable. “But medical students see themselves as poor in basic knowledge,” he protested, “They don’t like epidemiology and statistics. Students want new knowledge. They are consumed by it. They feel almost paranoid by anything that takes them away from it. It is sort of losing ground. What about disguising these objectives in clinical experiences?”
The suggestion to “disguise” the community curriculum angered the Regional Managers. Marginalized by the medical schools, frustration was growing. The single working-class representative on a community board charged that MSU followed “the golden rule, those with the gold rule.” He said, “MSU came in, hugged the community, went to the Kellogg Foundation and got the money, then took off. Then they looked back and saw the community behind. . . . [After much pressure] MSU went back to the community and formed the regional community board.”
Muskegon’s Region’s Manager planned a two-hour seminar, “Poverty and Health” which nursing students and MSU osteopathic students attended. One of the speakers was an elderly African American osteopathic physician, James Church, (pseudonym), who spoke favorably of a country that he had recently visited that had a strong health policy: Cuba. Church said that though they were experiencing economic trouble, Cuba “has not cut down on their medical care or their educational system.” Health providers there were “more accessible and less elitist” than U.S. medical workers. He advocated Cuba’s governmental programs as a model for the U.S. Church described the Cuban system as a neighborhood-based model that did not segment the population into different plans by class and was thus more accommodating to local people than U.S. medicine.
After his talk Church opened a box at the podium and hurriedly distributed scores of green and white colored pamphlets by a group called the National Organization for an American Revolution. They were titled, “A New Outlook on You, on Me, On Health” (See Boggs, 2008). They were reprints from 1975. The 55-page pamphlet said that “the present system is based upon maintaining the monopoly of the medical profession in health care.” Students gobbled them up. They had been long searching for leadership like this.
“Managed Care” Replaces “Primary Care”
Meanwhile, back on campus, within the C/UHP’s suite of University offices, a new health policy organization made preparations to take over some C/UHP space, as I was shocked to discover one day. At the doorway to project headquarters, the new group’s signage was hammered into a position above the Partnerships signage, symbolically supplanting project’s dominance in the office space. The new organization would operate a parallel program with no formal linkages to the C/UHP. The new sign read, “Institute for Managed Care.”
Medical educators, including C/UHP affiliated doctors and administrators, would go on to attend five splashy managed care seminars to prepare for “the new practice environment.” I attended them all. The C/UHP was never mentioned, nor were C/UHP community members invited. The Institute was established from a $1 million grant from a local insurance company. Increasingly in the project the metaphor of “parallel play” became commonplace within the medical schools as they worked on their exclusive curricula.
Unmasking Deeper Medical Contradictions
In their continued search for alternative medical curricula, the three regional managers were soon drawn to John McKnight, a biomedical critic and health activist who had authored a widely acclaimed work in 1995, “The Careless Society, Community and its Counterfeits”, in which he criticized medicine’s “tendency to convert citizens into clients and producers into consumers.” McKnight was friendly with two of biomedicine’s fiercest critics: Ivan Illich and Robert Mendelson (author of “Confessions of a Medical Heretic,” 1979).
McKnight would soon become a touchstone for a countervailing movement in the Saginaw region. They secured him as a consultant in 1997. As an evaluator, I built on this internal font of resistance in the C/UHP by highlighting attention on McKnight in various internal publications and forums. Ultimately, these developments were marginalized or ignored by C/UHP administrators who, when pressed, said they were constrained by accreditation standards from exploring “creative curricula.”
“Creative curricula” was the topic of Eisenberg’s 1997 speech before these same individuals. He suggested that the new Surgeon General issue a warning announcing that, “managed care is dangerous to your health” and warned that physicians were being proletarianized [micromanaged and deskilled] by corporate capital.
In the question and answer session that followed his talk, there was a very interesting exchange.
A student asked Eisenberg, “Do medical schools have any obligation to train doctors in relation to nurses?”
“If you know how much nurse practitioners do and how they can expand care, clearly yes,” he said. “Train them side by side. Why not do it?”
“But won’t the increased awareness of the income differential be problematic?” the student continued.
“What are you a communist?” Eisenberg retorted half-jokingly (for Eisenberg clearly had a socialist orientation). He then added, “side by side is not the same as the same education.”
The audience was speckled with numerous C/UHP veterans, including the allopathic dean, curriculum administrators, and affiliated faculty and students, but nobody mentioned the Community/University Health Partnerships program that at that very moment (and for the previous six years) was attempting to train doctors and nurse practitioners side by side. I noted also how the word “communist” was bandied about in reference to a training program that mirrored, in intent, the invisible Community/University Health Partnerships project.
Eisenberg’s address occurred at a ceremony to honor the maverick pediatrician Andrew Hunt, MD, the first Dean of Human Medicine at Michigan State University in the 1960s and 70s. Sitting in the front row, spry and tall at 81, was Hunt. The fact that Hunt was alive to witness this event was a vindication of enormous import as will become clear.
Recovering the Hidden History
Towards the end of the project C/UHP officials were dramatically brought to task in a very embarrassing incident. On September 24th, 1998 the Institute for Managed Care organized a conference titled, “Partnerships in Health Professions Education.” The keynote speaker hailed from Harvard and spoke of the importance of integrating clinical preventive services with “managed care.” At one point in his talk, he highlighted what he believed to be the major medical reform commissions and efforts at forging health partnerships within the past 10 to 15 years. He cited five of them. Amazingly every major health policy foundation in the country, like Pew and Robert Wood Johnson, was discussed, except one: the Kellogg Foundation.
Sitting in the audience was a top administrator from the Kellogg Foundation, who, at the completion of the talk, quickly raised her arm to speak. “I noticed in your discussion of the major medical reform studies, that you did not mention the Kellogg Foundation. Was there any reason for that omission?”
The speaker, caught off guard, said that the Kellogg Foundation did very important work, and that he simply couldn’t include everybody. It was just an honest oversight. The Kellogg administrator responded angrily: “The Kellogg Foundation spent nearly $50 million to finance health partnership programs across the country. This university received $6 million for one of them. So, to what extent is the university learning from our expenditures. Could you discuss this?”
Many C/UHP veterans at my table glanced nervously at one another wondering who would respond. After a long silence, an allopathic administrator slowly rose to speak. She paid homage to the Kellogg Foundation in her remarks and mentioned the “service learning” program in the Saginaw region. But at the end of her statement, she dismissed the C/UHP, saying that the foundation monies were insufficient for the larger purposes. “The world is moving too fast for a ‘bolus’ approach to curriculum change.”
A “bolus,” is a soft mass of chewed food passing rapidly through the digestive tract, I later learned.
From Medical Doubletalk to Inverted Totalitarianism
“Any situation in which some men prevent others from engaging in the process of inquiry is one of violence.”
Paulo Freire, Pedagogy of the Oppressed, p. 73
I’ve waited a dozen years to publish this study in an academic journal. A short editorial on it was published in a British journal (McKenna, 2010), but this is the first full exposition of the case study, aside from the dissertation (1998). What was lost by timeliness was gained by insight. As I was originally preparing to publish an earlier version of this article, a decade ago, I was taken aback when I discovered that it might be very dangerous to publicly call the C/UHP project a failure. When Dr. Andrew Hogan, a high level CP/HPE participant, a medical evaluator with tenure based at Michigan State University, attempted to tell the truth about failures of the CP/HPE project in 1998, he was charged with unacceptable research practices by MSU. Hogan had found that the $47.5 million project was not cost effective as had been publically asserted. Specifically he found that the nearly $107 million spent (in Kellogg Foundation and matching dollars) “had been expended to influence fewer than 3,000 students and there was no evidence of significantly increased choice of a primary care specialty (Hogan, 2001:1).”
As a result of his whistleblowing, Dr. Hogan suffered for years even though he was tenured. He later wrote about this publicly in the local newspaper, the Lansing State Journal in an article titled, “MSU suppresses unflattering views of research efforts” underlining the point that “whistleblowers are almost the only source of research misconduct. The public has no way to assure the integrity of the research it sponsors and no way to protect those who blow the whistle on research misconduct (Hogan, 2003).”
One year later, in a spectacular reinforcement of Hogan’s charges, Michigan State University’s Intellectual Integrity Officer and Assistant Vice President for Research Ethics and Standards, Dr. David Wright, publicly resigned. Wright specifically cited MSU’s College of Human Medicine whose “proposals . . . a large portion of the faculty view as secretive in development, ill-considered and highly objectionable (Wright 2004).” He charged that MSU was a university awash in secrecy and as a result, “an institution in persistent decline,” and “in serious difficulty (Wright, 2004:7).”
My dissertation provided a wealth of evidence to support these claims. Indeed, after hearing Eisenberg’s speech in honor of Dean Hunt, I made an astounding library find about Hunt. I discovered that in 1990, Hunt, then 74 and retired from MSU, wrote a scathing critique of his profession. In the frank text, titled, “Medical Education, Accreditation and the Nation’s Health, Reflections of an Atypical Dean,” he recounted the social forces that resulted in “a compromise of principle” at MSU. Biopsychosocial explanations were often treated as “temporary hypotheses . . . until the ‘real’ explanation comes along (Hunt 1990:51).” “Without consideration of humanistic and ethical considerations, [medicine] can be brutal and inhumane (Hunt, 1990:149).”
Hunt’s anger led him to suggest that an anti-trust suit might be the appropriate response. “While not “illegal” in the usual sense of the word, under the Sherman Act there is apparently an element of illegality. It seems conceivable that significant changes in medical school accreditation policies could emerge as a result of legal pressures. (Hunt, 1990:137).
A Medical Revolution? Social Amnesia Today at the Med Schools
Gaventa argued that the evocation of power has as much to do with preventing decisions as with bringing them about. Gaventa would likely view the C/UHP project as illustrative of all three dimensions of power that he uncovered in his portrait of self-interested Appalachian mine owners: 1) people were excluded from decision making power, 2) issues were avoided or suppressed, and 3) the oppressed’s interests went largely unrecognized.
In 1999 the historian Kenneth Ludmerer wrote an accomplished history of U.S. medical education titled “Time to Heal, American Medical Education from the Turn of the Century to the Era of Managed Care (Ludmerer, 1999). His conclusions reinforce my own. Ludmerer charged that in the 1990s “medical education started to become more tangential to medical practice.”
“What was notable,” he said, “was the absence of leadership of the nation’s medical faculty in the debate over quality.” Ludmerer asserted that “in the closing years of the twentieth century, as the public became more and more anxious about the quality of care under managed care, little was heard from medical school leaders on the subject. As Jerome P. Kassirer, editor –in-chief of the New England Journal of Medicine, observed, the air was filled with a ‘strained silence’ on the issue (Ludmerer, 1999:386).” Ludmerer concluded his work with these stern words, “Rather than challenge the more questionable medical practices of HMOs, most academic health centers reacted to managed care as a fait accompli and worked mainly to position their institutions to survive within the new marketplace – even adopting high physician ‘productivity’ requirements for their own faculty so they could better compete for managed care contracts. Academic medicine continued to speak of its unique altruistic and social mission. However, its actions suggested the primacy of self-interest (Ludmerer, 1999:386).
In other words, power (institutional self-reproduction and appeasement to higher powers) was – and continues to be – medical education’s “primary care.”
Gaventa noted that, “Freire’s notions provide useful insights into the relationships of power and participation . . . in situations of oppression the powerful try to prevent any real participation of the powerless, for non-participation serves to preclude ‘conscientization’” (Gaventa, 1980:209).
That describes my project, the C/UHP, evidently a project of oppression.
The medical schools succeeded in preventing any real community participation in the C/UHP even while claiming tremendous victory in doing so.
Today Michigan is a physician “export state” because too many doctors choose to relocate to “states with stronger economies and better climates.” By 2012, fourteen years after the C/UHP was laid to rest, Michigan State medical schools had failed, as per the $6 million C/UHP mission, to avert a primary care delivery crises in some of the associated C/UHP communities (like Alpena County, still a Health Professions Shortage Area). In response the colleges (osteopathic and allopathic) are increasing their class sizes and asking the state for much more public money in the form of Medicaid and Medicare reimbursements (that pays for education) as well as student loan repayment incentives for those willing to serve in physician shortage areas like the ones targeted by the C/UHP 2 decades ago. The lessons learned from Hunt and the C/UHP are not much in evidence
In the end times of the C/UHP, I consulted my key informant, a physician who chose the pseudonym Hephaestus, the Greek god of fire and metalworking. On the medical faculty for 25 years by 1996, Hephaestus orally relayed the following, “The only way to reform medicine is by revolution and if there is a catastrophic economic collapse. . . . Medicine is not concerned with the truth, but with its own aggrandizement. Our civilization is no better than Rwanda [where hundreds of thousands died in ethnic violence]. Civilization is the thinnest of veneers. . . . The provision of medical care is a socially acceptable but unconscious payoff for the depersonalization processes associated with an industrialized social structure. You have to mollify the mob somehow. The Roman Coliseum is fun and games. It’s Circus Maximus. Keep the mob in its place. As Nietzsche said, ‘Insanity in individuals is rare, in nations, epochs and eras it is the rule.’”
Incredibly, I soon found myself in the same situation as Dr. Hogan, when, in September 2001 I became a whistleblower myself. As Coordinator and lead researcher for the Ingham County Environmental Health and Improvement Project (1998-2001), after painstakingly uncovering a great deal of environmental hazards in Greater Lansing’s air, water, land and food, the government suppressed the first 130 page study (McKenna, 2001, 2010). The Kellogg Foundation was also a funder of the Health Department at the time. Subsequently we had the work released by a national whistleblower group named Public Employees for Environmental Responsibility (PEER). The medical schools were silent on the issue even though it drew much media attention. I won the environmental achievement award from The Ecology Center for this work. Unexpectedly, I was invited to become the weekly “Health and Environment” journalist for Lansing’s City Pulse (2001-2002) where I went on to write 44 columns on a wide array of social medicine topics that were largely ignored by the medical schools. In some cases, the medical schools and MSU were responsible for supporting corporate pollution and I reported on that locally (McKenna, 2002, McKenna 2010b).
Secrets from the House of Medicine
“The two most fundamental determinants of health are the relationship of people to the earth on which they stand and to the community to which they move.”
Carroll Berhorst, M.D.1922-1990
Today’s medical diagnosis is bleak. The sequelae of trauma from neoliberal capitalist policies leave millions people in the U.S. sick, injured or dead needlessly. Gross inequality, social isolation and alienation are endemic. It is not Virchow’s revolutionary movement, but an authoritarian movement that dominates our age.
The question we must ask ourselves, as the principle funders of medical education and graduate medical education through our fees and tax dollars, is why do we, as citizens, permit this to be so in a democracy? Why do we permit the very conservative Liaison Committee on Medical Education (LCME), the hierarchical culture of biomedicine and neoliberal university administrations to have hegemony over a form of education that severely and unnecessarily harms us through its restrictive ideologies, piecemeal practices and close alliances with corporate capital?
In 2002, a key informant, a local politician, exclaimed to me in the midst of a conflict between Lansing and General Motors, “Don’t you know, Brian, this is a company town?” I wrote about his remarks and the GM pollution (in which MSU and the Ingham County Health Department sided with General Motors, and in which the medical schools were silent) in several columns as a local journalist (McKenna, 2002a, 2002b). This conception has led me to diagnose Greater Lansing as a new-style company town, the subject of a larger, ongoing work.
Medical education refuses Berhorst’s mission. It is under siege from the “terror of neoliberalism” (Giroux, 2004; Wolin, 2008), a cultural wave that thwarts a fair and honest assessment of the causes of ill health that exist right outside of clinic walls. Neoliberalism tends to blame the victim while promoting individualized solutions to problems that can only be solved socially (Bauman, 2007). Neoliberalism nurtures cults of professionalism (Bledstein, 1976) and tightens the “disciplined minds” of conformity (Schmidt, 2000). In his important book, “Hippocrates’ Shadow: Secrets from the House of Medicine,” physician David Newman (2008) offers a “beginner’s list” of how biomedicine deceives us. As an insider he testifies that:
. . .our knowledge is far more limited than most believe; we advocate and interventions we know don’t work; we disagree on seemingly fundamental issues of science; at system levels we care nothing about communication; we choose technology over touch; we openly defy established evidence; we deny and decry a placebo effect while we tacitly accept and enlist it . . .(Newman 2008:195).
Anthropologist Daniel Moerman (2002) has written extensively about the placebo effect (what he calls the meaning response) and argues that it is a powerful healing modality that should be a fundamental part of medical education. But it is not. He argues that biomedicine’s neglect of emotion, ritual and culture mean that medical education is “as much of a hindrance as a help” (Moerman, 2002:13). Critical pedagogue Antonia Darder concurs, writing tellingly about the “pedagogy of love” that must also be a centerpiece of critical education. These two ideas are linked in their focus on loving people and “patients” (placebo means “I shall please”). Darder’s book, titled, Reinventing Paulo Freire (Darder, 2002), is apropos for the mission before us. In reinventing medicine, we must reinvent Freire and Virchow.
Independent scholars and journalists can rarely afford the time or energy to conduct holistic social medicine analyses of their own towns and cities to communicate these truths to the public. Such a wide-angle “history and physical” (H&P) of the community (to borrow the language of biomedicine which performs H&Ps on the reified patient only) is a crucial first step in creating the critical primary care for the 21st century. Several important social medicine groups are working hard on this front. They include the Social Medicine Portal, (2011), an up-to-the-minute assembly of news, readings and events in this field. It is associated with the Montefiore Department of Family and Social Medicine and the Latin American Social Medicine Association (see web site below). Dr. Timothy Holtz has assembled an exhaustive introduction to the topic in his 2007 Emory syllabus (Holtz, 2007). And the Peoples Health Movement, which carries on the work of the Alma Ata Assembly (see: http://www.phmovement.org/en).
And yet, even these vital groups have yet to fully explore how art, social science and journalism must become central to medicine. For example, consider the work of Rudolf Virchow, someone many radical physicians cite. Virchow was not only a physician but also an anthropologist who took enormous risks as a public intellectual. Virchow was viewed as a threat after “writing up about the people’s health”(McKenna, 2010) in a government report. He attributed the 1848 typhus epidemic in Upper Selesia to malnutrition, poverty and the machinations of the upper classes. He published his own weekly journal Die Medicinische Reform, from July 1848 to June 1849. He argued that “at a time when the overthrow of our old political institutions is not yet completed . . . medicine cannot alone remain untouched; it too can no longer postpone a radical reform in the field (Rosen, 1974:62).” In March of 1849 he was suspended from an academic position as Prosector at Charite Hospital. He so angered Bismark that it is rumored that in 1865 Bismark challenged him to a duel.
Medical students, even enlightened ones, are trapped in a rigid system of structural denial by their formal education (Schwenk, 2003, Singer, 2009, Waitzkin, 2005). By the time of the reclusive patient visit, the immense social power of a physician as a potential critical public intellectual had long ago been neutered by a prolonged socialization process stretching from “pre-med” to “MCAT” to “med school” to “graduate medical education” (GME) during which time she has been taught to refuse social science in deference to the natural sciences of biochemistry and pathophysiology. In the drama of medicine the doctor helps perform the hard work of a neoliberal culture by reproducing the conditions for “wage slavery” of the worker/citizen (Braverman, 1974), who is pacified to be “patient” not “active” (McKnight, 1995).
In his 2010 book, “The Rise and Fall of the American Medical Empire” Robert Linden, MD, a self-described “trench doctor,” performs an autopsy on “the death of primary care.” He carefully describes how “medicine has slowly mutated [over the past 30 years] from a highly respected professional sector to a commercialized, profit-motivated, market-based battlefield . . . .Decisions are often made behind closed doors in corporate boardrooms and are unavailable to citizens, physicians and government for review. Medical care of patients, the reason for the system in the first place, takes a back seat to venture capitalists” (Linden 2010:70).
Medicine is too important to be left to biomedicine and their neoliberal brethren. A critical pedagogy of medical education must entail the rediscovery of the historical conflicts over the meanings, limits, and possibilities of medical science.
George Bernard Shaw famously argued in “The Doctor’s Dilemma” that, “every profession is a conspiracy against the laity.” The struggle for critical social medicine in the U.S. is a battle against the silos of every profession. The educational struggle must engage both professionals and the laity. In the absence of internal reform, a vigorous social movement is necessary to alter the culture of health and medicine in the U.S. and across the globe.
Medicine is – potentially – a revolutionary force to transform the culture towards democracy and equality. It is a social science, politics by other means.
As Freire said, “Only dialogue, which requires critical thinking, is also capable of generating critical thinking. Without dialogue there is no communication, and without communication, there can be no true education” (Freire, 1970:81).
Brian McKenna lives in Michigan. He can be reached at:email@example.com
Note: A longer version of this article was published in the International Journal of Critical Pedagogy, Vol. 4, no. 1, 2012, pp. 95-117. Rochelle Brock and Leila Villaverde, editors. See open access at: http://libjournal.uncg.edu/ojs/index.php/ijcp/article/viewFile/217/269
Antonovsky, A. (1994 ). A Sociological Critique of the “Well-Being” Movement. Advances, Journal of Mind-Body Health, 10(3):6-12.
Asthana, S. (1994). Primary Health Care and Selective PHC: Community Participation in Health and Development. In Health and Development, pp. 182-196. London: Routledge.
Baer, H. and Singer, M. Eds., (2003). Medical Anthropology and the World System. Westport: Praeger.
Baer, H. and Singer, M. Eds., (2008) Killer Commodities: Public Health and the Corporate Production of Harm, AltaMira.
Bauman Zygmunt (2007) Liquid Times, Living in an Age of Uncertainty.
Berliner, H. S. (1975). A Larger Perspective on the Flexner Report. International Journal of Health Services 5:45-70.
Bledstein, B. J. (1976) The Culture of Professionalism: The Middle Class and the Development of Higher Education. New York: W. W. Norton.
Boggs, G.L. (2008) A New Outlook on Health (abridged). http://www.yesmagazine.org/issues/columns/2536
See also The Boggs Center: http://www.boggscenter.org/
Braverman, H. (1974). Labor and Monopoly Capital, The Degradation of Work in the Twentieth Century. New York: Monthly Review.
Cluster Evaluators (1992) Concept paper: Change in Community On Empowerment, Kellogg Foundation.
Cockerham, W. (2007). Social Causes of Health and Disease. Cambridge: Polity.
Coreil, J. and Mull J. (1990). Anthropology and Primary Health Care. Boulder: Westview.
Darder, A. (2002) Reinventing Paulo Freire. Boulder,CO: Westview.
Davis, D. (2007). The Secret History of the War on Cancer. New York:Basic.
Davis, D. (2010). Disconnect: The Truth About Cell Phone Radiation, What the Industry Has Done to Hide It, and How to Protect Your Family. Dutton.
Engel, G. L. (1977) The Need for a New Medical Model: A Challenge for Biomedicine. Science, 196:129-36.
Etzel, R. and Balk, S. Eds. (2003). Pediatric Environmental Health, 2nd Edition. ElkGrove Village, IL
Farquhar, L. J. (2007). Michigan’s Physician Shortfall and Resulting Advocacy Efforts. Institute for Health Care Studies, MSU: East Lansing.
Freire, P. (1970). Pedagogy of the Oppressed. New York: Seabury Press.
Gaventa, J. (1980). Power and Powerlessness. Urbana: University of Illinois.
Giroux, H. (1983). Theory and Resistance in Education. Massachusetts: Bergin and Garvey.
Giroux, H. (2007). University in Chains. Boulder: Paradigm Publishers.
Green, L. B. (1989). Consensus and Coercion: Primary Health Care and the Guatemalan State. Medical Anthropology Quarterly, 3(3):246-257.
Grossinger, R. (1980). Planet Medicine: From Stone Age Shamanism to Post- Industrial Healing. New York: Doubleday.
Heggenhougen H. K. (1984). Will Primary Health Care be Allowed to Succeed? Social Science and Medicine, 19(3):217-224.
Heggenhougen H. K. (1993). Review of “PHC and Anthropology: Challenges and Opportunities.” Culture, Medicine, and Psychiatry, 17:281-289.
Hogan, A. (2001). Was the W.K. Kellogg Foundation’s Community Partnerships in Health Professions Education Initiative a Cost Effective Model for Influencing Health Professions Student Choice of Primary Care Specialties?: Evidence from a Cluster Evaluation, Two Scientific Misconduct Investigations and Two Freedom of Information Lawsuits. Personal manuscript.
Hogan, A. (2003). Letter to the Editor. Lansing State Journal, February 2.
Holtz, T. (2007). Human Rights, Social Medicine and the Physician. Syllabus for Emory University course. See: http://www.hsph.harvard.edu/pihhr/files/syllabi/Emory_Syllabi/Social_Medicine_Syllabus_Emory_2007.pdf
Hunt, A. D. (1990). Medical Education, Accreditation and the Nation’s Health, Reflections of an Atypical Dean. East Lansing, MI: Michigan State University Press.
Illich, I. (1976). Medical Nemesis: The Expropriation of Health. New York: Bantam.
Institute of Medicine (2003) Who will Keep the Public Healthy? Educating Public Health Professional for the 21st Century. Gebbie, K., Rosenstock, L. and Hernandez, L. Eds., Washington DC: National Academies Press.
Kincheloe, J. and McLaran, P. (1994). Rethinking Critical Theory and Qualitative Research. In Handbook of Qualitative Research. Norman Denzin and Yvonna Lincoln, eds. Beverly Hills, CA: Sage.
Ludmerer, K. (1999). Time to Heal, American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford.
Luecke, R. Ed. (1993). A New Dawn in Guatemala, Toward a Worldwide Health Vision. Prospect Heights, IL: Waveland Press, Inc.
Lyon, J. (2003). In the Midst of the Crossfire, Protecting His Faculty. Medical Humanities Report. Volume 25:1.
McKenna, Brian (2010a) Take Back Medical Education, The Primary Care Shuffle. Invited Editorial for Medical Anthropology: Cross-Cultural Perspectives in Illness and Health 26(1) 6-14.
McKenna, B. (2003). Education for What? A Chronicle of Environmental Health Deception in Lansing, Michigan, Cooley Law Review, Volume 20:2, pp. 1 to 54. December 5.
McKenna, B. (1998). Towards a Rectification of Names in Primary Care: Articulations and Contests between Biomedicine and Community in a University-Based Primary Health Care Education Project in a Midwestern U.S. State. Dissertation for Degree in Anthropology. Michigan State University: East Lansing.
McKeown, T. (1976b). The Role of Medicine: Dream, Mirage, or Nemesis? Princeton: Princeton University Press.
McKnight, J. (1995). The Careless Society, Community and its Counterfeits. New York: Basic.
Mendelsohn, R. S. (1979). Confessions of a Medical Heretic. New York: Warner Books.
Michigan Primary Care Association. (2008). Shortage Designations.
Moerman, D. (2002). Meaning, Medicine and the ‘placebo effect’, Cambridge: Cambridge.
Mull, J. D. (1990). The Primary Health Care Dialectic: History, Rhetoric, and Reality. In Anthropology and Primary Care, pp. 28-47. Boulder: Westview.
Navarro, Vincente (2006). The Worldwide Class Struggle. Monthly Review 58(4) September. http://monthlyreview.org/author/vicentenavarro
Newman, D. H. (2008) Hippocrates’ Shadow, Secrets from the House of Medicine. New York: Scribner.
Nutting, P. Ed. (1990). Community-Oriented Primary Care. Albuquerque: University of New Mexico Press.
Pereira, O. and Almeida T. (2005). Medical Education according to Resistance Pedagogy. Interface, 9(16), 69-79.
Rhodes, L. A. (1990). Studying Biomedicine as a Cultural System. In Medical Anthropology, Contemporary Theory and Method, pp. 159-173. Thomas M. Johnson and Carolyn F. Sargent, eds. New York: Praeger.
Riska, E. and Vinten-Johansen, P. (1981). The Involvement of the Behavioral Sciences in American Medicine: A Historical Perspective. International Journal of Health Services, 11:4,583-595.
Rosen, G. (1974). From Medical Police to Social Medicine: Essays on the History of Health Care. New York: Neale Watson Academic Publications.
Sanders, D. (1985). The Struggle for Health. London: MacMillan.
Schmidt, Jeffrey (2000). Disciplined Minds, A Critical Look at Salaried Professionals and the Soul-battering system that shapes their lives. Lanham, MD: Rowman & Littlefield.
Schwenk, T. (2003). Public health- The Role of Family Physicians. American Family Physician 68(10) 1926, 1929-30.
Singer, M. (1989). The Coming of Age of Critical Medical Anthropology. Social Science and Medicine 28(11):1193-1203.
Singer, M. (2009) Introduction to Syndemics, A Critical Systems Approach to Public and Community Health. New Jersey: John Wiley & Sons.
Smith-Nonini, S. (2010) Healing the Body Politic, El Salvador’s Popular Struggle for Health Rights from Civil War to Neoliberal Peace. Piscataway, NJ: Rutgers.
Social Medicine Portal. (2011). See: http://www.socialmedicine.org/
Starfield, B. (1992). Primary Care, Concept, Evaluation, and Policy. New York: Oxford University Press.
Starr, P. (1982). The Social Transformation of American Medicine. New York: Basic Books.
Stufflebeam, D. L. and Shinkfield, A. J. (1985). Systematic Evaluation. Boston: Kluwer-Nijhoff.
Squires, D. (2010). International Profiles of Health Care Systems: Australia, Canada, Denmark, England, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. New York: Commonwealth Fund.
Waitzkin, H. (1991). The Politics of Medical Encounters: How Patients and Doctors Deal with Social Problems. New Haven: Yale.
White, K. L., M.D. and Connelly, J. E. (1991). The Medical School’s Mission and the Population’s Health. Annals of Internal Medicine, 155(12):968-972.
Wolin, Sheldon S. (2008) Democracy Inc., Managed Democracy and the Specter of Inverted Totalitarianism. Princeton: Princeton University Press.
Wright, D. (2004). MSU Official Quits Over Simon Appointment. City Pulse, July 28, pp. 3,7.