Paul Starr’s book about the social transformation of American medicine shines light on today’s debate.


Barack Obama is not the first president to shoot for national health insurance, as Paul Starr notes in his Pulitzer prize-winning book, The Social Transformation of American Medicine

Barack Obama is not the first president to shoot for national health insurance, as Paul Starr notes in his Pulitzer prize-winning book, The Social Transformation of American Medicine



An embattled Democratic president stakes much of his political capital in an effort to nationalize health insurance early in his tenure.  Opponents define the plan as socialized medicine-a charge he strongly denies, but in the process loses control of the political debate.

Sound familiar? 

If you said Barack Obama or Bill Clinton, you would be right.

But Paul Starr writes about the same dynamics occurring with former haberdasher Harry S. Truman in his Pulitzer prize-winning history,  The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. 

Truman’s ultimately failed effort at national health insurance is but a small part of this tome, which covers the period from 1760 to the early 1980s, when the book was published. 

Starr makes several major points in the book.   The first is one that social historians of medicine generally accept as a premise: that medical developments must not be considered on their own, but rather within the social, cultural and political contexts in which they occur. 

Beyond that, though, Starr traces the rise of the doctrine of professionalism within medicine, and how that doctrine has served to inure it to all manner of control to which other industries have been subject. 

Starr opens the book with a description of the social origins of professional sovereignty.  Drawing on sociological heavyweights, he breaks down the various elements that have contributed to the ethos of professionalism and the accompanying self-determination, regulation and independence from governmental intrusion that medicine as a whole has sought during the past 200 years.

From there he marches relatively directly through the 220 years beginning in 1760, noting historical moments like the transportation revolution, the rise of the concept of public health or the belief in the possibility of positive social reform during the Progressive Era that impacted medicine’s place in society during that time and the institutional configurations people in the field established. 

People familiar with the late 19th century will not be surprised to learn that this and the following decades was a period toward consolidated medical control over the profession, a retrenchment on commitments to public health and a narrowing definition of who should practice and receive medical care.  

In chapters that shed ominous light on the most recent effort to enact major health care reform, Starr discusses each of the major efforts to attain national health insurance-a version of which was implemented in many Western European nations in the late 1800s, he points out-and why each in their own way ultimately did not come to fruition.   People who think of Richard Nixon solely for the Watergate break-in and fallout or his foreign policy efforts will be surprised to see that a serious run was made at the goal during his tenure, and not completely with his opposition.  

Starr ends the book by talking about the rise of the corporation in the early 80s, and makes it clear that he believes that this trend could have serious consequences for the level of autonomy to which doctors are accustomed to working as well as for the type of care they provide their patients.

In the book’s penultimate paragraph, Starr writes, “Instead of public financing for prepaid plans that might be managed by the subscribers’ chosen representatives, there will be corporate financing for private plans controlled by conglomerates whose interests will be determined by the rate of return on investments.  That is the future toward which American medicine now seems to be headed.” 

Many of those corporations that he predicted would emerge have come into existence, and are, along with drug companies and politicians on both sides of the aisle, leading the opposition to Obama’s proposal.  

In his weekly address today Obama linked somewhat promising job numbers and the state of the economy more generally to the need for meaningful health care reform.  

His ability to translate what has become a major test of his young presidency into meaningful policy will have implications both for the rest of his term and for Americans for generations to come.  Reading Starr’s valuable work gives a better understanding of the reciprocal relationship between society and medicine in our country as well as the stiffness of the historical obstacles he is trying to surmount.


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