Man-Made Medicine: Women's Health, Public Policy, and Reformby Kary L. Moss
If not for the reproductive functions of women, would there be anything called women’s health care? A review of medical literature, practice, and policy in this country would suggest that the answer is no. Offering a startling view of the current state of health care for women in the United States and laying the foundation for a new, widely defined women’s medicine, Man-Made Medicine makes an urgent statement about gender bias in the medical establishment and its pernicious effects on the well-being of women and the care they receive.
These essays by physicians, lawyers, activists, and scholars present a rare interdisciplinary approach to a complex set of issues. Gender stereotyping and bias in the collection, analysis, and reporting of scientific data and in the ways health-related news is covered by the media are examined. The exclusion of women from the health care policy-making process and the effect such exclusion has on the determination of priorities among potential areas of research are also explored. With discussions of the plight of specific populations of women whose health care needs are not being sufficiently met—for example, immigrants, prisoners, the mentally ill, or women with HIV/AIDS, disabilities, or reproductive health problems—this book considers matters of race and class within the parameters of gender as it builds a fundamental challenge to the existing health care system. A range of current reform proposals are also evaluated in terms of their potential impact on women.
Suggesting no less than a radical rethinking of women’s medicine, Man-Made Medicine gives essential direction to the discussions that will shape the future of health care in this country. It will be of great interest to a wide audience, including health care advocates, policymakers, scholars, and readers generally concerned with women’s health issues.
Contributors. Ellen Barry, Laurie Beck, Joan Bertin, Janet Calvo, Wendy Chavkin, Kay Dickersin, Abigail English, Elizabeth Fee, Carol Gill, Nancy Krieger, Joyce McConnell, Judy Norsigian, Ann Scales, Susan Stefan, Lauren Schnaper, Catherine Teare
“This unique anthology fills a void in the literature of public health policy. It provides a prism for understanding how women’s well being is affected by hidden assumptions about color, class, and culture. Destined to become a classic, it is an indispensable guide in distinguishing science from pseudo-science, myth and mirage from medical fact.”—Patricia Williams, Professor of Law, Columbia University
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Women's Health, Public Policy, and Reform
By Kary L. Moss
Duke University PressCopyright © 1996 Duke University Press
All rights reserved.
MAN-MADE MEDICINE AND WOMEN'S HEALTH
The Biopolitics of Sex/Gender and Race/Ethnicity
Nancy Krieger and Elizabeth Fee
Glance at any collection of national health data for the United States – whether pertaining to health, disease, or the health care system – and several features stand out. First, notice that most reports present data in terms of race, sex, and age. Some races are clearly of more interest than others. National reports most frequently use racial groups called "white" and "black" and, increasingly, a group called "Hispanic." Occasionally, we find data on Native Americans and on Asians and Pacific Islanders. Whatever the specific categories chosen, the reports agree that white men and women, for the most part, have the best health, at all ages. They also show that men and women, across all racial groups, have different patterns of disease. Obviously, men and women differ for conditions related to reproduction (women, for example, do not get testicular cancer), but they differ for many other conditions as well – for example, men on average have higher blood pressure and develop cardiovascular disease at an earlier age. And, in the health care sector, occupations, just like diseases, are differentially distributed by race and sex.
All this seems obvious. But it isn't. We know about race and sex divisions because this is what our society considers important. This is how we classify people and collect data. This is how we organize our social life as a nation. This is therefore how we structure our knowledge about health and disease. And this is what we find important as a subject of research.
It seems so routine, so normal, to view the health of women and men as fundamentally different, to consider the root of this difference to be biological sex, and to think about race as an inherent, inherited characteristic that also affects health. The work of looking after sick people follows the same categories. Simply walk into a hospital and observe that most of the doctors are white men, most of the registered nurses are white women, most of the kitchen and laundry workers are black and Hispanic women, and most of the janitorial staff are black and Hispanic men. Among the patients, notice who has appointments with private clinicians and who is getting care in the emergency room; the color line is obvious. Notice who provides health care at home: wives, mothers, and daughters. The gender line at home and in medical institutions is equally obvious.
These contrasting patterns, by race and sex, are longstanding. How do we explain them? What kinds of explanations satisfy us? Some are comfortable with explanations that accept these patterns as natural, as the result of natural law, as part of the natural order of things. Of course, if patterns are that way by nature, they cannot be changed. Others aim to understand these patterns precisely in order to change them. They look for explanations suggesting that these patterns are structured by convention, by discrimination, by the politics of power, and by unreasonable law. These patterns, in other words, reflect the social order of people.
In this essay, we discuss how race and sex became such all-important, self-evident categories in nineteenth- and twentieth-century biomedical thought and practice. We examine the consequences of these categories for our knowledge about health and for the provision of health care. We then consider alternative approaches to studying race/ethnicity, gender, and health. And we address these issues with reference to a typically suppressed and repressed category: that of social class.
The Social Construction of "Race" and "Sex" as Key Biomedical Terms and Their Effect on Knowledge About Health
In the nineteenth century, the construction of "race" and "sex" as key biomedical categories was driven by social struggles over human inequality. Before the Civil War, the dominant understanding of race was as a natural/theological category – black/white differences were innate and reflected God's will. These differences were believed to be manifest in every aspect of the body, in sickness and in health. But when abolitionists began to get the upper hand in moral and theological arguments, proponents of slavery appealed to science as the new arbiter of racial distinction.
In this period, medical men were beginning to claim the mantle of scientific knowledge and assert their right to decide controversial social issues. Recognizing the need for scientific authority, the state of Louisiana, for example, commissioned one prolific proponent of slavery, Dr. Samuel Cartwright, to prove the natural inferiority of blacks, a task that led him to detail every racial difference imaginable – in texture of hair, length of bones, vulnerability to disease, and even color of the internal organs. As the Civil War changed the status of blacks from legal chattel to bona fide citizens, however, medical journals began to question old verities about racial differences and, as importantly, to publish new views of racial similarities. Some authors even attributed black/white differences in health to differences in socioeconomic position. But by the 1870s, with the destruction of Reconstruction, the doctrine of innate racial distinction again triumphed. The scientific community once again deemed "race" a fundamental biological category.
Theories of women's inequality followed a similar pattern. In the early nineteenth century, traditionalists cited scripture to prove women's inferiority. These authorities agreed that Eve had been formed out of Adam's rib and that all women had to pay the price of her sin – disobeying God's order, seeking illicit knowledge from the serpent, and tempting man with the forbidden apple. women's pain in childbirth was clear proof of God's displeasure.
When these views were challenged in the mid-nineteenth century by advocates of women's rights and proponents of liberal political theory, conservatives likewise turned to the new arbiters of knowledge and sought to buttress their position with scientific facts and medical authority. Biologists busied themselves with measuring the size of women's skulls, the length of their bones, the rate of their breathing, and the number of their blood cells. And considering all the evidence, the biologists concluded that women were indeed the weaker sex.
Agreeing with this stance, medical men energetically took up the issue of women's health and equality. They were convinced that the true woman was by nature sickly, her physiological systems at the mercy of her ovaries and uterus. Because all bodily organs were interconnected, they argued, a woman's monthly cycle irritated her delicate nervous system and her sensitive, small, weak brain. Physicians considered women especially vulnerable to nervous ailments such as neurasthenia and hysteria. This talk of women's delicate constitutions did not apply, of course, to slave women or to working-class women – but it was handy to refute the demands of middle-class women whenever they sought to vote or gain access to education and professional careers. At such moments, many medical men declared the doctrine of separate spheres to be the ineluctable consequence of biology.
At the same time, nineteenth-century medical authorities began to conceptualize class as a natural, biological distinction. Traditional, pre-scientific views held class hierarchies to be divinely ordained; according to the more scientific view that emerged in the early nineteenth century, class position was determined by innate, inherited ability. In both cases, class was perceived as an essentially stable, hierarchical ranking. These discussions of class usually assumed white or Western European populations and often applied only to males within those populations.
With the impact of the industrial revolution, classes took on a clearly dynamic character. As landowners invested in canals and railroads, as merchants became capitalist entrepreneurs, and as agricultural workers were transformed into an industrial proletariat, the turbulent transformation of the social order provoked new understandings of class relationships. The most developed of these theories was that of Karl Marx, who emphasized the system of classes as a social and economic formation and stressed the contradictions between different class interests. From this point onward, the very idea of social classes in many people's minds implied a revolutionary threat to the social order.
In opposition to Marxist analyses of class, the theory of Social Darwinism was formulated to suggest that the new social inequalities of industrial society reflected natural law. This theory was developed in the midst of the economic depression of the 1870s, at a time when labor struggles, trade union organizing, and early socialist movements were challenging the political and economic order. Many scientists and medical men drew upon Darwin's idea of "the struggle for survival," first expressed in the Origin of the Species in 1859, to justify social inequality. They argued that those on top, the social elite, must by definition be the "most fit" because they had survived so well. Social hierarchies were therefore built on and reflected real biological differences. Poor health status simultaneously was sign and proof of biological inferiority.
By the late nineteenth century, theories of race, gender, and class inequality were linked together by the theory of Social Darwinism, which promised to provide a scientific basis for social policy. In the realm of race, for example, proponents of Social Darwinism blithely predicted that the "Negro Question" would soon resolve itself–the "Negro" would naturally become extinct, eliminated by the inevitable workings of "natural selection." Many public health officers – particularly in the southern states – agreed that "Negroes" were an inherently degenerate, syphilitic, and tubercular race, for whom public health interventions could do little. Social Darwinists also argued that natural and sexual selection would lead to increasing differentiation between the sexes. With farther evolution, men would become ever more masculine and women ever more feminine. As proof, they looked to the upper classes, whose masculine and feminine behavior represented the forefront of evolutionary progress.
Over time, the Social Darwinist view of class gradually merged into general American ideals of progress, meritocracy, and success through individual effort. According to the dominant American ideology, individuals were so mobile that fixed measures of social class were irrelevant. Such measures were also unAmerican. Since the Paris Commune, and especially since the Bolshevik revolution, discussions of social class in the United States were perceived as politically threatening. Although fierce debates about inequality continued to revolve around the axis of nature versus nurture, the notion of class as a social relationship was effectively banished from respectable discourse and policy debate. Social position was once again equated only with rank, now understood as socioeconomic status.
In the early twentieth century, Social Darwinists had considerable influence in shaping public views and public policy. They perceived two new threats to American superiority: the massive tide of immigration from eastern and southern Europe, and the declining birth rate – or "race suicide" – among American white women of Anglo-Saxon and Germanic descent. Looking to the fast-developing field of genetics, now bolstered by the rediscovery of Gregor Mendel's laws and by T. H. Morgan's fruit fly experiments, biological determinists regrouped under the banner of eugenics. Invoking morbidity and mortality data that showed a high rate of tuberculosis and infectious disease among the immigrant poor, they declared "ethnic" Europeans a naturally inferior and sickly stock and thus helped win passage of the Immigration Restriction Act in 1924. This legislation required the national mix of immigrants to match that entering the United States in the early 1870s, thereby severely curtailing immigration of racial and ethnic groups deemed inferior. "Race/ethnicity," construed as a biological reality, became ever more entrenched as the explanation of racial/ethnic differences in disease; social explanations were seen as the province of scientifically illiterate and naive liberals, or worse, socialist and Bolshevik provocateurs.
Other developments in the early twentieth century encouraged biological explanations of sex differences in disease and in social roles. The discovery of the sex chromosomes in 1905 reinforced the idea that gender was a fundamental biological trait, built into the genetic constitution of the body. That same year, Ernest Starling coined the term "hormone" to denote the newly characterized chemical messengers that permitted one organ to control – at a distance – the activities of another. By the mid-1920s, researchers had isolated several hormones integral to reproductive physiology and popularized the notion of "sex hormones." The combination of sex chromosomes and sex hormones were imbued with almost magical powers to shape human behavior in gendered terms; women were now at the mercy of their genetic limitations and a changing brew of hormonal imperatives. In the realm of medicine, researchers turned to sex chromosomes and hormones to understand cancers of the uterus and breast and a host of other sex-linked diseases; they no longer saw the need to worry about environmental influences. In the workplace, of course, employers said that sex chromosomes and hormones dictated which jobs women could – and could not – perform. This in turn determined the occupational hazards to which women would be exposed – once again, women's health and ill health were viewed as a matter of their biology.
Within the first few decades of the twentieth century, these views were institutionalized within scientific medicine and the new public health. At this time, the training of physicians and public health practitioners was being recast in modern, scientific terms. Not surprisingly, biological determinist views of racial/ethnic and sex/gender differences became a natural and integral part of the curriculum, the research agenda, and medical and public health practice. Over time, ethnic differences in disease among white European groups were downplayed and instead, the differences between whites and blacks, whites and Mexicans, whites and Asians were emphasized. Color was now believed to define distinct biological groups.
Similarly, the sex divide marked a gulf between two completely disparate groups. Within medicine, women's health was relegated to obstetrics and gynecology; within public health, women's health needs were seen as being met by maternal and child health programs. Women were perceived as wives and mothers; they were important for childbirth, child care, and domestic nutrition. Although no one denied that some women worked, women's occupational health was essentially ignored because women were, after all, only temporary workers. Outside the specialized realm of reproduction, all other health research concerned men's bodies and men's diseases. Reproduction was so central to women's biological existence that women's nonreproductive health was rendered virtually invisible.
Currently, it is popular to argue that the lack of research on white women and on men and women in nonwhite racial/ethnic groups resulted from a perception of white men as the norm. This interpretation, however, is inaccurate. In fact, by the time that researchers began to standardize methods for clinical and epidemiological research, notions of difference were so firmly embedded that whites and nonwhites, women and men, were rarely studied together. Moreover, most researchers and physicians were interested only in the health status of whites and, in the case of women, only in their reproductive health. They therefore used white men as the research subjects of choice for all health conditions other than women's reproductive health and paid attention to the health status of nonwhites only to measure degrees of racial difference. For the most part, the health of women and men of color and the nonreproductive health of white women was simply ignored. It is critical to read these omissions as evidence of a logic of difference rather than as an assumption of similarity.
This framework has shaped knowledge and practice to the present. U.S. vital statistics present health information in terms of race and sex and age, conceptualized only as biological variables – ignoring the social dimensions of gender and ethnicity. Data on social class are not collected. At the same time, public health professionals are unable adequately to explain or to change inequalities in health between men and women and between diverse racial/ethnic groups. We now face the question: is there any alternative way of understanding these population patterns of health and disease?
Alternative Ways of Studying Race, Gender, and Health: Social Measures for Social Categories
The first step in creating an alternative understanding is to recognize that the categories we traditionally treat as simply biological are in fact largely social. The second step is to realize that we need social concepts to understand these social categories. The third step is to develop social measures and appropriate strategies for a new kind of health research.
Excerpted from Man-Made Medicine by Kary L. Moss. Copyright © 1996 Duke University Press. Excerpted by permission of Duke University Press.
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Kary L. Moss is Executive Director of the ACLU of Michigan.
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