Journal of Health Politics, Policy and Law
 
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Abstracts > Volume 25, Number 4 (August 2000)

Welfare Reform, Substance Use, and Mental Health

Rukmalie Jayakody, Sheldon Danziger, and Harold Pollack

Reform has transformed traditional entitlement to cash welfare under Aid to Families with Dependent Children (AFDC) into a transitional program known as Temporary Assistance to Needy Families (TANF). Because of the new work requirements and the time-limited nature of assistance, policy makers are increasingly confronted with what to do when welfare recipients do not effectively make the transition from welfare-to-work. Increasingly the language of public health is being used to determine who is 'employable' and who is not. Thus, renewed attention is being focused on the individual characteristics of participants themselves, particularly specific diagnoses that might reduce employability. This paper focuses on substance abuse and mental health problems among single mothers and examines their relationship to welfare receipt. We analyze data from the 1994 and 1995 National Household Survey of Drug Abuse (NHSDA), and find that 19 percent of welfare recipients meet the criteria for a DSM-III-R psychiatric diagnosis. About the same percentage have used illicit drugs during the previous year. Logistic regression results indicate that mental and behavioral health problems that are significant barriers to self-sufficiency are increasingly important in this era of time-limited benefits

System-Wide Effects of Medicaid Retrospective Drug Utilization Review Programs

William J. Moore, Karen Gutermuth, and Etienne E. Pracht

Aggregate pooled cross-sectional and time-series annual state data for 1985 to 1992 were used to estimate the system-wide effects of retrospective drug utilization review programs (Retro-DUR) on Medicaid drug and non-drug outcomes. The results provide evidence that these programs produce significant cost savings in the drug budget without spill-over effects (positive or negative) in other non-drug budgets within the Medicaid system. We also examine the influence of restricted formularies in this post-Retro-DUR era on drug and non-drug budgets in the Medicaid system; we find significant cost-savings in the former but positive spill-over effects in the latter.

The Implementation of California's Tobacco Tax Initiative: The Critical Role of Outsider Strategies in Protecting Proposition 99

Edith D. Balbach, Michael P. Traynor, and Stanton A. Glantz

Enacted in 1988, Proposition 99 increased California's cigarette tax by 25 cents per pack and allocated a minimum of 20 percent of the revenues to fund anti-tobacco education. Tobacco control advocates had used an initiative to secure the tax increase because the legislature had not increased the tobacco tax since 1967, even though public opinion polls showed that the tax was politically popular. Advocates, however, then had to return to the legislature to negotiate implementing legislation. Between 1989 and 1996, the legislature underfunded the Proposition 99 Health Education programs by over $273 million. This underfunding occurred because the public health groups failed to exercise power, ideas, and the leadership needed for legislative success. Even successful litigation against the governor failed to restore the programs. In July 1996, however, the underexpenditures stopped because the issue of the diversions received significant media and public attention. The tobacco control groups used a variety of outsider strategies, including paid advertising, free media, and a grassroots campaign, and the leadership of these groups, in addition to the lobbyists, got involved in the campaign to secure implementing legislation. Without on-going public pressure, it is likely that policy changes created by tobacco tax initiatives will dissipate into something acceptable to powerful insider interests, such as the tobacco and medical service provider industries.

What Prompts Health Care Policy Change? On Political Power Contests and Reform of Health Care Systems (The Case of Canada and Israel)

Iris Geva-May and Allan Maslove

This paper attempts to shed light on the complexity inherent in health care reform policies in the context of political power contests that trigger the changes imposed on the health care system. Rather than being solely a response to financial circumstances, as it is often claimed, we argue that these political contests lead to many of the changes in the systems. Furthermore, changes do not necessarily occur when worrying symptoms appear in the system, but rather when the contest reaches a peak and when neither side involved can emerge from the contest as winner or loser, and as defender of the public interest. While in both cases fiscal problems in the health systems are usually brought up in order to justify reform, the trigger for change in Israel has been the power contest between the two main parties-the Labor Party and the Likud Party-with the Likud attempting to impair the financial basis of the former. In Canada, the power contests are between the provinces and the federal government.

Learning from Outliers

John C. Campbell and Naoki Ikegami. The Art of Balance in Health Policy: Maintaining Japan's Low-Cost, Egalitarian System.
New York: Cambridge University Press, 1998. 240 pp. $54.95 cloth.
Donald W. Light. Effective Commissioning: Lessons from Purchasing in American Managed Care.
London: Office of Health Economics, 1998. 89 pp. 7.80.

Joseph White
Case Western Reserve
Email: jxw87@po.cwru.edu

A truism says that politics is the art of the possible. But how are we to know what is possible, so what may be produced by the politician's, or policy maker's, artifice? These two very different books address that question in highly interesting and productive ways. Each has a target audience: for Campbell and Ikegami, American policy makers and academics; for Light, their British counterparts. John C. Campbell and Naoki Ikegami mean to show how what might seem idiosyncratic Japanese policy choices illuminate how the United States might be able to create and afford universal health insurance. Donald W. Light above all wants British advocates of the "internal market" and its variants to understand the conditions for, and consequences of, using "market forces" in a way that has significant effect on health care delivery. Both analyses, however, are powerful enough to be worth reading for their pure intellectual power, as a way to expand one's own understanding of the dynamics and possibilities of health policy.

In their explicit efforts to draw lessons from one country for another, the authors must address objections that the countries being compared are too different for useful comparison. As Campbell and Ikegami put it, "Why should Americans care about the Japanese health care system" (vii)? They answer that the alternative to looking to international experience for reform ideas is to base reforms on "academic theories" that represent experience nowhere at all. Contrary to the notion that "the Japanese case is so different that it does not really offer many useful comparisons," they argue, "some aspects of the Japanese experience-even beyond the features that it shares with most other industrialized nations-are particularly worthy of attention by Americans interested in health care reform" (2).

Light begins his essay by remarking that, "It may seem odd that someone from the most overpriced, wasteful and inequitable health care system in the industrialised world should pen a report on how to make the U.K. National Health Service (NHS) more cost-effective" (5). The United States is actually as much of an outlier compared to the United Kingdom as Japan is compared to the United States, on virtually any health policy dimension you could name-funding levels, funding arrangements, capacity, norms of practice, political processes, and so on. Yet, he argues, "from the very deregulated nature of U.S. markets have emerged useful lessons, as the leading buyers (that's American for 'commissioners') face up to all the ways that they did not save money during the 1980s when they thought they had" (ibid.).

Light actually has an easier sell than do Campbell and Ikegami. Given the reform agenda as defined in the United Kingdom-"market-based reform," the United States has some face credibility. After all, the United States is the advanced industrial country in which the market has the most effect on health care, for good or ill. Moreover, the real issue is not the United Kingdom vs. the United States, but the requisites for successful (however defined) purchasing (or "commissioning") by an individual organization within either country. In discussing these factors, however, Light's analytical approach is not so different from Campbell and Ikegami.

These books are about very different events: the evolution of health care policy in Japan over many decades and the jumble of innovations in the NHS over the past decade. Yet the analyses in each focus on the incentives for and constraints on behavior by individuals. None of these authors would claim that "market forces" don't matter. Indeed, these book show how financial incentives can shape behavior even without a "market." But each shows that responses to incentives also depend on a provider's, or other actor's, ability to respond.

For example, payments for surgery under both the NHS and Japan's fee schedule are lower than surgeons may consider fair. Japanese physicians can increase their incomes somewhat by collecting extra "gifts" from some patients. Such gifts are technically illegal and create some inequality (94-98), yet their effect on the equity of Japanese medical care and output within the public-sponsored insurance systems hardly comes close to the effect of the income increasing strategies of British consultants on the performance of the NHS. Light argues powerfully that the way the consultants' contracts are written makes enforcing production standards virtually impossible because "solicitors do not think one could tell when a 'breach of contract' has occurred" (59). So the prospect of making much higher fees for private surgery, and the ways the NHS enables that practice, mean that about 2000 consultants essentially "use the NHS as a recruitment base for their private practice and their NHS salary to pay part of their tax bill" (60). Campbell and Ikegami provide no reason to believe that Japanese surgeons would not behave the same way if they could, but the system does not allow them to do so. The contractual relationships between physicians and hospitals, and relations of authority or autonomy within hospitals, prevent that behavior.

This focus on incentives and possibilities, in each case, provides the basis for inferring from one case to another. We do not need to believe that any given institution can be copied in order for the examples in these books to expand our understanding of what policy might accomplish and how. Or how not to accomplish much. Readers might best look to The Art of Balance in Health Policy to expand their horizons of the possible; they might best look to Effective Commissioning as a warning against trying to do the impossible.

* * *

Campbell and Ikegami make a powerful case that Japanese health finance arrangements have unique aspects, like any country's, but that neither Japan's universal access nor cost control are produced by immutable cultural factors. Rather, they follow from institutional and political arrangements, in large measure as unintended consequences but entirely explicable. Given that they cannot tailor premiums and benefits to attract some customers and discourage others, the incentives of Japanese health insurance managers "lead to an orientation much more that of a chief clerk than of an entrepreneur" (104). If Japanese physicians and hospital administrators seem in some ways less entrepreneurial than American, that also is because the reward structure and opportunities are different. It is hard to build a hospital empire if you do not have access to the capital necessary for expansions. Entrepreneurial activity is diverted, by policy, into relatively low-cost primary care and pharmaceuticals, rather than expensive surgeries. The authors describe the politics and opportunity structures for each of the major actors in the system, such as health insurance managers, bureaucrats, the Liberal Democratic Party, and physicians. Some of these effects are made possible by the institutionalization of interest-group power relationships within political processes-i.e., dominance of the fee-setting process by the Japan Medical Association, which favors private practice physicians over hospital-based providers.

Nobody should imagine that political values and structures are not a major impediment to universal health insurance in the United States, and Campbell and Ikegami do not downplay that difference. If the goal were to be achieved, however, how might it be done? They argue that, "it is unlikely that the United States will move to a 'single payer' system with the national government as sole insurer. It is also unlikely that health care needs and ability to pay can be evenly distributed across insurance pools, particularly if large firms continue to self-insure their own employees. If extreme inequality of burdens is to be avoided, therefore, some form of cross-subsidization across groups will be required" (114). From this perspective, Japan offers a plausible kind of pay-or-play-plus-Medicaid approach, and Campbell and Ikegami identify the most important principles for such a design (114-115). These include separate mandatory pools by type of employment (employees of individual large corporations, government, other employees, and non-employees); mandatory to avoid adverse selection and by employment type so subsidies can be directed to pools rather than individuals. The insurers can be administered (sponsored) by private employers, the national government, or local governments, so long as other provisions prevent egregious inequalities. Individuals pay proportions of their income, so the better off in a given pool subsidize those with lower incomes, and there are some equalization transfers across pools; in addition, general revenues are used to subsidize the less viable pools as a whole. The coverage in these pools is not exactly equal: the more viable pools have slightly richer benefits and lower cost-sharing. But that actually has political benefits: better off citizens pay more, subsidizing others, but, because they also get more, seem not to resent the subsidy. As Campbell and Ikegami note, the fact that benefits are higher for high- income people but not as much higher as their contributions is also "often cited as a key to political support for Social Security pensions in the United States" (94).

Japan's methods for controlling costs seem further out of the reach of American policy makers. The key is a binding fee schedule that finances virtually all services except those that are subsidized through public budgets for Japanese public hospitals. How that works provides some lessons that at least should make American readers see how their notion of normal relationships depends upon unstated conditions. For instance, quantity responses to price restraints depend not just on an individual provider's ability to induce volume (a factor that is acknowledged in American analyses) but on "time constraints." Thus, "the difference in fees between Japan and the United States is about the same magnitude for most procedures, but the low fees selectively impose a limit on procedures such as surgical operations, which take up a fixed amount of professional time" (161). When fees are low enough, and expenses cannot easily be reduced, fees approach marginal cost, and there is no incentive to increase volume. "In contrast, the time for prescribing medicine and ordering laboratory tests can easily be compressed to generate more revenue" (ibid.). Campbell and Ikegami also argue that, by dispensing with pseudoscientific justifications for fees, the Japanese emphasize what is most necessary for system stability and political support, namely, ensuring "that no particular group would be a winner or loser in the long run" (150). They also distinguish how the fee schedule is used to control costs in Japan from its use in other advanced industrial nations. In most countries, cost controls work mainly by adjusting the conversion factor that translates relative values into prices. In Japan, the relative prices are adjusted more frequently, so as to "provide a quick response to cost surges caused by technological change" or other factors (172).

These conclusions about system dynamics do not imply that the Japanese health care system is ideal. Some amount of the difference in costs between Japan and the United States is due to inferior amenities and, in some cases, quality in the former. The Art of Balance in Health Policy provides a careful discussion of those possible differences. But Campbell and Ikegami make a compelling case that the United States could do better on access and cost, and that even what seems like a very different case can expand readers' understanding of how those goals could be achieved.

* * *

I hope and expect Effective Commissioning was as much fun to write as it is to read. Professor Light comes out slashing, skewering the misleading language, meaningless goals, and self-serving rationales that permeate the NHS reform process. He begins with what may be the most important point: that effective commissioning is "no substitute for increased funding" (7). He debunks both the "waiting lists" as an indicator of the NHS's failures and the argument that there is no point in reducing waiting lists because there is a "bottomless pit of need." It is possible to identify waste and low value-for-money, he argues, but to "envision health care as efficient the way that a hotel or airline can be efficient is a mirage" (8).

The main challenge for this book was not interesting the British in American "lessons," but drawing lessons from previous experience. American buyers of health care services follow a remarkable array of strategies, and are not particularly forthcoming about the details. Determining what "works" in the United States and how well it works, therefore, are daunting tasks. On the other hand, it appears to be relatively easy to identify flaws in the successive designs of the NHS internal markets. In spite of the book's rhetorical stance, therefore, Effective Commissioning is best viewed as a critique of those reforms, in which American experience is brought in, from time to time, to provide commentary that would seem pretty logical even without that experience.

Thus, the British internal market has involved all sorts of complex situations in which it's hard to distinguish the purchasers from providers. In critiquing that, Light comments that, "a hard lesson of the 1980s for U.S. payers (employers) has been to disentangle themselves from being on hospital boards and identifying with hospitals in order to get their commissioning priorities straight" (20). Similarly, Light emphasizes the extensive resources of the most successful American purchasers in order to support his argument that, in the NHS, the Health Authorities, which have major purchasing responsibility, have been "understaffed and overextended," such that they are "functionally weak" (48-49).

Many of the lessons in this book involve hard choices. In spite of much rhetoric, Light argues, "the government (so far) has not been serious about effective commissioning. It has wanted shorter waiting times, but not if it means a face-down with consultants, disruption, or bad press. Yet that, American purchasers have learned, is what it takes" (61-62). Providers will have to give up some independence: "The handful of successful and leading-edge American commissioning groups insist that providers who contract with them adopt their chosen system for measuring clinical performance and report the data to them. No data, no contract" [his emphasis(31)]. The vision of a focus on clinical outcomes implies "that the medical profession will increasingly move towards an elite of clinical managers and evidence-based medicine, issuing standards and guidelines and managing the rank-and-file clinicians" (42). Rhetoric about "being consumer-oriented and meeting consumer demand" creates a political trap: "how will the government pay for the increased demand it creates" (43)?

Of course, politicians fudge hard choices because none of the possibilities are really attractive. Light bravely offers three kinds of constructive suggestions: reforms that would address peculiar failings of the traditional NHS's set of rewards and constraints; changes in the social contract between the government and the public, so as to bring demands in line with resources; and a broader reorientation of medical care.

The first category includes ways to address the "waiting list" problem. These would make sense regardless of all the "internal market" reforming. For instance, "the management of waiting pools must be taken out of the hands of consultants and co-ordinated by the commissioning organisation across a city or district" (57). Where capacity bottlenecks exist, they should be widened: "one bottleneck is having too few beds, so that urgent cases keep disrupting any effort to schedule elective procedures. This problem can be easily solved by not closing so many beds so fast" (ibid.). Most important, specialists should be paid on "performance-based contracts" (59-61).

The second category could be credited to the Rolling Stones: You can't always get what you want, but if you try sometime, you might find, you get what you need. In Light's version, the new social contract for health care would say, "The nation cannot afford all the health services that people might want, but with your help it can possibly provide all the health services people need. If you learn how to stay healthy, manage minor problems and cope with chronic problems, thus minimising demand, we can focus on providing excellent, equitable services when you really need them" (44). Unfortunately, it is likely to be just as hard to enforce such a contract as the current consultants' contracts. What would be done about the people who did not "stay healthy" and "manage" their "minor problems?" But it is at least an attempt to set a standard for the level of and priorities within NHS funding.

The third category is most problematic. Light advocates that commissioning be oriented to encourage "community-oriented primary care," a theme that is already present in some of the recent NHS White Papers (44-47). Based on both British experience and commentary, he identifies a wide range of obstacles to that vision. Yet he argues that, "despite these problems, creating broad community-based groups of primary care providers is worth the effort, because it would provide an organisational platform for making primary care services more equitable, less uneven in quality and more accountable" (46). Similarly, Light cogently debunks the idea that primary care groups can be the commissioners for most services, arguing that the successes of GP (General Practice) fundholding have been overstated and that a much less vital role is inevitable for many years. He reports there have been some successes from giving the health care budget to primary care groups in California, but the incentives have been different and, "even then, it has taken 10-15 years of unflagging effort for physician commissioning groups to extract better value from an overfunded, overpriced system with lots of excess utilisation and capacity" (52). He therefore argues that, while "extending general practice to integrated models of community and primary care will take one of the great strengths of the NHS and make it twice as strong" (ibid.) this would take a decade, and primary providers should, in the meantime, mainly advise Health Authorities that make the real purchasing decisions.

The obvious objection to Light's position is that the goal may not be attainable at all, and there appears to be a contradiction between a focus on primary care and the original observation that specialty care is underfunded. One of the lessons from comparative studies appears to be that lots of policy makers have attempted to emphasize "integrated" "primary-care led" medicine in many places, and the voters and providers rarely go along. Campbell and Ikegami show that the Ministry of Health and Welfare was stymied in its efforts to push Japan in that direction, long ago (46). Yet even readers who are skeptical of the goal may believe that Light's arguments about both its desirability and difficulty suggest the right balance of measures in the short run.

* * *

Both of these books have merits beyond their accounts of health policy. The Art of Balance in Health Policy, for example, could be read as an analysis of Japanese politics. Effective Commissioning provides a window through which to regard the "Third Way" being promoted by the Blair government (one sees a rather large component of fluff and, at best, self-deception). Yet I would recommend both books to readers of this journal especially for the ways they can expand one's notions of the possibilities in health policy: how various instruments can work and incentives or constraints be designed. Students of comparative health policy certainly should read them, but all students of health care finance should find them useful.

Making Sense of Medicaid Reform

Mark R. Daniels, ed. Medicaid Reform and the American States: Case Studies of Managed Care.
Westport, CT: Auburn House, 1998. 320 pp. $49.95 cloth.
Stephen M. Davidson and Stephen A. Somers, ed. Remaking Medicaid: Managed Care for the Public Good.

San Francisco: Jossey-Bass, 1998. 320 pp. $45.95 cloth.

Robert B. Hackey
Providence College
Email: rhackey@providence.edu

Over the past decade, state governments fundamentally reshaped the delivery of health care to the poor by shifting Medicaid beneficiaries from a cost-based, fee-for-service system to a variety of managed care arrangements. The scope and rapidity of this change is striking. As recently as 1993, only 14.4 percent of the total Medicaid population was enrolled in managed care (HCFA 1999a). With encouragement from the Clinton administration, a growing number of states received comprehensive demonstration waivers permitting states to change federal Medicaid eligibility criteria, benefits, and mandate enrollment in managed care plans. As a result, the number of Medicaid beneficiaries enrolled in managed care plans more than tripled in five years, from 4.8 million in 1993 to 16.5 million in 1998, or 53.6 percent of all Medicaid enrollees (ibid.). Ten states also used Medicaid demonstration waivers to expand access to care for more than 800,000 uninsured and the "medically needy" individuals (HCFA 1999b).

The rapid transformation of state Medicaid programs presents several important challenges for policy makers. The devolution of policy making to the states focuses new attention on the capacity of state health bureaucracies to design and implement cost-effective delivery systems that protect the needs of vulnerable populations. Protecting the interests of special needs populations imposes new burdens on state officials who must exercise renewed vigilance to ensure that patients in capitated health plans are not underserved. Finally, the implementation of Medicaid managed care plans creates new winners and losers among patients and providers; states need to preserve safety net providers to serve the poor and disabled while simultaneously introducing new competitors to challenge traditional modes of financing and delivering care to program enrollees.

The two volumes discussed in this essay seek to expand our knowledge of how states designed and implemented Medicaid managed care reforms over the past decade. Mark Daniels' edited collection of essays, Medicaid Reform and the American States, reviews the prospects and pitfalls of Medicaid managed care by presenting case studies of sixteen states that developed demonstration waiver programs in the 1990s. These cases offer an interesting snapshot of these waiver initiatives, but the absence of a shared intellectual agenda handicaps the book. Many contributors adopt a "black box" approach to the development of Section 1915 and 1115 waivers and offer little discussion of the representation of affected interests and groups in framing waiver applications and few insights into the decision making process (e.g., whether to use anticipated savings to expand enrollment for the uninsured). For students of comparative Medicaid policy, more comprehensive treatments such as F. J. Thompson and J. J. DiIulio's (1998) discussion of federalism and Medicaid reform offer a wealth of data coupled with analyses of difficult issues facing reformers (e.g., protecting safety net providers in a competitive marketplace).

In Remaking Medicaid: Managed Care for the Public Good, Stephen Davidson and Stephen Somers "want readers to recognize the great potential of Medicaid managed care, yet also recognize and respect the challenges that must be met for it to reach that potential. We also want to convey the difficulties inherent in these challenges even when the strategy is well conceived and public officials implement it with skill and determination, so that managed care will not be seen as a magic bullet can be simply forgotten once aimed and fired" (4). The editors largely succeed in their goal of providing a comprehensive and accessible overview of the challenges facing public officials and MCOs as they seek to implement Medicaid managed care programs. The contributors explore many issues in depth, including the intricacies of contracting, designing health-based payment systems, assuring access to quality care for special needs populations, measuring the quality of care provided by participating MCOs, and the obstacles and opportunities associated with fully capitated financing systems.

A Question of State Administrative Capacity

The rapid transformation of state Medicaid programs raises important questions about the administrative capacities of state health bureaucracies. Creating and sustaining competitive markets for health services places new demands on state governments and requires different policy-making skills than traditional cost containment initiatives such rate-setting or utilization review (Morone 1992). The characteristics of an effective claims processing organization in a fee-for-service reimbursement system are quite different from the actuarial and managerial skills required to negotiate benefits coverage for special needs populations, design effective enrollment and patient education systems, monitor the quality of care provided to beneficiaries, and sanction plans which provide substandard care.

State officials face numerous challenges in building provider networks, developing materials to educate beneficiaries about managed care, enrollment procedures, and setting capitated rates for participating MCOs. The shift to capitated financing brings to the forefront the administrative competence of state agencies designated to implement Medicaid managed care programs. As Robert Hurley notes in Remaking Medicaid, "Buyer performance has been critical to the origins and evolution of managed care-both in pursuit of greater value for money and in stimulating the formalization of organized delivery systems capable of meeting buyer requirements and demonstrating adequacy of performance" (33). Whereas earlier efforts at cost containment often relied upon cutbacks in payments to providers, low capitation rates may provide financial incentives for MCOs either to underserve Medicaid enrollees or to refuse to participate in the new system altogether.

Devolution raises more questions for policy makers than it answers. A basic question facing state policy makers is whether contract negotiations, building provider networks, enrolling beneficiaries, and developing new payment methodologies should be handled "in house" or subcontracted to private vendors or consultants. The shortfall between the administrative capacity of existing state Medicaid programs and the demands of the new medical marketplace led many states to hire outside consulting firms to draft Medicaid managed care waiver applications. The use of specialized consultants only serves to highlight the importance of building the bureaucratic capacity of state Medicaid agencies, however, since the need for specialized expertise in developing managed care contracts and assessing patient outcomes is ongoing, not episodic. In addition, as John Holahan, Alison Evans, and Stephen Zuckerman note in Remaking Medicaid, states may either capitate payments for non-acute services such as mental health care, case management, and home care to participating MCOs or "carve out" separate managed care or fee-for-service contracts with specialty providers. How might states accommodate safety net providers who have traditionally served the needs of the poor in a capitated delivery system? In answering these questions, state officials may choose from a variety of policy tools--some states have assigned such tasks to existing state agencies, while others embraced privatization for routine program operations.

Unfortunately, few of the cases presented in Medicaid Reform and the American States systematically explore the question of whether state governments possess the expertise and administrative competence to nurture new medical markets. In particular, a variety of organizational questions remains unasked. Did states seek to assist community health centers and other safety net providers in their transition to managed care by fostering the development of Medicaid-only HMOs or other organizational forms? If so, were these efforts successful? How did state waivers seek to measure patient satisfaction with the quality of services provided by MCOs and/or provide due process for patients who were dissatisfied with the services they received? Who was responsible for implementing these tasks? With the notable exceptions of Jacobson and Droskoski's discussion of Delaware's Diamond State Health Plan and the Olivers' profile of Maryland's Section 1115 waiver proposal, the cases shed little light on the policy-making context of developing and implementing Medicaid reform proposals.

HCFA has encouraged the development of information systems to monitor the quality of patient care under Medicaid (Jencks 1995), but existing fee-for-service based Medicaid information systems are ill-equipped to facilitate quality improvement in a managed care environment. In a fee-for-service payment system, utilization review programs focused on the identification of outliers; in capitated system, state officials must design and implement monitoring systems to assess patient outcomes and satisfaction. In most states, such initiatives must be designed from the ground up. In this context, the bureaucratic capacity and professionalism of state health bureaucracies is a crucial explanatory variable in predicting the success or failure of Medicaid reforms.

Some have claimed that Medicaid managed care programs promise to end the two-tiered system of care which has characterized Medicaid since its inception. Implicit in this argument is the assumption that mainstream providers will be able to offer more consistent, higher quality care than traditional safety net clinics and physicians. To assess this claim, however, state officials must gather data on the nature of patient interactions with MCOs. As several contributors to Remaking Medicaid note, however, such an undertaking requires a considerable investment in capacity-building, as the data sets, specialized personnel, and computer systems needed for ongoing outcomes assessments do not currently exist in most state Medicaid bureaucracies. In addition, a lack of education, political efficacy, and resources (e.g., internet access) limit the ability of many Medicaid beneficiaries to become "prudent purchasers" of health care. How can states ensure that Medicaid managed care beneficiaries have an opportunity to make an informed decision in choosing their MCO? Should states employ enrollment brokers to contact and educate enrollees about their plan options?

The mass migration of Medicaid enrollees to managed care occurs in the shadow of an ongoing national debate over the quality of care provided by MCOs. The managed care industry has been buffeted by criticism in recent years from physicians, policy makers, and the press. Policy makers and the public have been exposed to vivid stories of new mothers and babies being tossed from hospital beds by tight-fisted HMOs, or of patients whose longstanding relationships with physicians, pharmacists, and other providers were severed by selective contracting. The solutions fashioned by state policy makers to address such excesses of MCOs, however, have done little to augment the capacity of state Medicaid bureaucracies to monitor the quality of care provided to program beneficiaries. In recent years, most state initiatives to discourage MCOs from underserving their patients have been framed by anecdotes rather than hard data on patient outcomes under managed care (Rochefort 1998). New mandates such as legislation barring "drive through deliveries" and guaranteeing direct access to OB/GYNs did not require the development of extensive monitoring tools, but rather prohibited "excessive" conduct by providers and health plans.

To fulfill the promise of managed care, states must hold providers accountable for caring for the needs of different segments of the Medicaid population. As Sara Rosenbaum notes in Remaking Medicaid, states must develop new ways to finance services that are not covered within the standard benefits package of participating MCOs. Medicaid agencies can either purchase the standard benefits package offered by MCOs, or issue requests for proposals to develop new products that fulfill traditional Medicaid coverage standards (200-202). States have less experience in designing managed care contracts that hold plans accountable for the quality of patient care, mandate standardized data collection, and assess the adequacy of provider networks, patient appeals processes, and coverage of "medically necessary" services. The implication of Rosenbaum's analysis is clear: unless state Medicaid agencies actively recruit personnel who have prior experience in purchasing care from MCOs, states may be at a considerable disadvantage at the bargaining table.

Richard Kronick's and Tony Dreyfus' chapter in Remaking Medicaid argues for a risk- adjusted system of capitation in which "the payer seeks to adjust payments so that they vary according to the predictable element of risk associated with different individuals. In this system, plans can no longer make easy profits by avoiding individuals with predictably higher costs because a plan that enrolls disproportionately low risk members will be paid less than average" (226-227). Traditional approaches to setting capitation rates which pay providers a percentage of the average fee-for-service costs provide incentives for health plans to shun sicker than average patients; a reasonable system of risk-adjusted rates would encourage providers to enroll patients with chronic illness as long as the expenditures for patients could be predicted with a high degree of accuracy. As Kronick and Dreyfus point out, several diagnosis-based payment and classification systems now exist which could be used to construct risk-adjusted capitation rates, but many state Medicaid programs find themselves short of both the administrative and political resources needed to institutionalize new payment mechanisms.

Improving Care for Special Needs Populations

Designing an effective managed care network for poor and underserved patients requires a fundamental shift in the relationship between state health bureaucracies and providers. Enrolling poor, disabled, and elderly beneficiaries in managed care raises a number of thorny implementation questions. As Robert Hurley notes in Remaking Medicaid, states face challenges in preserving the full statutory benefits guaranteed to Medicaid beneficiaries, which in many cases exceed those offered by MCOs' standard benefits packages. To ensure that all enrollees, and patients with special needs in particular, receive services that they are entitled to, states must conduct ongoing performance evaluations of HMOs, assess the quality of service coordination for patients with chronic conditions, and insure that the capitation rates paid to MCOs are adequate to provide an appropriate level of care.

 Managed care has significant advantages for patients with chronic conditions because of its emphasis on prevention, coordination of caregivers, and periodic contacts with patients and their families. Indeed, successful HMO disease management programs can deliver more cost-effective care, producing better patient outcomes, higher patient satisfaction, and lower rates of hospitalization (Zelman and Berenson 1998: 94-99). Since the development of disease management systems requires a considerable investment, however, capitated rates of payment for chronically ill patients must take into account the special needs of the target populations. State efforts to develop capitated financing arrangements for the disabled and elderly must encourage participating MCOs to educate participating providers in the new treatment modalities, identify enrollees who would benefit from disease management, and empower patients and their families to actively monitor their condition. A capitated payment system encourages the use of innovative disease management approaches, but capitation rates, which are too low, may offer incentives for providers to withhold basic services.

Furthermore, as Robert Hurley and Debra Draper note in Remaking Medicaid, efforts to "mainstream" persons with disabilities into commercial MCOs are likely to encounter significant resistance from organized advocacy groups and providers who have traditionally served special needs populations. Reshaping the payment system by enrolling sizable numbers of chronically ill and disabled beneficiaries into capitated delivery systems requires both political entrepreneurship and administrative resources that are unlikely to be present in all states.

The Politics of Mandatory Enrollment in Managed Care

The extraordinary variation in state managed care enrollment raises a crucial question for comparative research: What can account for the willingness of public officials to first embrace, and then successfully implement, managed care programs for Medicaid? By 1998, managed care penetration in state Medicaid programs ranged from a low of 0 percent (Alaska, Wyoming) to a high of 100 percent (Tennessee). Although eleven states had enrolled more than 80 percent of their Medicaid caseload in managed care, seven other states reported managed care enrollments of less than 20 percent (HCFA 1999c).

Medicaid Reform and the American States misses an opportunity to explore the politics which accompanied the development of state waiver applications. Why, for example, did most states opt to enroll only poor women and children in managed care on a mandatory basis? Did these decisions reflect the political clout of nursing homes and other health providers, or the relative difficulty of designing capitated payment systems for patients in institutional settings and persons with chronic disabilities (e.g., AIDS)? While more than 60 percent of Medicaid enrollees are young families, this group only accounts for less than 30 percent of program expenditures in most states. The average cost for elderly and disabled beneficiaries and the rate of spending growth for these populations are much higher than for AFDC/TANF eligible enrollees (Thompson and DiIulio 1998). Although the real potential of Medicaid managed care to control costs and improve patient outcomes will remain unrealized until states shift elderly and disabled patients to capitated settings, the contributors to Medicaid Reform in the American States do not discuss the political obstacles which accompany mandatory enrollment in managed care for these groups.

Too many chapters in Medicaid Reform and the American States seem divorced from the political context that shapes Medicaid policy decisions. This is unfortunate, for the book includes case studies of many states that have not received much attention in the scholarly literature (e.g., Alabama, Delaware, Kansas, and Oklahoma). Many of the cases could offer a richer analysis of how Medicaid reform reached the formal policy agenda if there had been greater discussion of how the proposals were defined by issue expanders and containers in legislative debates, and how governmental actors, institutions, and organized interests sought to advance their interests through the policy-making process. This is a difficult, but not impossible task, as illustrated by Michael Sparer's (1996) study of Medicaid policy in New York and California. Had the case studies in Medicaid Reform in the American States followed a similar logic, the book would be a significant addition to both the literature on state politics and policy making and to our knowledge of the politics of Medicaid and state level health care reform.

Drawing upon national data, case studies, and practitioners' reports from the field, one of the real contributions of Remaking Medicaid is its discussion of which policy decisions will be devolved to the states. Many recent discussions of managed care have been characterized by either strident criticism or unabashed enthusiasm, but the contributors to Remaking Medicaid provide a balanced assessment of the circumstances under which managed care can meet policy makers' expectations.

Conclusion

Over the past decade, state officials have reinvented how Medicaid provides acute care services to the poor. At century's end, however, Medicaid programs face a greater challenge in enrolling the chronically ill, disabled, and elderly in managed care. State governments must play a vital role in building markets as both purchasers and regulators. As purchasers of health care, Medicaid agencies must use their market share to negotiate cost savings while ensuring that MCOs have the resources necessary to deliver cost-effective care to vulnerable populations. A capitated delivery system also imposes new responsibilities on the state to advocate for the interests of Medicaid enrollees and monitor the behavior of MCOs. If past experience is any guide, many states will rise to the tasks before them, while others will falter. States that are able to build their internal policy-making capabilities have a remarkable opportunity to improve the quality of care for underserved populations and to restore predictability and order to the budgetary process. In the absence of the specialized expertise and administrative competence required to monitor patient outcomes and plan performance, however, state Medicaid managed care programs are likely to disappoint both policy makers and patients.

References

Health Care Financing Administration (HCFA). 1999a. National Summary of Medicaid Managed Care Programs and Enrollment. Online at http://www.hcfa.gov/medicaid/trends98.htm.

--. 1999b. States with Comprehensive State Health Reform Demonstrations. Online at http://www.hcfa.gov/medicaid/1115dm98.htm.

--. 1999c. Medicaid Managed Care State Enrollment, June 30 1998. Online at http://www.hcfa.gov/medicaid/mcsten98.htm.

Jencks, S. F. 1995. Measuring Quality of Care under Medicare and Medicaid. Health Care Financing Review 16 (4): 39-54.

Morone, J. A. 1992. Hidden Complications: Why Health Care Competition Needs Regulation. The American Prospect 10: 40-48.

Rochefort, D. A. 1998. The Role of Anecdotes in Regulating Managed Care. Health Affairs 17 (6): 142-49.

Sparer, M. 1996. Medicaid and the Limits of State Health Care Reform. Philadelphia, PA: Temple University Press.

Thompson, F. J., and J. J. DiIulio. 1998. Medicaid and Devolution: A View from the States. Washington, DC: Brookings Institute.

Zelman, W. A., and R. A. Berenson. 1998. The Managed Care Blues and How to Cure

Alcohol, Freedom, and Responsibility:

Judith Rumgay. Crime, Punishment, and the Drinking Offender.
New York: St. Martin's Press, 1998. 234 pp. $59.95, cloth;
Mariana Valverde. Diseases of the Will: Alcohol and the Dilemmas of Freedom (Cambridge Studies in Law and Society).
Cambridge: Cambridge University Press, 1998. 264 pp. $59.95, cloth; $19.95, paper.

James Harold
University of Minnesota

If I break a law or a promise to a friend, would it matter if I were drunk at the time? What if I were an alcoholic-would that make a difference? How does alcohol affect the way we attribute responsibility (legal as well as moral) and, more importantly, should alcohol use or alcoholism affect attributions of responsibility? These questions are at once moral, legal, medical, and philosophical. The fact that a person is drunk while committing a crime or is an alcoholic does change the way we think about their character, their actions, and the responsibility they bear for those actions; it's not always clear how or why alcohol has this effect on our thinking. Two recent works, in very different ways, focus critically on the complex relationship between alcohol, moral behavior, and responsibility. Judith Rumgay's Crime, Punishment, and the Drinking Offender takes aim at the criminal justice system and its practices towards crimes involving alcohol. Rumgay takes a close look at the role the intoxication excuse plays in evaluating and punishing criminal offenders, in Great Britain. In Diseases of the Will, Mariana Valverde looks at the history of society's perceptions of and attitudes toward alcohol and alcoholism over the last hundred and fifty years. Valverde does not limit herself to issues of law, but takes up broader issues such as character and moral responsibility. Both authors inspect closely different aspects of the relationship between alcohol and responsibility.

Virtually all of us have had to face questions about alcohol and responsibility at one time or another. Whether it is a parent, child, friend, lover, or oneself, nearly everyone has had to decide whether or not to blame someone they care about for an act committed while intoxicated. Typically, our intuitions about the relationship between responsibility and alcohol equivocate. What we would like to have is an account of how and whether alcohol influences one's ability to act freely, and hence, what degree of responsibility it is reasonable to expect of people. If we are interested in understanding the relationship between alcohol and responsibility, a natural way to begin is by looking at criminal, that is, legal, responsibility. The criminal law is less complex than are the principles of moral responsibility. Attributions of criminal responsibility are also public, and hence easier to study.

The attitude of British criminal law towards intoxicated crime is the topic of Crime, Punishment, and the Drinking Offender. One of the theses of Judith Rumgay's carefully researched work is that what she terms the "intoxication excuse" is both ubiquitous and fallacious. Her primary goal, she says, is to provide a diagnosis of the popularity of the intoxication excuse given her contention that the excuse is without merit. A good part of the book is devoted to a report of a small, but very detailed study she conducted in an unnamed British city magistrates' court. This study supports and explains claims made in the remainder of the book: that alcohol neither excuses nor mitigates criminal behavior, and that the persistence of the excuse is a result of widespread, though false, beliefs about alcohol's effects on behavior. Hence, Rumgay's book is a call for radical revision in legal practice-she believes that the law should give an unambiguous "Yes" in response to the question "Are intoxicated persons legally responsible for their acts?"

Contemporary British law, like our own intuitions, is not unambiguous. In chapter 1, Rumgay describes what she calls the "legal dilemma" over alcohol and responsibility. The dilemma is that on the one hand, allowing people to give alcohol as an excuse for criminal behavior would have terrible consequences for society, since the difficulty of verification means that nearly everyone could use the excuse; yet, on the other hand, the rights of the defendant demand that the defendant's state of mind be taken into account. This dilemma has a long history. In the 17th century, John Locke noticed that his theory of personal identity implied that acts committed while intoxicated were not consciously done, and hence, it seemed that the actors were not responsible. He wrote:

Is not a man drunk and sober the same person? -Why else is he punished for the act he commits when drunk, though he be never afterwards conscious of it? . . . Human laws punish . . . because, in these cases, they cannot distinguish certainly what is real, what counterfeit; and so the ignorance in drunkenness . . . is not admitted as a plea. For, though punishment be annexed to personality, and personality to consciousness, and the drunkard perhaps be not conscious of what he did, yet human judicatures justly punish him . . . (Fraser 1959: 462-463).

For Locke, the consequences of allowing the intoxication excuse clearly outweighed the fact that an act committed while under the influence of alcohol might not be consciously committed. Modern British law is less clear-although law expressly forbids the alcohol excuse, the intoxication excuse has come into use through consideration of other issues, especially mens rea (the guilty mind). Rumgay describes the way in which contemporary law has struggled to reconcile the potentially disastrous consequences of allowing a blanket excuse for criminal conduct with the belief that in at least some cases, drinking precludes people from forming the necessary criminal intent. Various solutions to the dilemma have been proposed, including creating a new crime for intoxicated offenders-"dangerous intoxication"-and subsuming cases of intoxicated crime under the category of recklessness. These strategies seek a way out of the dilemma, but they do not question the assumptions that underlie the problem. Rumgay proposes to dissolve the dilemma by eliminating its second horn, since she claims that alcohol use does not and cannot effect mens rea. If Rumgay is right, the dilemma is a product of false, though widely held, beliefs about alcohol.

Beginning in the second chapter, Rumgay criticizes the belief that alcohol inhibits freedom, and hence reduces responsibility. She reviews the major academic theories of intoxicated crime, and argues that all of these theories either are overly deterministic (more so than can be supported by the evidence) or else rely implicitly on popular but questionable assumptions. Some theories that claim a deterministic relationship between alcohol use and crime are clearly unsupportable. It is possible to drink and not commit crime. Some rely implicitly on "common sense" beliefs about alcohol use, beliefs that are at least questionable. Chapters 3 and 4 continue this work, as she attacks theories that propose to neutralize or mitigate intoxicated crime. These theories too, Rumgay insists, either fall into deterministic thinking, or else rely on unsupported beliefs.

One striking feature of Rumgay's approach is that she is not merely interested in discrediting these theories; she is also interested in understanding why so many people have come to believe that alcohol inhibits free will. As she observes, "The significance of cultural and social learning in the transmission of beliefs about and attitudes to alcohol has been stressed in much academic theory and research" (48); a driving force behind this cultural currency, she believes, is the flexibility and the effectiveness of the alcohol excuse. Each time a defendant successfully appeals to intoxication as a sufficient or contributing cause of her crime, this strategy reinforces the belief that alcohol does cause crime. Rumgay offers some evidence to show that those who are already motivated to commit a crime may drink so that they can do what they desire and avoid taking the blame.

The core of the book, and what many will take to be the most revealing part, is the report of her study of a city's magistrates' court. This takes up chapters 5 through 8. Here she is centrally interested in understanding how magistrates, probation officers, and offenders typically view the role of alcohol in crime. The descriptions are illuminated by her earlier assertions that the intoxication excuse can be invoked to explain widely divergent and even mutually contradictory behavior. She notes that it is commonly believed that alcohol "positively transforms experiences, enhances social and physical pleasure, enhances sexual performance and experience, increases power and aggression, increases social assertiveness and reduces tension" (47). But how could alcohol both increase aggression and reduce tension? This inconsistency bolsters Rumgay's claim that lay beliefs about alcohol's effects are false. Rumgay's suggestion is that alcohol is believed to have all of these widely divergent effects because it is advantageous for drinkers to attribute these features to alcohol, rather than to themselves.

Rumgay's study of the city magistrates' court supports her claims in part by giving ample evidence of the wide range of offenders, motivations, and crimes that are linked with alcohol in one way or another. Especially interesting is her discussion of the "hopeless cases" (130-133), lifetime alcoholics who appear to court workers to be lost, almost childlike. Magistrates and probation officers alike are ready to concede that such people have little responsibility or even awareness of anything that they do (including their actions during court appearances). But Rumgay maintains that, given the lack of evidence that alcohol causes behavior, even such "hopeless cases" are in fact responsible for their acts.

Rumgay's thorough and well-argued book nicely illustrates the complexities and occasional inconsistencies of the intoxication excuse. She makes a convincing case that one of the central attractions of the excuse is its effectiveness and flexibility, and that its effectiveness depends on dubious assumptions. But we may be somewhat hesitant to accept her claim that there is no connection between intoxication and responsibility. In a brief passage, Rumgay concedes that academic theories of intoxication have been very effective in predicting the habits of alcoholics over a long period of time (50). That is, theories about the effects of drinking, while not sound predictors at the level of the individual act, are nonetheless reliable over the course of a lifetime of drinking. This raises the question of whether alcohol might affect responsibility not on an act-by-act basis, but rather by having an effect on the character of the person who drinks. Is it possible that drinking, while not determining one's acts, nonetheless yields some indirect influence by increasing some desires and decreasing others, or by instilling certain habits?

In her book, Diseases of the Will, Mariana Valverde returns to the idea of habit again and again as a way of understanding the effect of alcohol on responsibility. Her project focuses on habitual drinking, and on the history of alcohol and alcoholism; she is particularly interested in the 'governance' of alcohol-that is, the ways in which political and social groups have attempted to control alcohol consumption. Hence, Valverde has several interconnected theses: that alcohol has a long-term effect of weakening or altering the will; that alcohol has this effect through habit, a mechanism which she believes has been ignored by academics; that alcoholics have, through Alcoholics Anonymous (AA) and similar organizations, themselves had a remarkable degree of control over how alcoholism is understood; and that thinking about alcoholism can teach us about the will and about moral responsibility. She pursues these different lines of argument concurrently.

In the first chapter, Valverde introduces the concept of "habit," a term which she attributes to William James (and, to a lesser extent, the other American pragmatists). Habitual acts, while not determined by habits, nonetheless are not completely freely willed. We might say that habits constrain the will, so that we are inclined towards certain kinds of actions; not acting in the way that our habits incline requires unusual effort, sometimes more so than we can reasonably be expected to expend. Valverde writes: "Habitual action, such as drinking too much or taking opium, is thus best reformed not by attempting to suddenly flex one's will by mental effort, but rather by physically stopping the chain of behaviors and neural connections that have been set up and worn into a groove by previous repetitions" (36). Habit is concerned not with individual actions, but rather with character: virtues, vices, and dispositions. Hence, the alcoholic is responsible for developing those traits of character that, in turn, have some (though not total) control over her actions.

Valverde argues that the practice and rhetoric of Alcoholics Anonymous express the attitude that alcoholism is a habit (this despite the fact that AA labels it a disease). AA is, she notes, an explicitly pragmatic organization, interested not in theory but in solutions that work. The famous "twelve steps" nonetheless embody the middle ground between determinism and complete freedom of the will. They emphasize both the alcoholic's helplessness in face of her habit and the importance of taking responsibility. These two aspects, Valverde implies, seem mutually inconsistent in the context of the freedom and determination dichotomy. Valverde further emphasizes that these twelve steps evolved as part of a new approach to addiction, distinct from both religion and medical science. This new approach has been adopted to situations as diverse as internet addiction and incest survivor syndrome.

The second chapter of Valverde's book traces the early history of medical attitudes towards and theories of alcohol and alcohol addiction. Ultimately she concludes that the attempt to 'medicalize' alcoholism failed. Even the slogan "alcoholism is a disease" is a slogan promoted not by the medical profession, but by recovery groups such as AA and by temperance organizations. Victorian medical practitioners attempted to study and treat alcoholism by grouping it with various forms of mental illness, under the term "monomania." The idea was that monomaniacs suffered from diseases of the will, and that doctors should seek to develop treatment to heal and restore the will. The will was thought to be weakened by alcohol, so that the alcoholic could not suppress the desire for more alcohol. The natural remedy, then, is to medically fortify the will. Not surprisingly, none of the techniques Valverde discusses succeeded in doing this. The will, unlike some other mental capacities, like memory, has never been satisfactorily reduced to some set of biological functions.

In the third and fourth chapters, Valverde pursues this history further. First, she studies the late nineteenth century effort to define an inebriate identity that would be stable enough to regulate and control. This drive was not merely medical but also legal; it was thought that a medical identity would give the state the power to institutionalize recognized inebriates. This effort failed because physicians were never able to "offer an agreed-upon therapy for inebriety, whether physical or psychological, other than the general hygienic regimes used for all nerve diseases" (74). As medical efforts at treating inebriates lapsed, so did the laws that punished them. After the second world war, the social view of drinking changed, and so did the legal and medical efforts to control it. The belief that alcoholism was a "disease of the will" was rejected and replaced with a call for moderate, controlled drinking. The idea was (and to some extent still is) that the desire for pleasure is natural and drinking is pleasant. Excessive drinking was still viewed as a problem, but not as a disease. The medical profession has distanced itself from alcohol and alcoholism, and the study of alcohol fell into the hands of psychologists and sociologists. Here alcoholism came to be thought of as a symptom of a personality problem. Drinking (even excessive drinking) was not thought to cause disease; rather, it is the result of some preexisting problem. But as this "alcohology" approach to the study of alcohol turned its attention increasingly to ethnicity and heritage as the underlying cause of alcoholism, it too fell into disrepute.

Chapter 5 of Diseases of the Will takes a close look at the techniques of Alcoholics Anonymous. Valverde takes pains to show that, despite AA's official claim that alcoholism is a disease and an identity, its techniques and practical wisdom fit better with the model of alcoholism as habit. There is a tension within, she argues, between the organization's insistence on the concreteness of the alcoholic identity and the relative flexibility of the category of habit. Valverde claims that the group would do better to renounce identity and pursue the "more novel possibility of a fully habitual ethics" (142).

In chapters 6 and 7, Valverde turns her attention to the state's current efforts to control and regulate alcohol. She argues that the United States, Canada, and Britain have moved away from efforts to control people (e.g., inebriate laws) and towards efforts to control practices. These efforts include controlling how, when, where, and which alcoholic beverages may be consumed. Other efforts include attempts to reduce risk and prevent harm: for example, the public campaign to persuade pregnant women not to drink. These techniques of regulation, she argues, depart from the Foucaultian model that she criticizes.

In chapter 8, Valverde concludes with a discussion of the law's attitude towards alcohol and responsibility. For the most part, the law has been reluctant to officially recognize any alcohol excuse. However, in practice, and especially in regard to mens rea, alcohol has been used to excuse crime and mitigate punishment. Valverde spends some time discussing the Canadian Supreme Court decision, later reversed by the legislature, which allowed an "intoxicated autonomism" excuse. Valverde's account of the law, unsurprisingly, agrees for the most part with Rumgay's findings, but Valverde differs with Rumgay in her critique of the law. Where Rumgay finds that magistrates erred when they explicitly or implicitly recognized an alcohol excuse, Valverde decries the law's failure to recognize any intermediate category between an involuntary and a freely willed act; again she returns to habit. She suggests that a recognition of habit would increase our ability to understand and respond to alcoholism.

Valverde's ambitious book is not always easy to follow. Her determination to address several interconnected questions simultaneously at times makes it difficult for the reader to get clear on each point. Nonetheless, the author succeeds admirably at her primary goal: to introduce the idea of habit as a third alternative to complete freedom and determinism, and to persuade us that it is worth further exploration. Of course, we should not expect that either of these two books will fully address the questions that they inevitably raise; the topic is simply too broad and complex for that. It may be that the case of alcohol can help us to rethink in a general way the connection between free will and moral responsibility-a connection which, as Valverde notes, philosophers have lately neglected. Valverde's account of habit is suggestive and incomplete, but that should be taken as an invitation for further thinking and study on the subject. She never sets out to give a complete account of habit herself; she instead aims to reinvigorate our thinking about alcohol, and this is certainly welcome. The questions that Valverde and Rumgay leave unanswered are questions worth asking and pursuing further. Some of these unanswered questions are: Can we develop an account of habit that is consistent with the medical and psychological evidence? If so, what would this account say about the alcoholic's responsibility (criminal and moral) for her actions? And could such an account give us greater insight into the more general question of individual responsibility?

One step in exploring these questions is to investigate the ideas of freedom and responsibility, to see if there is sufficient depth to them to accommodate something like habit. It may be helpful in this regard to revive a very old philosophical distinction. In the Nicomachean Ethics, Aristotle stressed the distinction between holding someone responsible for their acts and holding someone responsible for having the kind of character that they do. Selfish or lazy people, Aristotle said, become so voluntarily, but once they are selfish or lazy, they cannot immediately cease to be such, and their vices of character inevitably shape their actions. "[T]o the unjust and selfish man it was open at the beginning not to become men of this kind, and so they are unjust and self-indulgent voluntarily; but now that they have become so it is not possible for them not to be so" (McKeon 1941). The distinction between responsibility for actions and responsibility for character opens an intriguing possibility: perhaps alcoholics, while fully responsible for becoming alcoholics, are nonetheless relatively powerless to change their alcoholism. And being alcoholics, their freedom to act in certain ways is impaired by the propensities and habits which alcoholism entails. We may then come to see responsibility as a more complex matter than it initially appeared. We are responsible not only for our individual acts but also for developing those habits and traits of character which facilitate our acting in certain ways and inhibit our acting in other ways. On such a view, while the alcoholic does not act under strict coercion, she nonetheless acts under the influence of a habit that she freely chose but cannot freely abandon.

Just as we can distinguish between these two kinds of responsibility, we might borrow from Immanuel Kant a distinction between two kinds of freedom (Beck 1995). "Negative" freedom is mere freedom from determination; "positive" freedom, according to Kant, is freedom to legislate rules for oneself, and act accordingly. To be negatively free it must be the case that one's actions are not strictly caused by something else. But a person who acts in an utterly random manner is free in this sense: nothing compels him to do this or that; he simply rolls some mental dice and acts. To be positively free, by contrast, is an accomplishment. (Interestingly, this mirrors a claim of AA: that sobriety is a state of freedom achieved only through hard work.) To be positively free is to be capable of acting in a way that expresses a commitment to a plan. It is to be the cause of one's own actions, rather than simply a site of spontaneous activity. Is the alcoholic free? In the negative sense, surely the answer is yes- alcohol does not control his or her actions. But are alcoholics free in the positive sense? The answer to this question is not so obvious. The point of complicating matters with additional terms and distinctions is not to confuse the issue, but to expand our set of tools for understanding how alcohol might affect responsibility. If we believe both that Rumgay is right in thinking that alcohol does not determine actions, and that Valverde is right to think that habit nonetheless impacts the will, then we need to describe different degrees and varieties of freedom and responsibility.

One way of understanding the complexity of attributions of responsibility is through the wide range of "reactive attitudes" we take up towards those we take to be responsible persons (Strawson 1962). These attitudes include resentment, gratitude, love, forgiveness, and indignation (cf. Wallace 1996). Perhaps it would be worth thinking through which attitudes and practices are reasonable with regard to alcoholics, or intoxicated behavior. It is conceivable that in some cases, only some of these attitudes seem reasonable, and only to some degree (in much the way that we hold children to be only partially responsible). Further, one can also experience reactive attitudes towards oneself: remorse, anger, and even "moral pain" (Care 1996). In his book, Living With One's Past, Norman Care describes what he calls the "problematic agency" of an alcoholic or similarly impaired agent. A dry alcoholic may feel anger and frustration at the person he has (freely) become; he can regret the choices that led him to alcoholism, but he might feel anger, not regret, about the acts he committed while intoxicated. Such reactive attitudes express a decidedly complex view of the nature of responsibility. Developing a more careful account of the reactive attitudes and their relation to responsibility may be helpful, and the psychological character of reactive attitudes invites empirical study.

Reading Crime, Punishment, and the Drinking Offender and Diseases of the Will makes one wonder whether our usual categories of freedom and responsibility are up to the task. There are a number of ways in which we might broaden our philosophical tools for thinking about the problem. And if freedom and responsibility are not as straightforward as they appear, perhaps we need a more sensitive system of criminal law, which addresses not only whether or not the accused is responsible, but also in what sense she or he is responsible. Rumgay's study showed the ways in which magistrates and offenders found ways to sneak the intoxication excuse in through a back door. But could we develop a way for the intoxication excuse to have some legitimate impact on punishment? It would be a remarkable accomplishment if these two books provoke more of us-lawyers, health professionals, philosophers, and policy makers-to take an interest in the intricate relationship between alcohol, freedom, and responsibility.

References

Beck, L. W., trans. 1995. Kant's Foundations of the Metaphysics of Morals, 2nd ed. Upper Saddle River, NJ: Prentice Hall.

Care, N. 1996. Living With One's Past: Personal Fates and Moral Pain. London: Rowan & Littlefield Publishers.

Fraser, A. C., ed. 1959. Locke's Essay Concerning Human Understanding, Complete and Unabridged. New York: Dover Publications.

McKeon, R., ed. 1941. The Basic Works of Aristotle. New York: Random House.

Strawson, P. F. 1962. Freedom and Resentment. Proceedings of the British Academy 48: 1-25.

Wallace, R. J. 1996. Responsibility and the Moral Sentiments. Cambridge, MA: Harvard University Press.

C. E. Schneider. The Practice of Autonomy: Patients, Doctors, and Medical Decisions.

New York: Oxford University Press, 1998. 307 pp. $39.95 cloth.

Debra Roter
Johns Hopkins School of Public Health

In his challenge to the autonomy paradigm, Carl Schneider strikes at the soft underbelly of a virtually uncontested tenet of modern medical practice. After documenting the failings of routinized and often proforma practice inspired by the letter of the law, Schneider suggests several alternatives by which patient preferences and needs may be more effectively met.

The method of presentation is both scholarly and personal. Schneider draws heavily on an impressive mastery of the qualitative and quantitative research literature, including the rich body of published pathographies, as well as his own research on medical decision making. A special joy in reading Schneider's prose is his wonderful ability to present complex ideas in concise and appealing style. When reporting on the work of others, or in presenting portions of ethnographic transcripts, he has a rare ear for capturing and conveying the perfect quote, often in a colorful, literary, or even entertaining manner.

There are four central arguments to Schneider's thesis. The first questions whether the objective of autonomy can ever truly be achieved in the modern context of depersonalized medical care and patients' rights. The second argument is that there is an inherent contradiction in the autonomy principle as it has been transformed from a doctrine which entitles, but does not require the patient to take an active role in treatment decision making, to a mandatory view that treats patients as morally obligated to act autonomously. Third, disregard for individual patient preference or resistance, reluctance, or incompetence by physicians has sometimes resulted in proforma and useless autonomy rituals. Finally, fourth, there are alternatives to the autonomy paradigm that may more effectively meet patient needs.

I'll briefly comment on each of these.

Patient autonomy is regarded as the preeminent bioethical value, superceding beneficence and social justice in patient-physician relationships. The ascendance of the autonomy paradigm over the past several decades, supported by modern medical case law, has become the guiding value driving health-care provider behavior. Legal support for the autonomy doctrine originated as a largely protective principle designed to inoculate patients against the possible transformation of legitimate medical authority to medical paternalism.

That these protections have achieved some success is evident in such pronouncements of victory over paternalism as those made by Arthur Caplan: "The Freddy Kreuger of bioethics for the better part of two decades has been the doctor who pushes his or her values onto the patient ...This devil has been completely exorcised and a large part of contemporary bioethics scholarship seems to be devoted to the task of assuring that the paternalistic doctor stays dead and buried..." (4).

This victory, however, may only be illusory; while the letter of the law has produced the appearance of protection against paternalism, the spirit has often been neglected. Only an idealized patient-physician relationship could be sufficiently personal and sensitive to the various, ambivalent, and fluid preferences patients have for autonomy. "Exactly because patients' views about making medical decisions are so complex and dynamic, it would be hard even with perfect information to match doctors and patients on that basis"(183). The reality of medical practice makes so individualized and flexible a relationship unlikely to ever have been common and even less likely to exist now as medical bureaucracies act to shift doctors' orientation from "Hippocratic individualism," in which the interests of particular patients are paramount, to consideration of the collective health of an entire patient panel. Even if this shift has been overstated, the current emphasis on practice efficiencies and productivity requirements that pressure physicians to see more patients in shorter time periods is likely to curtail the opportunities to personalize the relationship and optimize the decision-making process.

The consolation for patients in the loss of decisional control and bureaucratic impersonality, Schneider argues, is a formalization of patient rights and administrative due process. Ironically, however, "rights exacerbate the impersonality of the relations between doctor and patient ... and the process is self-reinforcing: Trust wanes as relationships become more bureaucratic and less personal. This creates a call for rights. The rights solution further alienates doctor and patient because it distances them and because the doctor resents the distrust that motivated the solution" (201).

The second argument against the hegemony of the autonomy principle raised by Schneider is the inherent contradiction in a notion of "mandatory autonomy." The autonomy principle has been transformed from a doctrine which entitles, but does not require the patient to take an active role in treatment decision making, to a mandatory view that treats patients as morally obligated to act autonomously. Schneider argues that the doctrine of patient autonomy has gone beyond a principle of medical conduct, that is, prescribing how doctors should treat patients to prescribing how patients should conduct themselves. This refocusing "edges toward imposing on patients the duty of freedom, the moral obligation to make their own medical decisions" (xiv). Not only have patients lost the right to decide not to decide, but a refusal to assume the obligations and responsibilities of mandatory autonomy is viewed as a moral failing deserving of contempt and blame.

The third argument raised by Schneider in his challenge of the autonomy paradigm is that its objectives are often pursued regardless of patient preference, reluctance, or incompetence to assume an autonomous role in the medical relationship. Indeed, there are some patients, and perhaps many patients at especially vulnerable junctures and in particular circumstances who do not want to or cannot assume the burden for their medical decisions. It is here that Schneider devotes much of the documentation of the book, establishing the patient's voice through excerpts from pathographies and ethnographic interviews. The poignancy with which this voice expresses confusion, fear, and hopelessness provides devastating insight into the ambivalence of patients autonomy experience. More often than openly acknowledged by the law or bioethicists, those procedures established to assure patient autonomy in informed consent and treatment decision-making have become performa and useless autonomy rituals. Schneider concludes that "...the world is too complex for the wooden versions of autonomy principle that dominate the law and ethics of medicine. That principle has been too monolithic to accommodate the different kinds of patients, doctors, illnesses, and contexts that characterize the world of medical decisions" (33).

Fourth, Schneider argues, patients want something more, or different, than autonomy in their relationship with their physician. In lamenting the small and perhaps even shrinking likelihood of achieving an optimal level of autonomy for each patient, Schneider suggests that patients prize other more attainable goals. Patients, he argues, want and value competence and the kindness of solicitous personal care above all else. Schneider proposes the institutionalization of standard care guidelines to achieve the former and ten rules of civility to achieve the latter.

Guidelines are offered as a normative standard for medical care as well as a reflection and embodiment of patients' social experience with that care. Suggesting a creative addition to traditional guidelines that goes beyond simply guiding physician behavior with a consensus of expert opinion regarding treatment decisions, Schneider suggests that guidelines can help both physicians and patients through the decision-making process by providing insight into patients' common experience with treatment decisions. "For example, a patient considering a kidney transplant might rather learn whether the average nephrologist would decide to have a transplant instead of continuing with dialysis and to learn whether the average patient chooses a transplant and is glad afterward than to hear that in X percent of transplants a new kidney lasts Y years with Z percent complications" (213).

Schneider concludes that guidelines used in this manner could provide a resource to patients that mediates between the dangers of coercion or paternalism and the sense of disorientation and abandonment many patients experience when facing an overwhelming body of information from which medical and treatment decisions must be made.

To achieve kindness and personal solicitous care, Schneider proposes ten easy to follow rules of civility designed to establish the habit of acting in ways which are "at least inoffensive and at best solicitous, generous, and gratifying" (220). These rules include such common sense recommendations as: do not keep people waiting, respect privacy, introduce yourself to strangers, grant other adults the same courtesy in titles you accord yourself, express sympathy when you deliver bad news, return phone calls, think about the effect on your patients of what you do and say, and finally, take the time you need to talk to the patient, and listen and seem to listen. It is only the last two rules that are distinguished as "...the most difficult to apply because they require judgment. Doctors need to discover what is worrying patients and to take their histories, so patients need to be allowed to talk. But left to their own devices, many patients will roam and ramble. In short doctors need to acquire information as politely as possible, and always with at least an appearance of attentiveness" (225).

Surely, no one can argue with the merits of good manners; how can the world not be a better place if even basic rules of civility are followed? However, more than manners are involved in talking and listening to patients. It is a matter of skill and competence. Disappointingly, Schneider dismisses, almost out of hand, teaching communication skills to physicians: "...the "dialogue school" of bioethics tends to forget that the quality of dialogues varies widely, even when the participants are willing. ...Such skills are rare, hard to teach, and prone to crumble under the pressures of practice" (183).

Schneider's dismissal of a large and convincing literature in the area of training in communication skills is disappointing and incorrect. Physician communication skills can be effectively taught to physicians in training, as well as physicians already in practice (Roter and Hall 1992; Roter et al. 1995). Furthermore, communication skills have been linked to patient satisfaction, compliance, and patient recall and comprehension of information (Hall, Roter, and Katz 1988), as well as a variety of patient health outcomes(Stewart 1996).In sum, Schneider's arguments are made forcefully and, with the exception of the last, convincingly. Patients' rights advocates, bioethicists, medical sociologists, health services and health care communication researchers, as well as physicians and medical students, will all appreciate Schneider's careful documentation and insightful critique of the near sacrosanct principle of patient autonomy. Dr. Schneider is clearly a gifted writer and researcher who weaves the law, logic and reason with both empirical evidence, a good sense of the reality of medical practice, and a kind heart.

References

Hall J. A., D. L. Roter, and N. R. Katz. 1988. Meta-Analysis of Correlates of Provider Behavior in Medical Encounters. Medical Care 26:657-675.

Lipkin, M., C. Kaplan, W. Clark, and D. H. Novak. 1995. Teaching Medical Interviewing: The Lipkin Model. In The Medical Interview: Clinical Care, Education, and Research, ed. M. Lipkin, S. Putnam, and A. Lazare. New York: Springer-Verlag.

Roter, D. L. and J. A. Hall. 1992. Doctors Talking to Patients/ Patients Talking to Doctors: Improving Communication in Medical Visits. Westport, CT: Auburn House.

Roter, D. L., J. A. Hall, D. E. Kern, L. R. Barker, K. A. Cole, and R. P. Roca. 1995. Improving Physicians' Interviewing Skills and Reducing Patients' Emotional Distress: A Randomized Clinical Trial. Archive of Internal Medicine 155:1877-1884.

Stewart, M. A. 1996. Effective Physician-Patient Communication and Health Outcomes: A Review. Canadian Medical Association Journal 152:1423-1433.

Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800-54.
Cambridge, England: Cambridge University Press, 1998. 368 pp. $64.95 cloth.
Nancy Tomes, The Gospel of Germs: Men, Women and the Microbe in American Life.
Cambridge, MA: Harvard University Press, 1998. 351 pp. $29.95 cloth.

Graham Mooney
Wellcome Institute for the History of Medicine, London

Today's preventive health professional in the developed world would not recognize the public health panorama of Britain in the mid-1840s. Water, filth and sanitary engineering dominated at the expense of medical involvement. Nowadays, however, public health is concerned as much with food quality and immunization as it is with drains. As Christopher Hamlin observes, "in many societies this 'public health' has an authority to act on lives and property greater than that of any public agency save a fire department" (Hamlin: 1). One might reasonably ask, how did public health come to be so widely defined, considering it possessed such as narrow focus in its beginning? A large part of the answer lies with those 'apostles of the germ' who form the topic of Nancy Tomes's fascinating account of how, in America at least, society was transformed by microbiology in the late nineteenth century. But the success of new ideas about preventive health based upon the germ theory of disease was contingent on the endurance of widely-held hygienic beliefs that had been formulated in the age of sanitary reform that is the focus of Hamlin's contribution. And what Hamlin does so brilliantly is show that this age was itself by no means historically inevitable.

Hamlin provides us with a remarkably perceptive and stimulating revision of a crucial period in the history of public health. Although focus is directed towards the role of Sir Edwin Chadwick in shaping the nascent sanitary reform movement, Hamlin's account will be unrecognizable to those acquainted with previous biographical treatments by Samuel Finer (1952), R. A. Lewis (1952) and Anthony Brundage (1988). We are already aware of Chadwick's cantankerous nature, obdurate position-taking and his readiness to dismiss opinions contrary to his own; Chadwick was a difficult customer. But the final choices that he made, and the principles on which he made them-choices that indelibly shaped the form of the public health movement-have rarely been questioned. Indeed, the possibility that there was an alternative to the world created by Chadwick has not been seriously raised until now.

There was indeed another option, buried deep in what might be termed a 'lost age' of modern public health history. Concurrent with Malthusian debates surrounding the 'sustainability' of the working population, the years 1790 to 1840 witnessed an intensely politicized debate concerning the interactions of poverty, welfare and health, overwhelmingly centered on the workplace and the workhouse. All manner of medical men, from the metropolitan elite through provincial practitioners to amateur 'medical activists,' testified to Parliamentary Select Committees about the dangers to health that were presented by long hours of factory work. Although it was then unclear exactly which elements of factory work dealt the severest blows to the human constitution, medicine rubber-stamped early epidemiological studies which demonstrated the simple fact that the laboring population had worse health than the wealthiest members of society. Thus, Hamlin suggests that medicine offered an interpretation for one of the dominant social issues of the day in a way that philosophy, religion and law were unable to better. But it is not to Chadwick alone that Hamlin directs responsibility for the marginalization of medical opinion in the sanitary reform movement. For one thing, respected medical authorities themselves often exhibited an ambivalent attitude towards the great social problems of the early nineteenth century and the possible solutions to them. For another, in this period the concept of 'health,' the intellectual content of medicine and theories of disease causation, were all open to dispute.

For Chadwick-the principal architect of the 1834 New Poor Law which enshrined his philosophy of forcing people into employment via the workhouse deterrent-the Sanitary Report of 1842 was, of course, unable to admit that work might actually harm laborers (Hamlin: 172). The original purpose of the Sanitary Inquiry was to investigate fever in London, but the fact that approximately one third of Hamlin's book is devoted to the Sanitary Report, its genesis, structure and impact, demonstrates the wider significance that it assumed. The report took three years to compile and in that time Chadwick solicited evidence from a range of interested parties across the country, including assistant Poor Law Commissioners, clerks to Boards of Guardians, union medical officers, and distinguished local medical practitioners. Hamlin identifies five issues that shaped Chadwick's views over this period. One was 'Scotland' (see the discussion of Alison below). Another was related to starvation, supposedly prevented by the Poor Law but registered as a cause of death in 63 of the 148,000 deaths in the second half of 1837. Hunger leading to death offended liberal society, and Chadwick attempted to remove it from political discourse by swiping 'disease from the domain of the social by attributing it to mysterious poisons that acted randomly, at least with respect to the most politically sensitive social conditions' (Hamlin: 147). Third, Robert Slaney's parliamentary select committee on the 'Health of Towns' in 1840 set a broader public health agenda than Chadwick had initially envisaged. Fourth, the new Tory government of 1841 feared that failure to control an increasingly filthy urban environment would provoke the so-called 'dangerous classes' into revolution (for some commentators, this environment was in any case an indication of those classes' inherent moral degradation).

Identifying this assortment of influence serves Hamlin's purpose in a variety of ways. First it enables him easily to reclaim the political for his brand of medical history. Furthermore, the way in which he discusses the Poor Law's encroaching into public health via the starvation debates serves to illustrate the pragmatic, interwoven career path of Chadwick. Finally, and with yet another source of change to Chadwick's thinking, namely 'medical criticism of sanitarian principles' (Hamlin: 123), we are left to ponder what Chadwick himself chose to ignore: this is the alternative history to public health. Hamlin reminds us that Chadwick's contribution to the Sanitary Report was merely to precis the evidence he had been asked to collect. Or, more accurately, to precis the evidence that he hadn't chosen to ignore. Writing at the time, a glut of medical men contended that the only way to eliminate fever involved addressing the basic conditions of human misery-lack of food, clothing, warmth and adequate space for living. Chadwick, however, chose to dismiss the role of indigence, preferring to emphasize the physical conditions of existence, miasmas emanating from putrefying matter: "The closest Chadwick would come to admitting deprivation as a cause [of disease] was that it might prevent the poor from buying soap to remove the filth that cause the miasma" (Hamlin: 173).

One of the commentators Chadwick attacked was William Pulteney Alison, the distinguished Edinburgh medical man and campaigner for Poor Law reform north of the border. Hamlin consistently singles out for particular attention Alison's evidence compared to Chadwick's investigation. This is because, unlike all other reporters, Alison subordinated economics to health rather than vice versa; he seemed to empathize with forgotten sections of marginalized society, such as elderly widows; and he did not represent human beings and their morality solely in relation to their physical environment. This outlook offended Chadwick's beliefs, as did other Scottish contributions to the Sanitary Inquiry that tended to collude with Alison's campaign to link destitution with the prevalence of fever. In this sense, then, Hamlin portrays Chadwick as something of the anti-hero. Alternatively, Hamlin harbors glowing admiration for Alison's unstinting role as advocate. Pretty much to the detriment of Chadwick, he juxtaposes the position of the two protagonists in the 1840s: "Alison continued to produce analyses of the economic causes of disease, yet he was unable to halt the juggernaut of sanitarianism. For Chadwick had conceived a policy far more innocuous than the redistributionism of a food-work conception of health, and one with a real treat for the dutiful middle classes: new porcelain water closets and ready water, for cooking, cleaning, even drinking" (Hamlin: 83).

Nancy Tomes makes a comparable link between class and the reception of ideas about cleanliness in nineteenth century America, illustrating that anxiety about hygiene in the late 1800s was highly class-sensitive. Cleanliness was the passport to respectable middle-class life. Besides, the emergent domestic hygiene movement of the 1870s and 1880s publicized itself via journals that were priced beyond the scope of the working class family budget. But what was this hygiene, this 'gospel of germs,' and how did it differ from previous versions of sanitary science? Tomes demonstrates that although germ theory itself was a new development, the domestic rules of hygiene that it came to justify-ventilation, disinfection, isolation-were already standard practice in many homes. She suggests that, "The union of the old sanitary science and the new germ theory of disease was facilitated by a shared vision of the human body as a potent source of pollution" (Tomes: 57). In Britain in the 1840s, the efficient removal of human excrement was indeed the primary purpose of new sewer and drain systems (although it was believed that miasmas were generated by all sorts of decomposing matter, including human waste). In America in the late 1800s, the accumulation of human waste was not only seen as being dangerous in itself, but rather it came to be held as a breeding ground for deadly germs.

Social class was one of the divisions within American society that served to drive the pace and direction of some health policies, as shown by Tomes's case-study of the creation of the Joint Board of Sanitary Control in 1910 in New York City. Tomes shows how at a time in which garment workers sought to gain union recognition and improve sanitary conditions in the workplace, a deal was brokered whereby a board comprising management, unions and representatives of the public investigated and inspected workshops. Tomes argues that overcoming some worker skepticism and resistance, the Joint Board of Sanitary Control met with some success in reducing rates of tuberculosis in the sweated industries by 1930. Ethnic and race divisions proved to be of equal significance elsewhere. The Negro Anti-Tuberculosis Association of Atlanta, for example, was formed in a context in which tuberculosis death rates for blacks were three to four times higher than for whites. This provides Tomes with a further example of how the gospel of germs traversed social chasms. Crystallizing after the race riots of 1906 and a controversy among whites in 1909 concerning the threat of disease transmission via the clothes washed by black laundresses, the association represented a coalition of both races' interests. For whites, admittedly, it promised to reduce the menace posed by high rates of disease in the black population. For the African-American community, the association was seized upon to address some of the fundamental problems of racial inequality. By the early 1920s, the association was not only advocating sanitary privies and the cleansing of yards, but was also demanding improvements in the 'colored' schools of the segregated educational system and had successfully pressurized for the building of a 'negro library' (Tomes: 227).

Tomes perceptively notes that such movements could also serve either to compound division or to create alternative regimes of difference. Reform in New York was achieved at a cost to the diseased worker, who was forced from the shop floor and eschewed by fellow workmates (Tomes: 219-220), although ostracization of the sick has not been historically uncommon. In Atlanta and elsewhere, the hygiene literature provided to black schoolchildren perpetuated 'images of little blond crusaders dressed in white,' unavoidably signifying that 'whiteness and cleanliness were one and the same' (Tomes: 231-232). The gospel of germs also deepened gender differences. The shift of public health into the domestic sphere represented a challenge to female housekeeping abilities. (This is not to say that hygienists allowed men to shirk all domestic responsibilities, as they could be inveigled into house maintenance and plumbing.) Even though the reception of new ideas by women differed from place to place, and between classes and races, Tomes pays special attention to the fact that housewives and mothers bore the brunt of the 'antisepticoncious' exhortation, carrying the burden of guilt and anxiety in order to keep the family home spotless and free from disease.

Estimating the probable impact of such public policies and actions on the health and well-being of the population at large has occupied the time of many demographic and medical historians in recent years. However, Tomes compels us to consider the wider implications of scientific advances for everyday life. A progressive aesthetic emerged that replaced the ornamentation of the Victorian period with minimalist design. Home furnishings came to emphasize the desirability of materials such as metals and glass, which harbored dust and germs less readily. For personal appearances, clean-shaven faces for men and shorter and narrower skirts for women were both prompted by the hygienists' preference for a 'stripped-down' aesthetic. In the public sphere, too, the gospel of germs transformed many aspects of American life, albeit in apparently minor detail. For example, hoteliers' practice of folding the top of long bedsheets back over a heavy blanket was in direct response to the dangers pointed out in tuberculosis literature that heavy blankets may retain harmful bacteria. There was also massive dispute over the suitability, in health terms, of the 'common-cup' used at public fountains and wells.

Tomes's work is an exemplary social history of medicine and I had but two serious criticisms of the book. First, the narrow epidemiological panorama is a disappointment. The lion's share of attention is directed towards tuberculosis and, to a lesser extent, typhoid; both diseases preyed predominantly on adults. Yet, as mentioned earlier, she makes much of the role of mothers in ensuring a healthy domestic environment for children and she certainly appreciates the significance of this in a society where infant death rates stood at 20 percent. Tomes's own list of ailments, the portentous symptoms of which "left many Americans with a profound sense of dread" (Tomes: 26), includes not only the two diseases mentioned above but also cholera, smallpox, pneumonia, whooping cough, scarlet fever, diphtheria and infant diarrhea. These diseases, however, receive only brief attention throughout, and if we add measles to this list, the impact of germ theory on the average late nineteenth-century American child's encounters with ill-health begs for future examination. Secondly, the state apparatus for promoting public health policies is largely ignored. This is understandable in one sense, as Tomes's primary purpose is to concentrate on the implications of germ theory for everyday life, and this cannot be gauged purely through an institutional analysis, hence her emphasis on proletarian participation in attempts to alter working and domestic conditions and promote healthy behavior. In addition, Tomes could justifiably point to other studies that have ably handled the question of government health policies (Duffy 1990; Rosner 1996). Yet, as Hamlin demonstrates, the rejection or acceptance of one disease theory or another by the state executive is crucial to the overall direction of policies which in turn are partly responsible for fostering a climate for change and raising public awareness.

Perhaps significantly, there are similarly-titled sections in both of these impressive books. In Public Health and Social Justice, Hamlin describes the establishment of the Health of Towns Commission in 1843-1845 as 'Sanitation Triumphant.' Several witnesses to the commission shared Chadwick's opposition to the 'poverty equals disease' argument. In what Hamlin characterizes as 'a descent into the pit of technical minutae' (Hamlin: 233), the commission placed drains, sewers, waste and water at the forefront of sanitary progress at the local level. The dénouement of germs is proclaimed in Part II of Tomes' book with "The Gospel Triumphant" describing the period 1890-1920. This section, concerned with how converts to the germ theory transformed laboratory discoveries into realizable ideas, is suitably followed by another, "The Gospel in Practice", which details the wide ranging effects that their actions had. Given the revisionist scope of Hamlin's work and Tomes's use of an underused set of sources, coupled with her predilection for the bottom-up story that they convey, it is gratifying that the recognition of this triumphalism does not lead them to reinforce a traditionalist approach that prefers to tell only the winner's story. "The Gospel in Retreat," the final section of the American history, highlights the emergence of a 'new public health' in the first decades of the 1900s, which quietly demoted obsessions over sewer gas, filth, cleanliness, and disinfection and subtly replaced them with a new emphasis on the accuracy of laboratory diagnoses, the importance of person-to-person infection and introduced the concept of the healthy carrier of disease. Conversely, Chadwick's demise was far more abrupt. In its final chapters, Public Health and Social Justice recounts how local authorities resisted the comprehensive systems favored by Chadwick's General Board of Health. His professional decline was hastened by technical arguments with those civil engineers employed as the board's inspectors and who were responsible for building the sanitary systems that he promoted. Even the engineers eventually deserted Chadwick once they realized his patronage was not required to win local authorities' contracts. A generation after the fall of Chadwick, the 1870s witnessed the emergence of a public health that "was an emasculated form of the still-born political medicine of a half century earlier" (Tomlin: 47). Promising us additional work on this theme, it will be intriguing to compare Hamlin's interpretation of public health in Britain in the late nineteenth century with that of Tomes on America.

References

Brundage, Anthony. 1988. England's "Prussian Minister": Edwin Chadwick and the Politics of Government Growth 1832-1854. University Park: Pennsylvania State University Press.

Duffy, John. 1990. The Sanitarians : A History of American Public Health. Urbana : University of Illinois Press.

Finer, Samuel E. 1952. The Life and Times of Sir Edwin Chadwick. London: Methuen..

Lewis, R. A. 1952. Edwin Chadwick and the Public Health Movement, 1832-1854. London: Longmans, Green.

Rosner, David, ed. 1996. 'Hives of Sickness': Epidemics and Public Health in New York City. New Brunswick, NJ: Rutgers.

Alan Derickson. Black Lung: Anatomy of a Public Health Disaster.

Ithaca: Cornell University Press, 1998. 237 pp. $29.95 cloth.

Michael Gochfield
UMDNJ-Robert Wood Johnson Medical School

One of the inconsistencies of the Nixon presidential era was the passage of several landmark pieces of public health legislation, among them his signing of the Coal Mine Health and Safety Act (CMHSA) in late December 1969. Fifteen years later, Allen Koplin (a former United Mine Workers' physician, who is pictured on page 164 of the book) arranged for the two of us to lead a class of public health students through a coal mine in western Pennsylvania. I remember three unforgettable things about that tour: a former school teacher turned miner telling me that coal mining was safer and more enjoyable than teaching; the constant spray used to control the environmental dust as a "continuous" mining machine ground away the coal face; and sneezing away the fine black dust that nonetheless seeped through my face mask and filled my nostrils during our memorable tour. I could readily imagine what my nose would have contained prior to the implementation of dust control technologies and without my face mask. The human and economic burden of occupational disease in general and dust diseases in particular, was often ignored in the process of industrialization.

Alan Derickson, a labor historian, recounts the human tragedy associated with coal production, particularly regarding Black Lung Disease, technically referred to as Coal Workers' Pneumoconiosis (CWP). Whereas, even today, government officials see the huge costs of the black lung compensation embodied in CMHSA, the author demonstrates that all these costs and more could have been averted because like all occupational diseases, black lung disease is entirely preventable, and, ironically, the necessary knowledge was already in hand a century ago.

Coal mining is intrinsically dangerous, and explosions and collapses often take multiple lives that capture national headlines and become romanticized in song. For example, the lyrical "Springhill Mine Disaster" recounts nine deaths in a deep Nova Scotia mine in 1958. The dramatic nature of mining's inherent dangers could readily influence the public and Congress to think that coal miners willingly accept risks most people would find intolerable, hence they could hardly expect society to be sympathetic about miner's asthma or other debilitating illnesses.

As recently as the 1950s, coal was the major source of home heating and industrial power, and today it continues to be one of the primary sources of electrical energy production in the United States and abroad. China, for example, generates more than three quarters of its electricity from coal. Despite its widespread use, and the nation's need for coal which made coal strikes front-page news, coal was competing with increasing use of hydroelectric power, petroleum, and an emerging nuclear industry. And there was interregional competition among coal sources as well. The industry exploited this competition to raise the specter that mines would close and jobs would be lost. Maintaining competitiveness is still a common tool to combat labor, environmental, and occupational health regulations.

Derickson admirably documents that the relationship between coal mining and debilitating respiratory diseases was well established in the biomedical literature before 1900. Yet the first fifty years of the twentieth century saw a systematic attempt by the coal producers to downplay, misrepresent, or discredit the evidence. Their cause was abetted by a number of industry-supported physicians who managed to dominate the literature and professional discussion with claims that coal dust was relatively harmless and did not damage miners' lungs. Derickson examines such perfidious arguments in detail, but leaves the reader to decide whether these medical opinions were wholly purchased or merely swayed by an industry that provided so many jobs for the community, including its physicians.

In the early twentieth century, occupational medicine was slowly developing as a discipline, with Dr. Alice Hamilton as its chief spokesperson. Identifying and preventing hazardous workplace exposures and resulting disease remain the unifying theme of our profession. Yet even today many occupational medicine physicians rationalize away evidence regarding relationships between workplace hazards, such as solvent exposure, and chronic debilitating disease, and insist on proof beyond a shadow of a doubt.

Derickson carefully lays out the chronology of arguments which from the 1910s to 1930s bent medical opinion to the view that the main occupational lung disease, interstitial fibrosis or pneumoconiosis, was solely caused by silica. Thus coal miners who had pneumoconiosis got it because of silica exposure, and conversely coal miners without silica exposure need not fear (nor be compensated for) pneumoconiosis. It was a grand delusion; some might say deception. Yet as David Rosner and Gerald Markowitz (1994) point out in their book Deadly Dust, gaining acceptance for silicosis as an occupational disease, was perhaps equally stormy and illustrates the sluggishness of occupational health progress in general.

By the mid-1930s, however, silicosis was widely recognized, in part due to the several hundred deaths engendered by the tunnelling venture at Gauley Bridge, West Virginia, as documented by Martin Cherniak's The Hawk's Nest Incident (1986). The period leading up to World War II was also rich in the history of public health advances (for example, the maturing of epidemiology) and in unionization, which set the stage for the successful movement of the 1960s to recognize black lung disease. Derickson highlights the roles of a progressive social medicine community interacting with black lung activists, to make this part of the 1960s dialogues.

In the immediate post-World War II period, United Mine Worker (UMW) head, John L. Lewis, arguably the best known labor figure of the mid-twentieth century, was apparently ambivalent about black lung disease, recognizing that although the increased mechanization (e.g., "continuous" mining machines) greatly increased dust levels, they were an essential part of the vitality of the industry on which his members depended. Years ago, Dr. Lorin Kerr, long the lead UMW physician, explained it to me more sympathetically in terms of identifying union priorities, which included maintaining the viability of the long fought-for welfare and retirement fund.

Like a well-constructed suspense novel, Derickson recounts the series of small victories and crushing setbacks, with a patient choreography of unions, workers, and occupational health specialists prodding resistant industry and ambivalent government officials to improve compensation and regulate the workplace. Although this book focuses on the coal industry, it is important to appreciate that the trajectory of progress in preventing CWP parallels other advances in occupational health. The Occupational Safety and Health Act, for example, was signed into law in 1970, only a few months after the CMHSA. Corporate resistance to expanded regulations in the coal industry paralleled those in the nation at large, as recounted by David Rosner and Gerald Markowitz in Dying for Work (1987) and even more politically by Daniel M. Berman in Death on the Job (1978). Coal producers threatened that tighter dust regulations would weaken the industry, close mines, and result in lost jobs. Union officials, even in the late 1960s had to balance these claims against the protection of worker health, and the arguments were slow to change as Richard Kazis and Richard L. Grossman emphasize in Fear at Work (1982).

It is probably predictable that the political climate of the 1960s facilitated the advancement of the miners' cause which had been thwarted for so long. The public at large, the congress, and the industry were accustomed to debates over social policy which departed dramatically from the complacency of the 1950s. Derickson devotes particular attention to the watershed year, 1969, describing the ascendancy of arguments that eventually led to the passage of CMHSA before year-end. He attributes this in large measure to the collectivization of miners' concerns and the increased health and safety militancy of the UMW, coupled with the moral suasion by the numerous debilitated miners who testified before Congress. Against the panoply of long-time mine workers, gasping for breath, mine owners reluctantly conceded on a number of crucial points they had long opposed. These included, for example, an "irrebuttable presumption" clause, by which a 10-year history of mine work, coupled with X-ray or autopsy evidence of severe lung damage, guaranteed compensation. Equally important was a "rate retention" clause which allowed workers with progressive lung disease to transfer to jobs with lower exposure without loss of pay, seniority, or benefits.

And on this note, the book ends rather suddenly, with only a brief paragraph that serves as an epilogue to passage of the CMHSA. Within a decade, a half million miners or their beneficiaries were awarded black lung benefits. To union vigilance, Derickson attributes, the decline in dust levels and consequently a decline in new black lung cases in ensuing years. But eternal vigilance is required. Even though successful, the regulations rely on the coal producers to monitor their own environment. This is a tenuous arrangement as James Weeks, industrial hygienist for the UMW, noted in documenting recent examples where the mine companies falsified air sampling results, to avoid tightening their environmental controls (Weeks 1991).

Despite its subtitle, Dr. Derickson is carefully dispassionate and objective in his writing. At times this makes the role of some of the players unclear. For example, was Anthony Lanza (who represented insurance interests in 1933), simply playing a cost-containment role, or was he a successful, industry-supported, crusader against expanding the definition of occupational lung disease, as Barry Castleman depicts in his volume Asbestos (1996). The product of extensive research, Derickson's treatment is dry, but swift, and comforting since one knows that despite 60 years of setbacks and cruel ironies, coal miner health wins out.

Derickson tells a fascinating story for those interested in the history of public health, American labor, the rise of corporate influence on government, and our political process in general. As an occupational health specialist who entered the field in 1969, only months before the passage of the CMHSA and the OSH Act, I found those successes vitally reassuring. In reading this book I alternately experienced outrage, frustration, and ultimately gratification. However, occupational health specialists can hardly be complacent even when regulatory battles have been won, and I appreciate even the slight reassurance that the political victory in 1969 has actually led to a reduction of disease in the ensuring decades.

This book follows a long tradition of scholarship on the interface of medicine and occupational health policy in general and mining and respiratory disease in particular, which in this century can be traced to Alice Hamilton's pioneering volume, Exploring the Dangerous Trades (1943). Subsequent examples include, Rosner and Markowitz's, Deadly Dust, and Cherniak's The Hawks' Nest Incident as well as Derickson's own book on Workers' Health, Workers' Democracy.

References

Berman, Daniel M. 1978. Death on the Job: Occupational Health and Safety Struggles in the United States. New York: Monthly Review Press.

Castleman, Barry. 1996. Asbestos: Medical and Legal Aspects, 4th ed. Englewood Cliffs NJ: Aspen Law & Business.

Cherniak, Martin. 1986. The Hawk's Nest Incident: America's Worst Industrial Disaster. New Haven: Yale University Press.

Derickson, Alan. 1988. Workers' Health, Workers' Democracy: The Western Miners' Struggle for Health and Safety, 1891-1925. Ithaca: Cornell University Press.

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Kazis, Richard, and Richard L. Grossman. 1982. Fear at Work: Job Blackmail, Labor and the Environment. New York: Pilgrim Press.

Rosner, David, and Gerald Markowitz . 1987 Dying for Work: Workers' Safety and Health in Twentieth-Century America. Bloomington: Indiana University Press.

--. 1994. Deadly Dust: Silicosis and the Politics of Occupational Disease in Twentieth-Century America. Princeton: Princeton University Press.

Weeks, J. L. 1991. Tampering with Dust Samples in Coal Mines (Again). American Journal of Industrial Medicine 20:141-144.

David B. Morris. Illness and Culture in the Postmodern Age.

Berkeley: University of California Press, 1998. 345pp. $27.50 cloth

Uta Gerhardt
University of Heidelberg

To be fair, this is not a scientific book. This fascinating tour d'horizon of the folklore of the mind within the sick person is not scientific but aims at nothing less than to change the direction of medical science. David B. Morris proposes to replace traditional so-called bio-medicine by a newly created biocultural model, "situated at the crossroads of biology and culture" (71).How does Morris approach his topic? How does he proceed, or what is the narrative of his book?

The introduction entitled "How to Live Forever," starts out with a quote from Nietzsche eluding to both the animal nature and irredeemable sickness of man ("he is the sick animal"), supposedly a remark on the human side of the man as a cultural being. From this vantage point, Morris pronounces that in today's postmodern world (that exists beyond the fixed meaning structures of knowledge systems), the health of the person might depend on his ability to stop searching for perfection whether it's masquerading as obtainable through medicine or otherwise. "Our health as individuals may depend directly on how we understand crucial, specific changes implicit in the experience of postmodern illness," is the author's message to the reader, characterizing his "concrete," "very basic" approach. (6).

The book's program evolves in eight chapters. Chapter 1, "The Country of the Ill," presupposing ubiquity of illness and/or disease, focuses on two issues. Using Andy Warhol as a role model embodying postmodernism, Morris endorses everyday experience as the nucleus of contemporary culture. Also, using as model narrative of the patient who refused crippling though life-saving surgery and preferred to die, Morris endorses a patient's will as an unquestionably authoritative source of the meaning of illness. Clarifying this further, chapter 2, entitled "What Is Postmodern Illness?," starts out with bubonic plague as horror epidemic in the Middle Ages, mentions TB as the mystery epidemic of the 19th century, and leads on to the age of cancer, then AIDS. While Morris evaluates various illnesses for their suitability as epitomes for postmodernism, he ends up suggesting not only that illnesses and their presumptive causes are culturally relative but, even more alarming, that the postmodern age is possibly worse than others before: "Now researchers clone large animals in the laboratory, and even Mars bears on its surface the marks of human culture. Postmodern illness belongs to this new, if far from innocent, age"(77). Chapter 3, then, addresses these surreptitious, universal dangers looming in the fabric of allegedly beneficial modern civilization. Its title, "The White Noise of Health," is taken from a Don DeLillo novel about normal life in a college turning out to be only desperately normalizing thing in a community condemned to slow mass death from toxic fumes that emanate from a cloud hanging over the doomed locale. "What threatens us is not the end of the world," concludes Morris, "but rather a gradual, unending, cumulative deterioration in the name of progress" (106).

As a first field of application of his plea for a change of attitude, Morris chooses pain. "Reinventing Pain," chapter 4, deals with how this illness that is no illness fools not only physicians unable to diagnose or cure, but, as well, the pharmaceutical industry intent on finding efficient relief drugs. What helps, Morris reports from a personal narrative, is to attempt to ignore the pain that is intolerable, adopting the Japanese cultural interpretation of pain endurance as a sign of character. Here, Morris thinks, is a good example how illness involves not just biology but culture as well. "Utopian Bodies," his next topic, castigates the "utopian desire" for "building the perfect body" (140). "Postmodern bodies", to Morris, mark a shaping of modern citizens' lives by images masterminded by pop culture, advertising, and other outside influences, leading to such ironic diseases (or, rather, illnesses) as anorexia, which he elucidates throughout as "the biology of self-starvation" (157ff). No wonder Morris ends the chapter with a warning against utopias.

Further proving that illness is but in the mind-although this includes rather than excludes medical diagnosis and therapy-in chapter 6, Morris turns to "Neurobiology and the Obscene." Now neurological disorders are the topic, and the issue is that the obscene, as culturally arbitrary and as necessarily banned through decorum in any community, is an example of how culturally unacceptable forms of speech and behavior may belong to the natural endowment of (hu)mankind but nevertheless require taboos. "We might ... begin to appreciate the uses of obscenity and apply our ancient language of filth and outrage somewhat more selectively to whatever it is within the vastly altered postmodern world order that truly threatens our survival," recommends Morris (189).

From this vantage point, Morris reaches a crucial theme of his saga-narrative. Chapter 7, entitled "The Plot of Suffering," underscores the impotence of "the biomedical model" by focusing on suffering "because suffering seems to resist the methods of science" (193). Through anecdotal evidence taken from art, literature, etc., he proves that suffering is often overlooked or denied by others, which in general could be remedied by, but often is simply documented in, narratives authored by the afflicted or their next of kin. Furthermore, high art and also television and other forms of popular culture, depict suffering; from these media develop genres of text deemed appropriate to the subjective experience. Tragedy looms large, pictured through suffering, in novels or in the real life of those with AIDS, Morris knows. Suffering is "not a natural phenomenon that we can classify and measure, despite its links with biological processes-but a fluid social state: a status that we extend or withhold," he emphasizes (216). Chapter 8, "Illness in the Time of Disney," returns to the major diseases that are the killers of today's populations-stroke, cancer, and heart disease, arguing their connection with risk-taking life-styles and considers other diseases that are common but less often connected to cultural constructs, like depression and Alzheimer's disease. Ironically, the latter disease could be paradigmatic for the postmodern present, as Morris pictures it, dissolving the interpersonal order of personal identities in a flood of delusion and forgetfulness. However, he utters his plea for human dignity in the face of increasing threats from both commercialization and Alzheimer's (acronym AD): "How will our newly commodified images of vigorous and lusty elderhood play back against the realities of an aging population where a significant population of all people above retirement age suffer from AD?" (236).

After a brief look at "postmodern dying" (237 ff), Morris returns to the topic of the country of the ill, treated in chapter 1, now arguing that wellness is more widespread than is suggested by statistics that document a wide distribution of illnesses and disabilities. Indeed, he concludes, what matters is the image which people have about their bodies, selves, and worlds. As long as people can manage their symptoms, no matter whether diagnosed or not, and stick to a view of health which they themselves accept, all is well. "Postmodern illness occurs in a world in which representations and simulations have as much power as microbes and mosquitoes," he maintains. "Some representations help us, some hurt us, some put a little harmless pleasure into our lives; the point is to learn the difference" (246).

After this marathon tour d'horizon through the imagery of illness and its recognition or rejection by physicians or patients, often addressed in the guise of seemingly all-pervasive medicine or through artistic or personal texts, Morris draws a conclusion. Under the title of "Narrative Bioethics," he pleads for postmodern writing, stories by everyone for everyone, each person inventing narratives about him/herself, which should enable the modern citizen to plug into the richness of culture in the guise of text. "Narrative, like illness, is a biocultural phenomenon," Morris knows, continuing that there are "three concepts foreign to most medical literature...that deserve consideration in any future narrative bioethics: emotion, dialogue, and the everyday" (259). These are then sketched, followed by some thoughts connecting Susan Sontag's Illness as Metaphor to Nietzsche's warning against the sufferer's suffering from thinking about his illness more than from the illness itself. Returning to the prostate cancer patient who preferred death to mutilating surgery, Morris concludes his book by pleading for the simple and the ordinary in the lives of today's overcivilized : "We still retain access to the resources of the ordinary, the everyday, and the uneventful, if we can learn how to recognize and to recover them. This recovery-the word carries potent medical connotations-may involve an act much like the process of healing" (273). The book ends on a note of crisis cum hope: "This new postmodern narrative certainly immerses us in confusion, as befits a transitional moment when ideas about health and illness are in flux. It also points to important and promising changes ahead" (278). Thus, alas, sounds the book's last paragraph.

Since the book is not scientific, its value should not solely be judged on the basis that its argument is inconsistent and circular. My review will be confined to three issues that may need mention if some of the conceptual tangles are to be unravelled that confound this book's apparently "concrete, very basic approach."

First, to introduce culture into biology, as new as it appears to Morris, may not be as new as he makes it out. Although he thinks that "fifty years ago, only a few mavericks or visionaries within mainstream medicine would have risked describing illness as a mental, emotional, bodily event constructed at the crossroads of biology and culture," (19) he fails to notice that not in mainstream medicine (whatever that may be) but in mainstream sociology (in the early 1950s, following up on a first study conducted in the middle 1930s) there was just such a maverick or visionary-it was, interestingly, Talcott Parsons. In the introductory part of Chapter X of The Social System, Parsons pleaded for a medicine that deserved the name psychosomatic (without a hyphen though Parsons himself inserted one for his time and age.) Indeed, he argued that the interconnection not only with culture, but also society as structure of reciprocities, made a social system between physician and patient. The latter system, he suggested, contained a healing potential that he addressed as "unconscious psychotherapy." No doubt, such conception was a far cry from any mechanically conceived somatic process. Indeed, the interrelation between biology and culture (society), suitably interpreted anew several times between the 1950s and 1970s in the wake of subsequent major innovations in biological science as well as neuropsychiatry, became a topic for Parsons until his very last book. In the latter, which Morris cites but erronously describes as a monograph, Parsons had an essay on health and disease. There he addressed the issue in the light of then recent progress in cognitive science under an entirely novel concept for the action potential of life-teleonymy (Parsons 1978:66-81). Had Morris familiarized himself more thoroughly with these sociological insights which managed to reconcile the most modern medical science with Harvard's seminal tradition in cultural studies, maybe he would have been less certain of himself in his view how groundbreakingly new was his idea of a "biocultural model."

Another issue concerns Morris's "postmodern" way of dealing with history. Whereas he occasionally ventures into the vagaries of the bubonic plague in the Middle Ages or an epidemic of melancholia during the Renaissance, his chronological sense of history is amazingly underdeveloped. Regarding our twentieth century, a treatise on the relationship between illness and culture-focusing on the unity between biology and culture where it serves to understand subjective experience of disease-should not have completely omitted the experience of stigmatization, especially not that imposed through political illness-like categories such as race or the "asocial" character of Nazi Germany. (Had he included this topic, by the way, he would have realized an ominous side of the relationship between biology and culture which so far he seems to have overlooked.) Regarding the United States, on which he says he chooses to concentrate, the topic of evil cultural-political forces imposing illness-like categories on unwanted populations should have drawn Morris to the literature of the post-World War II period explaining anti-Semitism as a social disease (Simmel 1946; Gerhardt 1989). In this way, political aspects of what is said to be illness could have alerted Morris to the ethical implications of political régimes, an issue older than so-called post-modernism that spurred the apparent iconoclasm of authors such as Jacques Derrida or Michel Foucault in their quest for humanism. To be sure, discussing political connotations of illness as well as disease as they affected the struggle between totalitarianism and democracy in the twentieth century would have meant to endorse the politics of medicine and suggest democracy as the only viable genre of politico-social community. On this note, it should be remembered that Nazism in Germany was opposed to individual professional medical care, aiming to replace it by "natural medicine" on a strictly public-health basis (Procter 1988).

My third point casts doubt on the cultural pessimism that is woven into the book in many places. For instance, one tenet is that progress of (hu)mankind will be halted unless "we" return to more simple, "natural" ways of life (see above). Nietzsche, of course, fits into this picture beautifully. It is interesting that Morris mentions Nietzsche's health about which the philosopher was constantly concerned, but omits discussion of the diagnosis. In 1890, Nietzsche lost his senses (his disease today would be called VD) and in the last ten years of his life suffered the mental breakdown which at the time was labelled progressive paralysis. (Only a decade after his death a drug treatment became available that cured venereal disease which, for centuries, had been the doom of men). Morris, who does not go into these details, misses the opportunity to discuss mental illness as opposed to bodily symptoms, ending up with a mixture where involuntarily he suggests that illnesses are all alike, as long as "we," the postmodern humanity, become aware of the dangers of entrusting "ourselves" to the likes of physicians, summarily subsumed under medicine (even, bio-medicine).

A last note on narrative: On page 49, Morris credits Jerome Bruner's truly important book on meaning construction with an insight misunderstood, "Narrative, of course, is among the most common and most powerful instruments we possess to confer meaning upon experience." Would it upset Morris to learn, as Bruner knows, that experience, on principle, is constituted through meaning (a concept that predated post-modernism when it was explicated by Kant in the latter half of the 18th century)? There is, regrettably without any room for further argument, no experience whatsoever unless constituted through meaning; the latter, no doubt, is conferred through narrative as well as other forms of interpersonal, conceptual as well as intuitive, understanding.

References

Bruner, J. 1990. Acts of Meaning. Cambridge: Harvard University Press.

Gerhardt, U. 1989. Ideas About Illness: An Intellectual and Political History of Medical Sociology. London: Macmillan.

Parsons, T. 1951. The Social System. Glencoe, IL: The Free Press.

--. 1978. Action Theory and the Human Condition. New York: The Free Press.

Procter, R. N. 1988. Racial Hygiene: Medicine under the Nazis. Cambridge: Harvard University Press.

Simmel, E., ed. 1946. Antisemitism-A Social Disease. New York: International Universities Press.


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