summarize

5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h C a r e

S o l o t n o n , H . A . 1 9 8 4 . T h e E x a r c i s e M y t D . N e w Y o r k : H a r c o u r t B r a c e J o v a n o v i c h .

S p i l m a n , M . A . , A . C i o e t z , J . S c h u l t z , R . B e l l i n g h a m , a n d D . J o h n s o n . 1 9 8 6 . E f f e c t s o f a H e a l t h P r o m o - t i o n P r c r g r a n t . J o u r n a l o f O c c u p a t i o n a l M e d i c i n e 2 8 : 2 8 . 5 - 8 9 .

S t e i n , . f . 1 9 8 5 . I n d u s t r y ' s N e w B o t t o m L i n e o n H e a l t h Ciare Costs: Is Less Better? Hastings Center Report l - 5 ( . 5 ) : l 4 * 1 8 .

S t e r l i r r g , J . D . , a r . r c l f . . f . W e i n k a m . 1 9 8 6 . E x t e n t , P e r - s i s t e n c c a n c l C l o n s t a n c y o f t h e l { c a l t h y W o r k e r o r H c r l t l . r y P e r s o n F . f f e c t b v A l l a n d S e l e c t e d C l a u s e s o f

Death. Journal of Occupational Medicine 28:348- 5 3 .

S y m e , L . S . , a n d L . F . B e r k m a n . 1 9 7 6 . S o c i a l C l a s s , Susceptibility and Illness. American Jonrnal of Epr demiologl' I 04: l-8. ,

U.S. Department of Health, E,ducation, and !ilelfare. 1,979. Healthy People: The Surgeon General's Re- port on Health Promotion and Disease Preuention.'Washingtorr.

'Walsl.r, D.C. 1984. Corporate Smoking Policies: A Revrew and an Analysis. Journal of Ocarpational M e d i c i n e 2 6 : 1 7 - 2 2 .

A Cesn FoR RrpocussrNc Upsrnndtvt: THE Pouucet EcoruouY oF lrrlurss

. l o h n B . M c K i n l a y

M y f r i c n c l , I r v i n g Z o l a , r e l a t e s t l - r e s t o r y o f a p h y s i c i : r r r t r y i n g t o e x p l a i n t h e d i l c m r n a s o f t h e r n o c l e r n p r a c t i c e < l f r r e d i c i n e :

" Y o u k n o r , " ' , " l r c s a i c l , " s o r l e t i r n e s i t f e e l s l i k e t l - r i s . T h e r c I a m s f a n c l i n g b y t l r e s h o r e o f a s w i f t l y f l o w - i n g r i v c r a n t l I h e e r t h c c r y o f l c l r o w n i n g m a n . S o I j r r n r p i n t o t l i c r i v c r , p u t n 1 y r r r n s a r o u n c l h i m , p u l l h i r n t o s h o r e a n c l a p p l y a r t i l i c i a l r c s p i r a t i o n . . f u s t w l r c n h c b c g i n s t o b r c a t h c , t h e r c i s r r t o t h e r c r y f o r h c l p . S o I j u m p i r r t o t l r c r i v e r , r c : r c h h i m , p u l l h i n r t o s h o l c , a p p l v a r t i f i c i e l r c s p i r a t i o n , a r - r d t h e n j u s t a s h e b c g i r r s t o b r e a t h e , r l n o t h e r c r y f o r h e l p . S o b a c l < i n t l r c r i v e r r r g r r i n , r c r r c h i n g , p u l l i n g , a p p l y i n g , b r c a t h i n g a l i c l t h c n r u r o t h c r v e l l . A g a i n a n c l a g a i n , w i t h o u t e u c l , g o e s t h c s c q u e n c e . Y o u k n o w , I a n r s o b u s y j L r r r - r p i n g i n , p r - r l l i n g t h e m t o s h o r e , a p p l y i n g a r t i 6 c i r l r c s p i r a t i o n , f h r r t I h a v e n o t i m e t o s e e w h o t h c ' h e l l i s u p s t r c r r n . r p u s h i n g t h e n r a l l i n . " r

I b e l i e v e t h i s s i r l r p l e s t o r y i l l u s t r a t e s t w o i m - p o r t r r r l t p o i n t s . F l r s r , i t h i g h l i g h t s t h e f a c t t h i r t a c l e a r r n a j o r i t y o f o r " r r r e s o u r c e s a n c l i r c t i v i t i e s r n t h e h c a l t h f i e l d a r e c l e v o r e d t o w h a r I r e r m " c l o w n s t r e a n r e n c l e : r v o r s " i n t l - r e f o n n c l f s u o e r f i - c i a l , c a t c g o r i c a l t i n k e r i n g i n r e s p r l n s e t . , a f m o s t p e r e r . r n i a l s h i f t s f r r t r . n o r . r c I ' r e a l t h i s s u e t o t h e n e x t , w i t h o r - r t r c a l l y s o l v i n g a n y t h i n g . I a n t , o f

c()urse, not suggesting that sucl.r effclrts are en- t i r e l y f u t i l e , o r t h i t t a c o n s i d e r a b l e a m o u n t o f short-te n'n good is not being accomplished. Clearly, people iurd groups have important im- rnediate rreeds which must be recognized and at- t e n d e d t o . N e v e r t h e l e s s , o n e u r u s t b e w a r y o f tlte shryt-tertn nLtture

^nd ultinxate futility of

s u c h c l o w n s t r e a r n e n d e a v o r s . Sec.ond, the story indicates that we should

sor.nchow ceasc oLlr preoccupirtion with this short-tern-r, problem-specific tinkering and begin focussing ()ur attelltion upstrearrr, where the real problen.rs lie. Such a reorientation would mini- mally involve irn anirlysis of the nreans by which vrrricrrrs inclividr.rals, interest groups, and large- scale, profit-oriented corporations are "pushing preople it.r," arid h<tw they subsequently erectr at sorne point downstreanl, a health care structure t,, ,.rui.. the Ireeds wlrich they have had a hand in creirting, ancl for which rnoral responsibility o u g h t t o b c a s s u m e d .

in this paper two related themes will be devel- oped. First,'l wish ,o highligh, the activities of tlie "manufa*urers of ilinesi"-those individu' als, interest groups, and organizations which, in addition t., iroiuiittg maieriat goods and ser-- vices, also produce, ai an inevitable by-product'

wides of thi focusr vidua be re range nomi(

The to rev tofs lr a t - r i s k r e q u e s n-rake irnd sc h i n d t polnt. term " l e a s t t c o u l d , the fan how tl: levels < v i c e s . 2 p a r t i c u t u t i o n s stfuctu p a t h o l < c o u l d r spectru forces r d i s e a s e ,

. . , I that th, vention the inirr s o c i a l c decidinl evet ls newly e of healt little at; ness.a It develop Inls parl

A p o suggests

the t ,adequat

s r t t l e

2 8 3 4 8 -

r l C l a s s , I o f E p i -

W e l f a r e . ryal's Re- e u e n t i o n .

r l i c i c s : A 'tpational

widespread morbidity and mortality. Arising our of this, and second, I will develop rr case for re- focussing our attention away frorn those indi- viduals and groups who are mistakenly held to be responsible for their condition, roward a range of broader upstrean-l political and eco- nomlc Iorces.

The task assigned to nre for this conference was to review some of the br<tad social structural fac- tors influencing the onset ()f heart diseirse rrnd/or at-risk behavior. Since the issues coverecl by rhis request are so varied, I have, of necessity, had t<r rnake sorne decisions concerning lroth c.m;rhasis and scope. These decisions and the rcasoning be- hind them should perl"raps be expl:rinecl at this point. With regard to what can be cclvered by the t e r m " s o c i a l s t r u c t u r e , " i t i s p o s s i b l e t o i s o l a t e a t l e a s t t l . r r e e s e p a r a t e l e v e l s t , f a b s t r a c t i o n . O n e could, for example, focus on such subsystenrs irs the family, irnd its associated social networks, and how tl.rese rnay be inrportantly linkecl to clifferent levels of health status :lnd the utilizatior.r <lf ser- vices.2 Or-r a second level, clne cor.rld consicler lrorv p a r t i c u l a r o r g a n i z a t i < l n s a n d b r o a d e r s o c i a l i n s t i - t u t i < x r s , s u c h a s n e i g h b r l r h o o d r r r r c l c r : r n r n r u n i t y s t n r c f u r e s , r l l s o a f f e c t t h c s < l c i a l c l i s t r i b u t i c l n o f p a t h o l o g y : r n c l : r t - r i s k b e h a v i o r . t ' f h i r c l , r t t t e n t i o n c o u l d c e n t e r o n t h e l r r o a d e r p o l i t i c i r l - c c o n o m r c spectnlnr, and how thesc irclurittedly ntorc rcntote forces uray be etiologically involvecl in the onset of o l s e a s e . . . .

. . . l l n t h i s p a p e r l I w i l l a r g u e , f o r e x a r r p l c , t h a t t h e f r e q t r e n t f a i l u r e o f r n : r n y h c a l t h i n t e r - vention prograrl.ls can bc Iargely' ilttributcrd t() t h e i n a c l e c l u a t e r e c o g r " l i t i o r r w c { i v c t o r r s l ' r e c t s o f s o c i i r l c o n t e x t . . . . T h e m o s t i r n L r o r t a n t f a c t o r r n d e c i c l i n g o n t h e s u b j c c t r r e i r ( ) f r h i s p . 1 P s L h e \ \ , , - ever, is tl-re fact that, r.vhile there aprpreirrs t() be;r n e w l y e m e r g i l t g i n t e r e s t i n t h e r p o l i t i c r r l e c o n o l n y o f h e a l t h c r r r e , s o c i a l s c i e n t i s t s h a v e , a s y e t , p a i c l little atterrtiorr to thc- ltolitical "r,rrr,rrriy

,rf ill- a e s s . a I t i s n r f i n t e n t i o n i n t h i s p a p e r t o b e g i n t o d e v e l o p a c i r s c f t r l t h e s e r i o u s c o n s i c l e r a t i o n o f this paiticular :1rell.

A C a s e f o r R e f o c u s s i n g U p s r r e a m : T h e P o l i t i c a l E c o n o m y o f l l l n e s s 5 1 7

long time, criticism of U.S. health care focussed on the activities of the An-rerican Medical Asso- ciation ancl the fee for service system of physi- cian peryment.t'. Lately, however, attention ap- pears to be refocussing on the relationship between irealth care arrangements and the struc- tr"rre of big business.T Ir hes, for: ex:rnrple. been suggested that:

. . "vith

the ncw rrncl apparently pcnnancnt in- volventent of n'rajor corpor:ttions in health, it is be- coming ir.rcrcasinglv inrprobablc tliat tlic Unitcd Statcs cirn redircct its he:tlth priorities withour, ar the same time, changing thc ways in which Anreri- crn industry is orgarrized and thc wrys in whicl-r m o n o p o l y c a p i t a l i s r n w o r k s . s

I t i s m y i m p r c s s i o n t h a t n r a n y o f t h e p o l i t i c a l - economic .rrgllments concerning developlnents i n t h e o r g a n i z a t i o n o f l r e a l t h c a r e a l s o h a v e c o n - s i c l e r a b l e r e l e v a n c e f o r a h o l i s t i c u n c l e r s t a n c l i n s of thc etiology ancl distribution of nror:lriclity, r n o r t a l i t y , a r r d a t - r i s k b e h a v i o r . I n t h c : f o l l o w i n g s e c t i o n s I w i l l p r e s e n t s ( ) n r c i r t r p o 1 1 1 1 1 1 J s p c c t s ( ) f these arsunlents in thc hope clf contributing to r.r b e t t c r u n d e r s t a n c l i n g o f a s p e c t s o f t h e p r > l i t i c a l e c ( ) u o n l y o f i l l n e s s .

AN UNEQUAL BATTLE

Tlre downstreanr efforts of hcalrh reseirrchers ancl practiticlncrs agrrinst thc upstreanr c'fforts of the nrirnr-rf:rcturers of illness havc fhc irp;lcarirncc of art rrncqual w:rr, uitb a resounding uicttny as- sured for those on the sicle of illness ancl the cre- a t i o n o f d i s c a s e - i n c l u c i n s [ ) c h a v i o r s . T l r e b . . r t t l c - betwecn heirlth '"l,orl<ers ancl thc n'rrrnufacturcrs of illncss is Lrneclu:rl on rlt lc:rsr nvo grclunds. In the first place, we alw.l),s seenr t() rrn'ive rxr the scene irnd begin to worl< rrfter tl'rc rerrl danrage h a s a l r e a d y b e e n d o n e . B 1 ' t h e t i r r e h e r r l t h w o r k - e r s i n t c r v e n e , p e < l p l e h i r v e a l r c . a c l i , f i l l e d t h e r r r r i - fici:rl needs created fitr tltent bv the rn;lnufirctur- e r s o f i l l n e s s : r n c l r r r e h r r b i t u : t t c c l t o v a r i o u s a t - r i s k b e h a v i o r s . l n t h e a r e a o f s n r o k i n g b e h a v - i o r - , f o r e x i l m p l e , w e h r r v e e n i l l u s t r r r t i o u n o t only of tl.re lateness of health rvorkers' arrival on t h e s c e n e , a n d t h e e n o r m i t y o f t h c t a s k c o n - fronting them, but i,rlsci, jLrclgine by recent evi- c l e n c e , o f t h e r c s o u n d i n g d e f e a t b c i n g s t r s t a i n e d

; are en- rount of rplished. tant lm- I and at- wary of ,tility of

should ith this rd begin the real ld mini- y which d large' pushing ?rect, at tructure a hand

nsibiliry

e devel- ,ities of rdividu' hich, in nd ser- roductt

ii , l

I

it l l ri il I

A p o l i t i c a l - e c t > r r o r r i c a n a l y s i s < l f h e i r l t h c a r e suggests that the entire structure of institutions ur the United Stares is such irs to preclr-rdc the a d e q u a t e p r o v i s i u r r o f s e r v i c e s . ' I n . . r e a s i n g l y , i t qeems, the provision of care is being tied to rl-rc

r i t i e s o f p r o l i t - r n a k i n g i n s t i t u t i o n s . F o r a

518 fbw ard Altcrnatives in I'{e rith Clare

in this area." To push tlte river analogy even fur- ther, the tzrsk becornes one of furiously swim- ming against the florv and {inally being swept away when exhausted by the effort <lr through c l i s i l l u s i o n m e n t w i t h a l a c k o f p r o g r e s s . S o l o n g :rs we continue to fight the battle clowllstream, a'rncl ir-r suclr rrn incffective maltrter, we are cloomed to fnlstration, r'cgreatcd failr"rre, ilnd per- h a p s u l t i n r a t c l v t o a s i c k e r s o c i e t y .

S e c o n d , t h c p r o n r o t e r s o f d i s e i r s e - i n c l t r c i n g b e - h a v i o r a r c n r a n i f e s t l y m o r e c f f e c t i v e i n t h c i r u s e of lreh:rviorirl scier.rce knou'lec]ge than rrre thoser of r.rs whil arc collcernccl with the eraclication of s u c h b e h a v i < l r . I n d c e c l , i t i s s o r l r e w h r r t p a r r r d o x i - crrl tl-rat wc shor-rld be rnceting here to consicler how bchavioral scic'ncc l<r.rowleclgc arld tech- niques can bc' effectively cr.r.tployecl to reclrtce or prcvent irt-risk bchavior, rvhen that sarnc body <rf knowleclge has alrcadlt been usecl to creatc t h e a t - r : i s k b e h a v i o r u ' c s c c l < t o c l i r n i n a r e . H o u , c r n b i r r r a s s i n g l y i n c f f c c t i v c i r r e o u r t r . t ; . t s s I t r e t ] i r r c f f o r t s i n t h c h c r r l t h f i c l c l ( c . g . , a l c o h o l i s n r , o b e - s i t , v , d r t r g a b u s e , s a f c c l r i v i n g , p o l l u t i o n , e t c . ) i.vhen cornparccl r,vitl-r nrrrny of tl-rc trtx c-xempt p r o n r o t i ( ) n a l c i f o r t s o n b c h a l f < l f t h c i l l r t e s s g c n - c r r r t i n g r l c t i v i t i c s o f l a r g c - s c r r l c c o r p o r r r t i o t r s . l ( r I f i s a f a c t t l r e t w c r t r e c l c l t t o n s t l a b l y t t r o r e c f f e c t i v c i r r p c r s u r r r . l i n g ; r e o p l c t o 1 . r 1 1 1 c h 1 1 s g i t c n r s t h c v n c v e r c l r c i r n r f t h c y r v o u l c l r r c c c l , o r t ( ) p u r s u e i r t - r i s l < c o u r s c s o f r r c t i o n , t h l r n w e r r r c i t t p l c v c t t t i t r g r i r h a l t i n g s u c h b e l . r a v i o r . M i r n y r r c l v c r t i s e n r c t r t s r l r e s ( ) i n g e r r i o L r s i r r t l r c i l a p p e a l t l r a t t h c y l ' r i r v c c u t e r t a i n n r c n t v a l u e i n t h c i r ' o r ' v n r i g h r r r r t c l b e - c < l r r r c c n r b o c l i c c l i n o u r r t r t t i r > t l t l f o l l i h t r n r o r . I l v r v a y ' o f c ( ) n t r i l s t , r - n r r t t v h e l r l t h i r c l v c r r i s e n r e r r t s l a c [ < r r n y c < l t n p a r a [ r l c r ' r , i c l c s p r e a c l a p p c : r l , o f t e r t r l p p c : l r [ > o l i n g , a v u r t c r r l a r ; i r n c l l a r g c l , v n r i s c l i - r c c t e o .

I w o u l c l a r s u e t h a t o r t c n r r r i o r p r o b l e n r l i e s r r r t h c f a c t t h i l t w c r r r c O v c r l y c o n c c r n c c l w i t h t h c r,r'er: itself, ancl witlr holv we crln urorc efiective ly p e r t i c i p i l t c i n i t . I n t h c h c a l t l t f i e l c l w c h r r v e u t t - q L l e s t i ( ) l i i n g l y e c c c p t c c l t l . r c i t s s u l l l p t i ( ) n s p r c ' - scntecl bi, the r.urrnufrlcturcrs of illncss rtncl, els a c o n s e q u c r l c c , h i r v e c o n f i n c c l o u r e f f o r t s t ( ) o n l , v c l < l r v n s t r e r r r n o f f e n s i v c s . A l i t t l e r e f l c c t i o n w o r - r l c l . I b e l i e v e , c o n v i n c e a n y o n e t l ' r a t t h o s c o n t h e s i c l c o f l . r e a l t l . r r r r c ' i n f a c t l r > s i n e . . B u t t ' r r t h e r t l " r a n nrerely tryirrg to u'in thc war, we Ireccl to stc1.r

back and question the prcmises, legitittracy and r r t i l i t y o f r h e w . r r i t s e l f .

THE BINDING OF AT-RISKNESS TO CULTURE

I t s e e m s r h i r t t h e ; r p p e a l s t o a t - r i s k b c ' h a v i o r t h a t rrrc engincerecl by the nratrr-tfacturers of illness a r e p a r t i c u l i r r l , v s u c c e s s f t r l l t c c a u s e t h c v a r e c o n - strllctecl in sr,rch a way as to bc incxtr:icably b o u n c l w i t h c s s c n t i r r l c l c n r c n t s c l f o u r e x i s t i n g c l o n r i n a r r t c u l t u r e . T h i s i s a c c o m p l i s h e d i n i n u r n b c r o f r v a y s : ( a ) E , x h o r t a t i o r - l s t o a t - r i s k b e - h a v i o r a r e o f t e n p i g g y b a c k e c l o n t h o s e l e g i t - inrizecl values, beliefs, rrncl nort.ns wl-rich are widcly recogniz.ecl rrncl arlhered to in tl.re dorni- r r r u r t c u l t u r c . T h c i c l e a h c r e i s t h a t r f a p e r s o n rttould onll do X, tl.re n thcy

"voulcl also be doing

Y and Z. (b) Apperrls rrrc rtlso aclvrtrtcecl which c l a i r r r o r i n r p l y t h a t c c r t i r i n c o u r s c s o f a t - r i s k a c - tion arc sulrscribed to or cnclorsecl Lly r.r.rost of t l r c c u l t u r c h c r o c s i n s o c i c t l ' ( e . g . , p e o p l e i n t h e c r r t e r t a i n n . r c n t i n c l u s t r ) ' ) , o r b y t h o s e w i t h t e c h n i - c r r l c o m p c t e n c c i n t h a t p a r t i c u l i r r f i e l c l ( e . g . , " c l o c t o r s " r c c o n i r l e n c l i t ) . T h e i c l c a l . r c r e i s t h a t if ir persorr rt.,ould onl1, i11 X, then he/she would bc rloing plctf\' nruch thc srrnre as is clone or rec- o r n n r e n d c c l l r y s u c h p r c s t i l i i o u s p e o p l e a s A a n d ll. (c) i\r'tificial necds rtre ttrrurufacttrrecl, the ful- f i l l i n g o f i v h i c h l r e c o n r c s r r b s o l t t t c l y e s s e n t i a l i f o r r c i s t o b c r t I n c r r n i n u f r r l a n c l u s e f u l m e m b e r o f socictr'.-I'hc itlea l.rcrc is th.rt if e pL-rsoll does not d o X , o r t t ' i l l r r o t r / r . , X , t h c l t t h c y a r c e i t h e r d e f i - c i c n t i n s o t . t t c i n r p o t ' r i l r t t r t : s p e c t , o r t h e y a r e s o r n e r l < i n c l o f l i a b i l i t y f o r t l r c s o c i a l s y s t e n l '

Varirrtiorts ()n thcsc rtttcl ttther kinds of appeal strrrtegies hrrvc', of cotlrscr, been employed for a 1,,,.,g ii,.t't. ttorv b1' thc pr()lroters of at-risk be- h,rvior. Thc rtrarruf:rcttrrcrs of illness are, for ex- a n r p l e , i o s t c r i n g t h e b c l i c f t h a t i f y o u w a n t t o b e rul attractivc, rltasculirlc llli-tllr of a "coolr" "nat' itrrll"'uvot.tlr,i,, 1'or.t rvill sn.rokc cigareftes;.that y o l l c a n o n l l ' l t e : r " g , r o . l p a r e n t " . i f y o u h a b t t u - rrte votrr chilclren tc, .:aniy' cookiei, etc:, And ,r,",''it,,"'";;';';';iy i,;;;i; *i1., voi' will feed v,,ur, l-ri'.lr.t.,cl foocis in", ,tihigh in cholesterol All of tl.rese appeals hlve isolated some baslc goals to which'nrost people subscribe (e'g'' peo'

ple w, ents, imply, throul r:egula h a v i o r b e h a v r twlnec h a p s e d i s p l a l b e r s h i l

S u c l at-risk en.rplcll hauirtr. concep p h y s i o l sented rnerrnin terrr. Tr we are w o r t h l c m o u t h v k i l l e r s , a n d s u c t h a t n t i r ity is a tencc. ( good nii b y t a k i r p h a r r n a r t a s k o f r q u a s i - h e p e n d e n c . edly four h a r m f u l .

There being or and the 1 appear fr never-en( be linkec have alre sumer. B quasi-hea ments of even crei

O I request al

and ple want to be masculine or feminine, good par- ents, loving spouses, etc.) and rnake clairn, or imply, that their realization is only possible through the exclusive use of their product or the regular display of a specific type of at-risk be- havior. Indeed, one can argue that certain at-risk behaviors have become so inextricably inter- twined with our dorninant cultural systen.r (per- haps even symbolic of it) that the routine public display of such behrrvior ahnost signifies menr- bership in this society.

Such tactics for the habituation of people to a t - r i s k b e h a v i o r : r r e , p e r h a p s p a r a d o x i c a l l y , a l s o employed to elicit what I ternl "quasi-health he- hauior." Here again, an artificially c()nstructed conception of a person in sorne fanciful starc of physiological and emotional equilibriunr is pre- sented as the ideal state to strive fclr, if one is to meaningfully participate in the wider social sys- tem. To assist in the attainment of strch a state, we are advised to c()nsulre a range of cluite worthless vitar.nin pills, rrrineral supple rneuts, n-routhwashes, htrir shar.npoos, laxatives, pain killers, etc. Cle:rrly, one cannot exucle radiance a n d s u c c e s s i f o n e i s n o t t a k i r r g t l r i s v i t a n r i r r , o r t h a t m i n e r r r l . T h e a c h i e v e l n e n t o f c l a i l y r e g u l i r r - ity is a prerequisite for: an effective socirrl exrs- t e n c e . O n e c a n o n l y c o m p c t e a n d w i r . r a f t e r a good night's sleep, and this can only bc ensurccl by taking such ar.rd such. Arr entre;rreneurial pharrnaceutical indusrry appears clevotecl to thc task of rnaking people overly conscious of tl.rcsc quasi-health concerns, ancl to engeuclering a cle- pendency or.r products which have been rcpeat- e d l y f o u n d t o b e i r r e f f e c t i v e , r r n c l c v c n p o t e n t i a l l y h a r r n f u l . r r

T h e r e a r e n o c l e r r r s i g n s t h a t s u c h a c t i v i t y i s being or will be regulatcd in any effcctive way, a n d t h e p r o u r o t e r s o f t l - r i s q u a s i - h e a l t h b e h a v i o r appear free to rallge ()ver the entire bocly in thi:ir never-ending search f<tr new arcas ancl issues to b e l i n k e d t i r t h e f a n c i f u l e q u i l i b r i u n - r t h a t t h c y have already engineered ir.r thc mirrcl of tl-re con- sumer. By binding the display of at-risk and q u a s i - h e a l t h b e h a v i o r s o i n e x t r i c a b l y t o e l e - m e n t s o f o u r d o m i n a n t c t - r l t u r e , : r s i t u a t i o n i s even created whereby t() request people to change or alter these behavi,r., i, ,.r.,or. or less to request abandonment of dominar.rt culrure.

A C l a s e f o r R e f o c u s s i n g U p s t r e a m : T h e P o l i t i c a l E c o n o r n y o f I l l n e s s 5 1 9

The term "culture" is ernployed here to de- note that integrated system of values, norms, be- liefs and pattems of behavior which, for groups and social categories in specific situations, facili- tate the solution of social structllral oroblems.L2 This de{rnition lays stress on two features com- n-ronly associated with the concept of culture. The first is the inter:relirtedness ancl interdepen- clence of the various elements (vaitres, ltorrns, b e l i e f s , o v e r t l i f e - s t y l e s ) t h a t a p p i l r e n t l y c o m - prise culture. The settnd is the vierv that a culturirl systr:lll is, in sor-ne llart, a response to social structural problems, rrncl thirt it can be re- g i r r d e d a s s o m e k i n d o f r e s o l u t i o n o f t h e r n . O f c o u r s e , t h e s e s o c i a l s t r u c t u r a l p r o b l e m s , i n p z r r - tial rcsponse to whicli a cultural patte rn errlerges, may themselves havc been engineerecl ir-r the interests of creating certail-r bcliefs, nornls, life styles, etc. lf one rrssullres that culture c:rn bc regr.rrclecl as s()u1c kincl of rcrlcti()r1 fonnatiorr, tlren onc must l)e nrinclfr-rl of tlre unrlnticiDiltcc{ s o c i l l c o n s e q u e n c e s o f i r r v i t i r r g s o n t e r t l t c i ; r r i o n in lrehirvior which is ir Dart <>f a clonrinrrnt clll- t t r r a l p a t t e n r . T h e r e c l u e s t f r o n r h c r r l t l r w o r k c r s f r l r a l t e r a t i o n s i r r c c r t a i r r a t - r i s k l r e h a v i o r s n r a y r c s r r l t i n e i t h e r i r r v k w a r c l c l i s l o c a t i o r r s o f t l r c i r . r - t c r r e l a t e c l e l e r n e n t s o f t h c c u l t u r a l p r r t t e r n , o r t h e c l e s f r u c t i o n o f a s y s t e r u o f v a l u e s r r n c l n o r m s , e t c . , w h i c h h a v e e n r e r g e c l o v c r t i n r e i n r e s p ( ) u s e t o s i t u a t i o n a l p r o b l e n r s . F r o n r t h i s p e r s p e c t i v e , a n c l w i t h r e g a r c l t o t h e u t i l i z a t i o n < l f n r c c l i c i r l c r r r c , I I . r a v e i r l r e a c l l , r r r g r r e d e l s e w h e r c t h a t , f o r c c r : t r r i r . r g r o u p s o f t h e p o p u l a t i o n , u n d e r u t i l i z - a - t i o n m i r y b e " h e a l t h y " b c h r r v i o r , : r n r l t h c r r c l v o - c a c y o f i n c r e r r s c d u t i l i z a t i o n a n " u u h c i r l t l . r y " r e o u e s t f o r t h c t r b a r r c l o r r n r e r r t o f e s s c n t i a l f e a - t u i e s o f c u l t u l e . r r

THE CASE OF FOOD

P e r h a p s i t w o r " r l d b c u s e f u l a t t h i s 1 ' r o i n t t o i l l u s - t r : r t c i r r s ( ) r ) ) r ' ! l e t a i l . f l o r n , r r r c P e r t i l r c n t : l r t J , t l r e stylc and nragnitucle of operation engagecl ir-r by t h e r n r u r u f i r c t u r e r : s o f i l l n e s s . I l l u s t r a t i o n s , r r e , o f c o u r s e , r c a c l i l y a v a i l a b l e f r o n r r r v a r i e t y o f d i f f e r - e n t t l r e a s , s u c h a s : t h c r e q u i r c n r e n t s o f e x i s t i n g o c c u p a t i o n a l s t r u c t u r e , e n r e r g i n g l e i s u r e p a t - t e r n s , s n r o k i n g a n c l d r i n k i n g b e h a v i o r , a n d a u t c l -

that lness con- :ably sting i n a k be- l e o i t -

I a r e lomi- erson Coing vhich rk ac- rst of n the chni- ( e . g ' ' that

'ould

and : ful- al if :r of i not defi-

are

peal o r a be- ex-

r b e nat- fiat 'itu- and'eed rol. lsic 'eo-

52O Toward Alternatives in Health Care

mobile usage.14 Because of current interest, I have decided to consider only one area which is irnportantly related to a range of large chronic diseases-namely, the 161 billion dollar industry involved in the production and distribution of food and beverages.l5 The present situation, with regard to food, was recently described as follows:

The sard history of or,rr foocl supply resembles the energy crisis, and not just because food nourishes our bodies while petrolcum fuels the society. 'We long ago surrendcred control of food, a vital re- source, to privatc corp()fations, just as we surren- dcrecl control of encrgy. The food corporations havc shaped thc kinds of foocl we eat for their grcater profits, just rrs tl-re er-rergy companies have dictatcd the kincls of fuel we use.r6

From all tl.re indeper.rdent evidence available, and despite clain.rs to the contrary by the food ir-iclustry, a wiclespread decline has occurred clur- ing the past three decades in American dietary s t a n d a r d s . S o r r r e f o r t y p e r c e n t o f U . S . a d u l t s a r e overweigl.rt or clowrrright fat.t7 The prevalence of excess weight in tl.re Anrerican population as a whole is high-so high, in fact, that in some s e g m e n t s i t h a s r e a c l - r e d e p i d e m i c p r o p o r t i o l l s . l s There is evidencer that the foocl industry is rna- n i p u l a t i n g o u r i m a g e o f " f o o d " a w a y f r o m b a s i c staples toward synthetic and highly processed iterr.rs. It l.rirs been estillated that we eat between 21 and 2-5 pe rcerrt fcwer dairy products, vegeta- bles, and fruits than we did twenty years ago, rurcl frorr 70 to u0 percent lnore sugary snacks a n c l s o f t c l r i n k s . A p p a r e n t l y , m o s t p e o p l e n o w eat more pr<lcessed encl synthetic foods than the real thing. There arc eveu suggestions that a fed- e r a l , n i r t i o n w i d c s u r v e y w o u l d h a v e r e v e a l e d how serious our clietary situation really is, if the Nixon Adrninistration h:rd rrot cancelled it after reviewing some enrbarrassing preliminary re- sults.r" The surve y :rpparently cor.rfirmed the trend towarcl deterioratins diets first detected in an earlier household f.rod consullption survey i n t h e y e a r s I 9 5 - 5 - l 9 6 . 5 , u n d e r t a k e n b y t h e D e - partrrcrnt of Agriculture.20

Of course, for the foocl industry, this trend to- ward deficient synthetics and highly processed iterr.rs makes good economic sense. Generally speaking, it is much chezrper to make things

look and taste like the real thing, than to actu- ally provide the real thing. But the kind of foods that result from the predominance of economrc interests clearly do not contain adequate nutri- tion. It is common knowledge that food manu- facturers destroy important nutrients which foods naturally contain, when they transform them into "convenience" high profit items. To give one simple example: a wheat grain's outer layers are apparently very nutritious, but they are also an obstacle to making tasteless, bleached, white flour. Consequently, baking cor- porations "refine" fourteen nutrients out of the natural flour and then, when it is financially convenient, replace some of them with a syn- thetic substitute. ln the jargon of the food indus- try, this flour is now "enriched." Clearly, the food industry employs this term in rnuch the same way that coal corporations ravage moun- tainsides illto mud flats, replant them with some soil and seedlings, and then proclaim their rnoral accomplishment in "rehabilitating" the land. While certain types of food processing may make goocl economic sense, it rnay also re- sult ir-r a deficient end product, and perhaps even prolnote certirin cliseases. The bleaching and re- fining of wheat proclucts, for example, largely eliminates fiber or rougha€te from our diets, and sorne authorities have suggestecl that fiber-poor diets can be blarnecl for some of our lnaior in- t e s t i n a l d i s e a s e s . l t

A vast chernic:rl additive technology has en- abled rnanufacturers to acquire enormous control over the food ar.rcl treverage tlarket and to foster phenorrenal prolitability. It is estimated that drug

-ornpanies

akrrre rnake sonlething like $500 mil- lior.r a year through chenrical additives for food. I have aiready suggested that what is done to food, in the way of processing and artificial additives' rnay actually be iniurioui to health. Yet, it isclear thai, despite such well-known risks, profitability makes such activity well worthwhile' For exam- ple, additives, likc preservatives, enable food that might perisl', in

" .h.rn period of time to endure

trnlhong.d for months ,,. .u.. years. Food man- ufacturers and distributors can saturate super- ln,rrket she lves across the country with their protl- ucts because there is little chance that they wtu spoil. Moreover, manufacturers can-purchase vast quantities of raw ingre dients when they arecbeap'

pro ther lonl prlc

T i t i s finer dietr b o r r brr s u g a 1 2 6 o f c < try i e a c h p e a r l - ^ : ^l r l J r L t i o n ' b l a d r deger peop w h i c g e t . I S e n a ( were tive, I leacl t

I n food sourc ceptlc hood m a n l l them as lnu nitudt to the pany,

I i n 1 9 sugar- enorm Unitec advice

Breai gove use c flavo

: . c o n t : 3mPl. becor

ctu- )ods )mic utri- anu- ,hich form ;. To )uter they

eless, I cor- rf the cially

syn- ndus- y, the ,h the noun- . some

their ;" the essing so re- s even nd re- rrgely ;, and ,poor rr in-

ls en- ,ntrol [oster drug ) m i l - r o d . I food, tives, clear bilitY Kam- that dure nan: to€r- ioa' vtill vast €4P:r' ''

produce and stockpile the proccssed result, and then withhold the oroduct from the market for long periods, hoping for the inevitable rise in prices and the consequent windfall.

The most widely used food additive (although it is seldom described as an aclditive) is "re- fined" sugar. Food manufircturers s:lturate our diets witl-r the substance fr<lm tlre cla1, we are b o r n u n t i l t h e d a y w e d i e . C l h i l d r e n i r r e f e d b r e a k f a s t c e r e a l s w h i c h c o n s i s t o f - 5 0 p e r c e n t sugar.22 fhe averagc Arle'rican aclult cor.rsurnes 1 2 6 p o u n d s o f s u g a r e a c h y c a r - a n d c h i l d r e n , of c<>urse, eat nruch nrore. For the candf ir-rclus- t r y a r l o n e , t l r i s a n r o u n t s t o a r o u l l c l $ 3 b i l l i c l n each year. The Arnerican sull:1r rnanirr, which ap- p e a r s t o h a v e b e e n c l e l i b e r e t e l y e n g i n e e r e d , i s a m a j o r c o n t r - i b l r t o r t o s u c h " d i s e r r s e s o f c i v i l i z a - t i o n " a s d i a b c t e s , c o r o n a r y h e a r t d i s c a s e , g a l l b l a d d e r i l l n e s s , a n d c a n c e r - a l l t h e i n s i d i o u s , degenerative conditions which urost often afflict people in aclv:rncecl cairitalist societics, br.rt which "underdcvel<>pcc1," nor.rsLrgar e rrtcrrs never g e t . ( ) n e w i t r r c s s a t a r e c e n t n r c e t i n g o f a U . S . Senate C'orln.rittc-e, srricl thirt if thc foocl irrciustry were proposing sugrrr toclay as :r nc'"v foocl rr.lcli- t i v e , i t s " n r e t i r b o l i c b e h a v i o r l v o u l t l u n r i o u l r t e d l v l e a d t o i t s b e i n g b r r n r r c c l . " 2 i

In sur.r-r, f[re rcfore, it see'r'r-rs that the Antcrrcirrr f o o d i n d u s t r y i s n r o b i l i z i n g p h e n o n r c n r r l r e - sources tr> aclvrrnce r-rrrd bincl r-rs to its ()\vn c()n- ception of food. We irrc lroml'rrrrclccl fronr chilcl- h o o d w i t h $ Z b i l l i o n r v o r t h o f d c l i b e r a t c l y m a n i p u l a t i v e i r c l v e r t i s e n r c n r s c a c h y e r r r , u r o s t ( ) f t h e m u r g i n g L l s t o c ( ) l l s u n r e , l l l n o n g o t l r c r t l r i n g s , a s n t u c l ' r s u g a r a s p o s s i b l e . T o h i e h l i s h t t h c n r l g - n i t u d e o f t h e r c s o u r c c s i n v o l v e d . o l l c c : 1 n D o r n r t o t h e a c t i v i t y o f o r r e w c l l - k r r o w n l . e v c l r q e c o n . r ^ p a n y , O o c r l - ( i r l r r , r v h i c h , r l o n c s p c n t $ 7 1 n r i l l i r l n t n 1 9 7 I t o a c l v c r t i s e i t s a r t i f i c i a l l l ' f l i t v o r e c l , sugar-srrturrrtecl ;rrocluct. lir:lly rccognizitrg thc enonnity of the problenr rcgarcling foocl in thc United Stete s, Zvr,e rdling ,iif.r. ilc- followirrg , advice:

A Casc for Refocussing Upstrean'r: The Political Iiconorny of Illness 521

THE ASCRIPTION OF RESPONSIBILITY AND MORAL ENTREPRENEURSHIP

So far, I l-rave considered, in some detail, tl-re ways in whicl-r industr;', through its manufacture irncl distribution of a variety of products, gener- ates at-risk behavior and disease. Let us now fo- cus on the activities of health workers further down tlre river irnd considcr their efforts in a so- cial context, which has rrlreacly been large[y s h a p e d b y t h e n r r t n u f a c t u r e r s u p s t r e a m .

Not only shoulcl wc be mindful of the cultur- ally clisruptive and largely unanticipated conse- quences of health inter:vcntion efforts mentioned earlier, but rllso of tl-re underlying ideology on which so rnuch of this activity rcsts. Such inter- vention appears basec{ <ln an assunlption of the culpability of indiuiduals or groups who ei- t h e r r n : r n i f e s t i l l n e s s , o r c l i s p l i r y v a r i o u s a t - r i s k b e h a v i o r s .

Fron.r thc ilssrurption that indiviclua[s ancl g r ( ) u p s w i t h c e r t i l i n i l l n c s s e s o r d i s p l a y i n g r , r t - r i s k b e h : r v i o r e r e r e s p o n s i [ r l e f o r t h e i r s t r r t e , i t i s e relafively e asy stcp to irdvocating solne clrirnges in behrrvior on the prrrt ()f tl.rose in- v o l v e c l . I l y a s c r i b i n g c u l p a b i l i t y t o s o m e g r o u p o r s o c i a l c a t e g o r y ( u s u a l l l ' c t l . r r - r i c r - n i n o r i t i e s a r r d f h o s e i n l o w e r s < l c i < l - e c o l . r o n r i c c a t e g o r i e s ) a n d h a v i r r g t h i s a s c r i p t i o n l e g i t i n . r a t e d b y h e a l t h p r o - fessionals irncl acceptecl by otlrcr segments of so- cicty, it is 1-rossible to rlobilize res()Lrrces to char.rgc' rhe offencling behirvior. Certain perople r r r e r e s p o n s i b l c f o r u o t i r p p r o x i n r a t i r . r e , t h r o u g h t h c i r a c t i v i t r e s , s o l r e c o n c e p t i o n o f w h a t o u g b t t o b c a p p r o p r i a t e l r e h a v i < l r o n t h e i r p a r t . \ i l / h e n n.rcrrsurecl agirinst thc artiflcial concepti<ln of w l u t c l u g h t t o [ r e , c e r t a i n i n d i v i c l u a l s i r n d groups are founci to bc' deficicrrt in several im- porfant respects. Tl-rey arc aither doing sonre- t h i n g t h a t r h c i r o u g h t n o t t o b c c l o i n g , o r t h e y r l r e n o r d o i n g s o n r e t h i n g t h a t t h e y o u g h t t o b e c l o i n g . I f o n l y t l r e y r ' v o u l c l r e c o g n i z e t h e i r i n d i - v i c l u a l c u l p a b i l i t y a n d a l t e r t h e i r b e h a v i o r i n sonre :rppropriate frrshion, they rvould irnprove t l r e i r h c : r l t h s t . r t u s o r t h e l i k e l i h o o d o f n o t c l e v e l - o p i n g c e r t a i n p a t h o l o g i e s . O n t h e b a s i s o f t h i s lir-rc of rcasoning, res()ulces are being rnobilized to bring those whcl clepart fnrn.r the desired con- ccption into conformit,v lvith what is thought t<r

B r e a k i n g t h r o u g h t h c f o o c l i n t l u s t r y r v i l l r e q r - i i r c S o v e n r n r c n t a c t i o u - b a n r r i n g o r s l r a r p l y l i n r i t i n g u s e o f d a n g e r o s s r c l . l i t i v c s l i k c i i r t i f i c i a l c o l o r s e n c l f l a v o r s ,

" ' , . 1 , ' . , g . , r . r r r r t l r c r l r r i r i n g w h c l r t p r ( ) c l u c t s t o

c o n t a i n f i b e r - r i c h w h e i l t l l c n l l , t o g i v c j u s t t w o c x -a m p l e s . F o o t l , i f i t i s t o l r c c o r n c s : r f c , w i l l h r l v c t o D e c o m e p r r t ( ) f D , , l i r i . s . l +

522 Toward Alternatives in Health Care

be appropriate behavior. To use the upstream- downstream analogy, one could argue that peo- ple are blamed (and, in a sense, even punished) for not being able to swim after they, perhaps even against their own volition, have been pushed into the river by the manufacturers of illness.

Clearly, this ascription of culpability is not limited only to the area of health. According to popular conception, people in poverty are largely to blame for their social situation, al- though recent evidence suggests that a social welfare system which prevents thern fron-r avoicl- ing this state is at least partly responsible.25 Again, in the field of education, we often hold "dropouts" responsible for their behavior, when evidence suggesrs that the school system itself is rigged for failure.25 Similar examples are readily available frorn the fields of penology, psychiatry, and race relations.2T

Perhaps it would be usefr,rl to bricfl1' outline, at tl-ris point, what I regirrd as a bizarre relation- ship between the activities of the manufacturers of illness, the ascription of culpability, ancl health intervention encleavors. .Firsl, imporrant segments of our social systent llp[)car to ire con- trolled and operatec'l in such a way that peciple must inevitably fail. The fact is tl.r:rt there is of- ten no choice over whether one can find employ- m e n t , w h e t h e r o r n o t t o d r o p o u t o f c o l l e g e , i n - volve oneself in unt<lward behavior, or beconre sick. Second, cven though inclividuals ancl g r o u p s l a c k s u c h c h o i c e , t h e y a t e s t i l l l r l a m e c l f o r n o t a p p r o x i m a t i n g t h e a r t i f i c i a l l y c o n t r i v e c l n o r r n a n d a r e t r e a t e d a s i f r e s o o n s i b i l i t v f o r t h e i r s t a t e l : r y e n t i r c l y w i r h t h e r n . F o r c x e i n p l c , son-re ilLress conditions r.nay be the rcsult of par- ticular: behavior and/or involver-nent in ccrtarr.r occup:rtional r:olc relationships over which those affected have little or no contrc>1.28 Third, after r e c o g n i z i n g t h a t c e r t a i n i n d r v i d u a l s a n c l g r o u p s h a v e " f a i l e d , " w e e s t a b l i s h , a t : r p o i n r c l o w l . r - stream, a substructure of services which are re- garded as evidence of progressive beneficence cln the part of the systern. Yet, it is tl-ris very systctr which had a primary role in manufacturing rhe problems and need for these services in the first prace.

It is around certain asDects of life stvle thirt m o s t h e a l t h i n t e r v e n t i o n e n d e , r v o r s a p p c i t r t o

revolve and this probably results from the observability of most at-risk behavior. The mod- ification of at-risk behavior can take several dif- ferent forms, and the intervention appeals that are employed probably vary as a function of which type of change is desired. People can ei- tber be encouraged to stop doing what they are doing which appears to be endangering their survival (e.g., smoking, drinking, eating certain types of food, working in particular ways); or they can be encouraged to adopt certain new patterns of behavior which seer-ningly enhance their health status (e.g., diet, exercise, rest, ear certain foods, etc.). I have already discussed how the presence or absence of certain life sryles nr some groups may be a part of some wider cultural pattent which ernerges as a response to social structural problems. I have also noted the p()tentially disruptive consequences to these cul- tural patterns of intervention programs. Under- lying all these aspects is the issue of behavior control and the attempt to enforce a particular tvpe of bel-ravioral conformity. It is more than coincidental that the at-risk life styles, which we irre all admonished to avoid, are frequently the rype of behaviors which depart from and, in a scnse, jeopardize the prevailing puritanical, mid- dle-class ethic of what ought to be. According to this ethic, activities as pleasurable as drinking, snroking, ()vereating, and sexual intercourse nrust be harrnful and oueht to be eradicated.

The implortant poilrt lrere is which segments of society ancl whclse interests are health work- els serving, and what are the ideological conse- quences of their acticlns.2e Are we advocating tl.re nrodification of behavior for the exclusiue purpose of ir.nproving health status, or are we r-rsing tlre cluc.stion of health as a means of <rbt:rining sorre kind of moral uniformity through the abolition of disapproved behaviors? -fo wlrat extent, if at all, are health workers ac- tively ir-rvolved in some wider pattern of social r c g u l r r t i o r t ? r 0-Such questions also arise in relation to the burgconing literature that links more covert per' ,,rnility ciraracteristics to certain illnesses and at-risk lrehaviors. Capturing a great deal of at' tention in this ..g"id are" th; recent srudies which associate hleart disease with what ls . terr.ued a Type A personality. The Type A p-e1 ,

i ,4 'i

S O n r sir tin se( ofr otl tin h i t o f i n s

l b a r nor pe( car i n i ing the tho tex' strr duc tise eml m a l ther

N. disr i n l pers age behr war conl faih"

ii trait how and itive

TI som' tionr deal ideo Paft festa

: Seca pro{ tem

A Case for Refocussing Upstream: The political Econornv of Illness 523

from the The mod-

;everal dif- >peals that unction of ple can ei' at they are ering their ing certain

ways); o/ :rtain new ly enhance e, rest, eat

discussed n life styles on-re wider 'esponse to r noted the r these cul- ns. Under- 'f behavior

particular more than , which we luently the r and, in a nical, mid- :cording to s drinking' rntercourse icated. 1 segments alth work- ,ical conse- advocating : exclusiue or are we means of

uniformitY behaviors? rorkers ac- ir of social

ion to the sovert per' lesses and deal of lr: nt snrdies r what .is ,pe A fili

sonality consisrs of a complex of traits which produces: excessive competitive drive, aggres- slveness, impatience, and a harrying sense of time urgency. Individuals displaying this pattern seem to be engaged in a chronic, ceaseless and often fruitless struggle with themselves, with others, with circumstances, with tirne. some- times with life itself. They also frequently ex- hibit a free-floating, but well-rationalized form of hostility, and almost rrlways er cleeD-seated insecurity.3l . Efforts to change Type A traits appear to be based on some ideai conception of a relaxed, non-competitive, phlegmatic individual to which people are encouraged to conform.32 Again, one can questiol-l how realistic such a conception ls in a system which daily rewards behavior result- ing frorn Type A traits. One can clearly quesrion the ascription of near exclusive culpaliility to those displaying Type A behavior when rhe con- text within which such behavior is n'ranifest is structured in such a way as ro guarantee irs pro- duction. From a cursory reading of job adver- tisements in any newspaper, we can sc.e tlrat e m p l o y e r s a c t i v e l y s e e k t o r c c r u i r i n d i v i d u a l s manifesting Type A characteristics, extolling thenr as positive virtues.sl . My earlier point concerning tlre potentially

disruptive consequences of requiring ilterations i n l i f e s t y l e a p p l i e s e q t r a l l y w e l l i n t h i s a r e a o f personality irnd dise:rse. If health workers nrarr- fge to effect sorne changes away from Type A behavior in a system which requircs o'id ,.- wards it, ther.r we must he aware irf rhe possible consecluences of sucl-r chauge in tern.rs ui fu,ur. f a i l u r e . E v e n t h o u g h t h e e v i d e n c e l i n k i n g T y p e A traits to heart disease appears cluite crnclui,uc, how can health workeis- ever liope t<l combat and alter it when such charircterisrics are so p()s- itive.ly and regularly reinforced in this society?

The various points raisecl in this section irave s o m e i m p o r r r n t n r o r a l a l t c l p r a c t i c a l i r t r p l i c l - ttons for those involved in health relateil en- deavors. First, I have argued that our prevailing

ldeo]og.f involves the asJription of culpability to' ' p a r t i c u l a r i n d i v i c l u a l s a n d ^ g r o u p s f o r ^ r h e m a n r -

ior and have access to a body of knowledge and resources which the.y can "legitimately" deploy for its removal or alteration. (A detailed discus_ sion of the means by which this mandate has b.gen.ac,9r1i1ed is expanded in a separare paper.) Tli1d, [it] is possible ro argue thai a gr."t i.oi of health intervention is, perh:rps unwittingly, part of a wide pattem of social regulation. Ve rnust be clear both as to whose intirests we are s e r v i n g , a n d t h e w i d c r i m p l i c a t i o n s a n c l c o n s . quences of the activities we sllpport through the appfication of our expertise. Finally, it is evident from arguments I have presented that n-ruch of our health interventiorr fails tct take adecuare ac- count of dre social corlrexrs wl-rich fostei rnd re- inforce the behaviors we seek to alrer. Tl-re liter:l- ture of prever-rtive medicine is rcplete with illustrations of the failurr of contexrless health lntervention programs.

THE NOTION OF A NEED HIERARCHY

A t t h i s p o i n t i n t h e c l i s c u s s i o n I s h a l l d r s r e s s sliglitly to consider thc relatior.rshirr lretrveen rhc u t i l i z a t i c l n o f p r e v e n t i v e h e . r l r h s e r v i c e s a n c { t h e c()ncept of neecl as r.nturifc'st in this society. We k n o w f r o n r : r v a i l a b l c t , v i t l c r r c c t h e t u p p c r i o c i o - e c o n o m r c g r o u p s : r r e g e n c r a l l y n r o r e r e s p o n s i v c to health intervention activitic's thrrn :rre fhose of Iower soci<l-ec<tnonric stntLls. To trartirrllv ac- c o u n t f o r t h i s p h e n o r . n c n o n , I h e v e f o u n c l i i u s e - ful to introducc the noti()n <>f a rteetl hicrarcby. Ily this I refer to tlre fact rhar sonte neecls (c.g., f o o c l , c l o t i . r i r r g , s h e l t e r ) a r e p r o b a b l y u n i v e r s , r l l y recognizcd as relartecl to slreer survivill rrncl t:rke p r e c e d e n c e , w h i l e o t h e r n e c c l s . f o r D i r r t i c u l a r s o - c i : r l g r o u p s , m a y b c p c r c e i v c e l a s l e s s i r n m e d i - ately intl'rortant (e.g., clental care, exercise, bal- arrced cliet). ln other worcls, I conceive of a hierarchy of necds, r:ruging frorr what cor-rlcl be termed "prirnary neecls" (which relate nrore or less to tl.re universally recognized imnrediate n e e d s f o r s u r v i v a l ) t l r r o u g h t ( ) " s e c o n d a r y n e e d s " ( w h i c h a r e n o t a l w a y s r e c c l g n i z e d a s m r - portant and which n'ray be artificially cngineered b y t h e n r a n u f a c t u r e r s o f i l l n e s s ) . S o m e w t e r e b e - tween the high priority, prirnary neecls and the less importanr, sec()ndary needs are likely to fall

tton of either disease cr. it-risk behavior. , it can be argued that so-callecl ,.health ionals" have acquired a mandate to de-

ine the morality of different rypes of behav-

: .i ii ifl

!:: *a, :i!,. ii.jl i;, Fifi,,)ll

l: ul. ., fr

524 Toward Altematives in Health Care

the kinds of need invoked by preventive health workers. 'Where one is located at any point in time on the need hierarchy (i.e., which particu- lar needs are engaging one's attention and re- sources) is largely a function of the shape of the existing social structure and aspects of socio- economrc status.

This notion of a hierarchy of needs enables us to distineuish between the health and illness be- havior of the affluent and the poor. Much of the social life of the wealthy clearly concerns sec- ondary needs, which are generally perceived as lower than most health related rreeds on the need hierarchy. If some patliology presents itseif, or some at-risk behavior is recognized, then they n a t u r a l l y a s s u m e a p r i o r i t y p o s i t i o n , w h i c h eclipses most other needs for action. In contrast, rnuch of the social life of the poor centers on needs which are understandably regarded as be- ing of greater priority than r.nost health concerns o n t h e n e e c l h i e r a r c h y ( e . g . , h o m e l e s s n e s s , u n e n l - ployrnent). Should sorr.re illness event preserlt it- self, or should health workers alert people and groups in poverty to possible further healti-r rteeds, then these needs inevitably assume a posi- t i o n o f r e l a t i v e l o w p r i o r i t y a n d a r e e c l i p s e d , perhaps indefinitely, by more pressing prinr:rry needs for sheer existence.

Frot.n such a perspectivc, I think it is possible to understand why so much of our health inter- ventiol.r fails in tl.rose very groups, at highest risk to r-norbiclity, whorn we l.rope to reach ancl influ- ence. The appeals that we rlake in alerting tl-rcm t o p o s s i b l e f u t u r e n e e d s s i r n p l y n r i s s t h c m a r k b y giving inadequate recognition to those primirry neecls which claily preoccupy their attention. Nclt only does the notion of a need hierarchy emphasize the clifliculty of contextless interven- t i o n p r o g r a m s , b r " r t i t a l s o e n a b l e s u s t o v i e w t h e rejection as :1 n()n-conrpliance with health pro- !1Alns, as, in a sensc, rational bel-ravior.

HOW PREVENTIVE IS PREVENTION? 'With regirrd to sorrre of the argurnents I have presented, concerning the ultimate futility of d o w n s t r e a m e n d e a v o r s , o n e m a y r e s p o n d t h a t effective preventive n-redicine does, in fact, take accout.rt <lf this pr<lblem. Indeed, ltlany preven-

tive health workers are openly skeptical of a predominantly curative perspective in health care, I have argued, however, that even our best preventive endeavors are misplaced in their al- most total ascription of responsibility for illness to the afflicted individuals and groups, and through the types of programs which result. While useful in a limited way, the preventive ori- entation is itself largely a downstream endeavor through its preoccupation with the avoidance of at-risk behavior in the individual and with its general neglect of the activities of the manufac- turers of illness which foster such behavior.

Figure 49-l is a crude diagrar.nmatic represen- tation of an overall process starting with (1) the activities of the rnanufacturers of illness, wliich (2) foster and habituate people to certain at-risk be- haviors, which (-l) ultimately result in the onset of certair.r types of morbidity and rnortality.sa The predominant cur:rtive orientation in rnodern med- icine deals alr.nost exclusively with the observable patterns of nrorbidity and rnortalitn which are the end-points in the process. The much heralded pre- ventive orientation focuses on those behaviors which are known to be associated with particular illnesses arrd which can be viewed as the midpoint in the overall pr<>cess. Still left largely untouched arc thc entrepre neur-ial activities of the manufac- turers of illness, who, tl.rrough largely unregulated activities, foster the at-risk behavior we aim to prevent. This bcginning pctint in the process re- mains unaffccted by rl1osf preventive ertdeavors, even though it is at this point that the greatest po- tential for change, and perhaps even ultimate vic- t o r y , l l e s .

I t i s c l c r t r t h : r t t l r i s p r r p c r r r t i s e s n l r l l y q u e s t i o n s and issues at a seneral level-more in fact than it

F i g u r c 4 9 - 1 .

1

T h e a c t i v i t i e s of the -'> manufacturers o f i l l n e s s

t Interventaon w i t h a p o l i t i c a l e c o n o m i c f o c u s

I

V a r i o u s at-risk -_' b e h a v i o r s

I I

lntervention w i t h a preventive focus

3

Observable morbiditY and mortalitY

A I

lntervention with a curativB focus

1 S p O S l has br with l: suing enoug Hopel u l a t e r tions I directi p l o y e < t h e o r strair.r i profiti c o n c l r three r

REC(

a. Leg I t i s p healtlr health tive ef long 1 w a r w w i l l r t i l l n e s s d i v i d u ties fo we ou. tion w !7ides latecl t ratioltl then s would as thir tising empt educat able rr verely activit true t their e of the ing wt

A s : ,,tion o

rtical of a in health

:n our best in their al- , for illness :oups, and rich result. ventive ori- n endeavor voidance of nd with its ,e tnanufac- ravlor. :ic represen- w i t h ( 1 ) t h e s s , w h i c h ( 2 ) n at-risk be- L the onset of 'tality.3a The nodern med- e observable vhich are the reralded pre- re behaviors th particular he midPoint y untouched i1e manutac- unregulated r we aim to ' process re- : endeavors' greatest po- -rltimate vtc-

ry questlons r fact than tt

Observable morbiditY and mortality

A I

lntervention with a curative iocus

is possible to resolve. Since most of the discussion has been at such an abstract level and concerned with broad political and economic forces, any en- suing recommendations for change must be broad enough to cover the various topics discussed. Hopefulln the preceding argument will also stirn- ulate discussion toward additional recommenda- tions and possible solutions. Given the scope and direction of this paper and the analogy I have ern- ployecl to convey its content, the rask becomes of the order of constructing fences upstream and re- straining th<lse who, in the interest of corpclrate profitability, continue to push people in. In rhis concluding section I will confine rny renrarks to three selected areas of recommendations.

RECOMMENDED ACTION

a . L e g i s l a t i v e I n t c r v e n t i o n It is probably true thirt one stroke of cffective h e a l t h l e g i s l a t i o n i s e q u i r l t o n l a r l y s r : p a r a t e health interventior.r endeavors and the currulrr- r i v e e f f o r t s o f i n n u m e r a b l e h e a l t h w o r k e r s o v e r l o n g p e r i o d s o f t i r n e . I r r t e r m s o f w i n r r i n g t h e war which rvas describecl earlicr, grczrter changes will result fron-r the coutinuecl r-roliticizatior.r of illness than from the nroclification of specific in- d i v i d u a l b e h : r v i o r s . T h e r e a r e r n a n y o p p o r t u n i - ties for a lcgislirtive reduction of at-riskncss, ar-rcl we ought to scizc theur. Let rr.re give one sugges- t i o n w h i c h r e l a t e s r o e a r l i e r p o i n t s i n t l r i s p a p e r . Widcspreilcl pr-r bl ic advcrtisi n g is i n.r portirr-rtl1' rc- l a t e d t o t h c g r < l w t h a n d s u r v i v a l o f l a r g e c o r p o - r a t i o n s . I f i t w c r c l t o t s o c l c m o n s t r a b l y e f f e c t i v c , then strch vilst sunls <lf nrot'rcy ancl resoLrrces woulcl not be clevotecl to this activity. Mclrcover, a s t h i n g s s t a n d a t p r e s e n t , a g r e a t d e a l o f a c l v e r - t i s i n g i s e n c o u r a g e d t h r o u g h g r a n t i n g i t t a x e x - empt st:1tlts olt solne vague grourrds 0f public education.3s Til irlace r-n<tre stringent, enforcc- able restricti()ns on advertisine would be to se- v e r e l y c u r t a i l t h e m o r a l l y a b h o r r e n t p u s h i r r g r n activities of the rnanufactnrers of illness. lt is t r u e t h a t l a r g e c o r p o r a t i o n s r r r c i n g e n i t - r u s r r r their efforts to :tvttid the consequences of rnttsr o f t h e c u r r e n r l c e i s l a t i v c r e s t r i c t i o n s o l r a d v c r t i s - ing which only prohibir cerrain kinds of appe:rls. . As a p<lssible solution to this anci in recogni-

t t o n o f t h e m o r a l c u l p a b i l i t y o f t h o s e w h o a r c

A Case for Ref<>cussing Llpstrearn: The Political Economy of Illness 525

actively manufacturing disease, I conceive of a ratio of advertising to health tax or a rario of risk to benefit tax (RRBT). The idea here is to, in some way, match advertising expenditures to health expenditures. The precise weighting of the ratio could be determined by independently ascertaining the severity of the health effects produced by the manufacture and distribution of the product by the corporation. For example, it is clear that smoking is injurious to health and has no redeeming benefit. Therefore, fclr this product, the ratio could be determined as say, 3 to 1, where, for example, a company which spends a non-tax deductible $ I rnillion to adver- tise its cigarettes would be required to devote a non-tax deductible $3 niillion to the area of health. In the area of quasi-health activities, where the product, although largely useless, may n o t b e s o i n j u r i o u s ( e . g . , n a s a l s p r a y s , p a i n killers, miner:al supplerrents, etc.), the ratio could be on, say, a 1 to I basis.

Of course, the manufacturers of illness, at the present time, do "donate" large sums of nroney for the purpose of research, with an obvious un- derstanding that thcir gift should be recipro- c a t e d . I n a r e c e n t a r t i c l e , N u e h r i n g a n d M a r k l e touch on the nature of this reciprocity:

One of the rnitst ironic pro-cigarcttc force s has becn thc American Medical Association. This now- e rful hclltl.r organization took a position in I yOS clearly favor:rble to the tobacco intercsts. . . . In acl- c l i t i o n , t h e A . M . A . w a s , u n t i l 1 9 7 i , c o n s p i c r - r o u s l y abscnt from the nrcnrbcrship of the N:rtir>nal Inter- ilgcncy Council on Surokingl en.l Hcrrlth, ;r co.rlitior-r of govcrnment agencies and virtually all thc na- t i o r r a l h c a l t h o r g a n i z a t i o r - r s , f o r m c d i n 1 9 6 4 . T h e A.M.A.'s largely pro-tobacco bchavior has been linked with the acceptirnce of largc research su[rsi- clies from the tobacco industry-anrounting, ac- corcling to thc industry, to sonrc 18 million dol- lrr rs.3t'

Cliven such rcciprocity, it would be necessary for dris health money from the RRBT to be han- clled by a supposedly independetrt government agency, like tlie FDA or the FTC, for distribu- tion to regular research instittrtions as well as to consumer organizations in the lrealth field, which are currently so unequally pitted against the upstream manufacturers of illness. Such leg- islation would, I believe, severely curtail corpo-

526 Toward Alternatives in Health Care

rate "pushing in" activity and publicly demon- strate our commitment to effectively regulating the source of many health problems.

b. The Question of Lobbying Unfortunately, due to present arrangements, it is difficult to discern the nature and scooe of health lobbying activities. If only *. ..,uld 1.,- c a t e ( a ) w h o i s l o b b y i n g f o r w h a t , ( b ) w h o t h e y are lobbying with, (c) what tactics are being en.r- ployecl, and (d) rvith what consequences for health legislation. Because these activities are likely to jeopardize the myths that have been so carefully engineered and fed to a gullible public by both the manufacturers of illness and varrous health organizations, they are clothed in secrecy.3T Judging from recent newspaper re- ports, concerning multimillion dollar gift-giving by the pharmaceutical industry to physicians, the occasional revelation of lo[rbying and politi- cal exchange remains largely unknown ancl Iiighly newsworthy. It is frequendy argued that lobbying on behalf of specific legislation rs an essential avenue for public input in the process <.lf erracting laws. Nevertheless, the evidence sug- gests that it is often, by being closely linked to the distribution of wealth, a very one-sidccl proccss. As it presently occurs, many legitinrate interests on a ranse of health rel:rtcd issues cl<l u o t h a v e l o b b y i n g i n p u t i n p r o p o r t i o n t o t l . r e i r uumerical strellgth and may actu:llly bc struc- t u r a l l y p r c c l u d e d f r o m e f f e c t i v e p a r t i c i p a t i o n . W h i l e r e c o g n i z i n g t h e i m p o r t : r n c e o f l o b b y i n g activity and yet feeling tl.rat for certrrin interests i t s s c o p e o u g h t t o b e s e v e r e l y c u r t a i l e d ( p c r h a p s in tl-re saure way as the proposed resulation arncl g l u b l i c a t i o n o f p o l i t i c a l c a r n p : r i g n c r l r r t r i b u t i o n s ) , I a m , t o b e h r l n e s t , a t a l o s s a s t o w h a t s h o u l c l be specifically rccomr-nended. . . . 'l-he questi()r'l i s : q u i t e a p a r t f r o m t h e s p e c i f i c i s s r - r e o f c h a n g i n g individual behavior, in what ways tt.ntld Luc pos- sibly regwlate thc disproportionatcly influentittl htbbying actiuitit's of tcrtain intert'st grottps irr the health field?

c. Public Education

In the past, it has been colluron to advocate the education of the public as a rneans of achieving irr.r

alteration in the behavior of groups at risk to ill- ness. Such downstream educational efforts rest on "blaming the victim" assumptions and seek to ei- ther stop people doing what we feel they "ought not" to be doing, or encourage them to do things they "ought" to be doing, but are not. Seldom do w e e d u c a t e p e o p l e ( e s p e c i a l l y s c h o o l c h i l d r e n ) about the activities of the rnanufacturers of illness and about how they are involved in many activi- ties nnrelated to their professed area of concern. How rnany of us know, for example, that for any "average" Thanksgiving dinner; the turkey may be producecl by the Greyhouncl Corporation, the Smithfield Han-r by ITI the lettuce by Dow Chern- ical, the potatoes by Boeing, the fruits and vegeta- bles by Tenneco or the Bank of America?38 I would reiterate that I arn not opposed to the edu- catiorl of people who are at risk to illness, with a view to altering their behavior to enhance life c h a n c e s ( i f t h i s c a n b e d o n e s u c c e s s f u l l y ) . H o w - ever, I would add the proviso that if we remain comnrittecl to the education of peclple, we must ensure that they are being told the whole story. And, in rny view, imrnediate priority ought to be given to the sensitization of vast nur.nbers of peo- ple to thc upstrear.n irctivities of the uranufactur- e r s o f i l l n e s s , s o r r e o f w h i c h h a v e b e e n o u t l i n e d i n this paper. Sucl.r a progranl, actively supported by the fe cleral government (pe rhaps tirrough revenue d e r i v e d f r o m t h e R R B T ) , r l l a y f o s t e r a grorrndswell of consLrr.ner interest which, in turn, rnay go solne way toward checking the dispro- por:tionately influential lobbying of the large cor- p o r r r t i ( ) n s a n c l i n t e r e s t g r o u p s .

NOTES AND REFF]RE,NCES l. l.K. Zola, "I"lelping-l)()es It M:lttcr: The Prob-

le rns rnd l)rospccts of Mutr.ral Aid Groups." Aclclrcsscd to thc Ur-rited Ostonry Associationt lL)70.

?. See, for cxanrple, M.\W. Susser and W. Watson, Sociology in Metlicine, New York: Oxford Uni- ver:sit1' Prcss, l97l . Eclith chcn, ct al.' "Family Structure in Relation to Health and Disease'" lournal of Ohronic Disctses, Vol. l2 (19601, p' .5-54--567; and R. Keelncr, Fantily IIt Health: An Inuestigatirnt in Cleneril Praciice, Charles C' -l'l-ronrrr-s, 19(r3. There is, of course, voluminous literaturc which rel:rtcs familv structure to mental illness. Fcr.r, studies m()ve to th" leuel of consider' ' ing thc bro,rclcr social forces wl-rich promote the t'

< to ill- rest on kto ei- "ought r things iom do r i l d r e n ) f illness / activi- oncern. for any

:ey may :ion, the v Chem- I vegeta- r i c a ? 3 8 I the edu- s, with a rnce life ). How- : remain ile must le story. ht to be of peo-

ufactur- :lined in >rted by revenue ,stef A in turn, dispro- :ge cor-

family structures which are conducive to the on- set of particular illnesses. !7ith regard to utiliza- t i o n b e h a v i o r , s e e J . B . M c K i n l a y , " s o c i a l N e t - works, L^y Consultation and Help-Seeking B e h a v i o r , " S o c i a l F o r c e s , V o l . 5 1 , N o . 3 ( M a r c h , 1 9 7 3 ) , p p . 2 7 5 - 2 9 2 .

3. A rich source for a variety of materials included in t h i s s e c o n d l e v e l i s H . E . F r e e m a n , S . L e v i n e , a n d L.G. Reeder (Eds.l, Handbook of Medical Soctol- crgy, New fersey: Prentice-Hall, 1972. I wotrld a l s o i n c l u d e h e r e s t u d i e s o f t h e l r e a l t h i m o l i c a t r o n s o f d i f f e r e n t l r o u s i n g p a t t e n l s . R e c e n r c v i d c n c c s u g - g e s t s t h a t h o u s i n g - e v e n w h e n h i g h l y d e n s e - m a y n o t b e d i r e c t l y r e l a t e d t o i l l n e s s .

4 . T h e r e h a v e , o f c o u r s e , b e e n m a n y s t u d i e s , m a i n l y b y e p i d e m i o l o g i s t s , r e l a t i n g d i s e a s e p a r r e r n s r o c e r t a i n o c c u p a t i o n s a n d i n d u s t r i e s . S e l d o r n , h o w - e v e r , h a v e s o c i a l s c i e n t i s t s p u r s u e d t h e c o n s e - quences of these findings in terms of a broader p o l i t i c a l e c o n o n l y o f i l l n e s s . O n e e x c e p t i o n t c r t h i s s t a t e m e n t c a n b e f o u n d i n s t u d i e s a n d w r r t - i n g s o n t h e s o c i a l c a u s e s a n d c o n s e q u e n c e s o f e n - v i r o n m e n t a l p o l l u t i o n . F o r a r e c e n t e l e m e n t a r y t r e a t m e n t o f s o m e i r n p o r t a n t i s s u e s i n t h i s g e n c r a l area, see H. Waitzkin and B. Waterntan, The Ex- ploitation ctf' Illness in Capitalist Socicty, New Y o r k : B o b b s - M e r r i l l C o . , 1 9 7 4 .

. 5 . S o m e u s e f u l i n t r o d u c t o r y r e i l d i n g s a p p e a r r n D.M. Gcrrdor.r (Ed.\, Problerns in Political Et'tnr omy: An Urban Perspectiue, Lcxtngton: D.C. H e a t h & C o . , 1 9 7 1 , a n d R . C , . l l d w a r d s , M . R c - i c h a n d T . E . \ T e i s s k o p f ( E d s . ) , T h e C a p i t a l i s t S y s t e m , N e w . f e r s e y : P r c n t i c e - H a l l , 1 9 7 2 . A l s o , T . C h r i s t o f f e l , D . F i n k c l h o r a n d D . G i l b a r g ( E d s . ) , U1t Against the American Myrb, New York: Holt, R i n e h a r t a n d W i n s t o n , 1 9 7 0 . M . M a n k o f f ( E d . ) , The Pouerty of Progress: The Politicttl Economy of American Social Prohleizrs, Ncw York: Flolt, R i n e h a r t a n c l W i n s t o n , 1 9 7 2 . F o r n r o r e s o p h i s t i - c a t e d t r e a t m e n t s e c t h e c o l l c c t i o n e d i t e d b y D . Mernrelstein, I'.conomics: Mahrstreant Readings a n d R a d i c a l C r i t i q u e s , N e w Y o r k : R r n d o m H o u s e , 1 9 7 0 . A d d i t i o r . r a l l y u s c f u l p a p e r s : l p p e a r i n J . B . M c K i n l a y ( E d . l , P o l i t i c s a n d L a t u i t t Health Cttre Pol/,:y. Ncw York: Proclist, 1973, a n d J . B . M c K i n l a y ( E d . ) , E c o n o m i c A s p e c t s o f H e a l t h C a r e , N c w Y o r k : P r o d i s t , 1 9 7 3 . F < > r a h i g h l y r e a d a b l e a n c l i n f l u e n t i a l t r e a t m e n t o f w h a t i s t e r m e d " t h e n - r e d i c a l i n d u s t r i a l c o m o l e x . " s c e B . a n d J . E h r e n r c i c h , T h c A t n c r i t a n H ' e a l t l t E m - pire: Power, Prctfits and Politics, New York: Vin- t a g e B o o k s , 1 9 7 1 . A l s o r e l e v a n r a r e T . R . M a r - yror, The Politics of Medicare, Chicago: Aldine P u b l i s h i n g C o . , 1 9 7 3 , a n d R . A l f o r c l , , , t h e p o l i t i - c a l E c o n o m y o f H e a l t h C a r e : D y n a n r i c s ' W i t h o u t

A Case for Refocussing Upstream: The Political Economy of Illness 527

Change," Politics and Society, 2 (1972), pp. 1 . 2 7 - 1 " 6 4 .

6. E. Cray, In Failing Health: Tbe Medical Crisis and the AMA, Indianapolis: Bobbs-Merrill, 1970. J.S. Burrow, AMA-Voice of American Medicine, B a l t i m o r e : J o h n s H o p k i n s P r e s s , 1 9 6 3 . R . H a r n s , A Sacred Trzst, New York: New American Li- b r a r y , 1 9 6 6 . R . C a r t c r , T h e D o c t o r B u s i n e s s , G a r d e n C i t y , N e w Y o r k : D o l p h i n B o o k s , 1 9 6 1 . " T h e A m e r i c a n M e d i c a l A s s o c i a t i o n : P o w e r , P u r - p o s e a n d P o l i t i c s i n O r g a n i z e d M e d i c i n e , " Y a l e L a w J o u r n a l , V o l . 6 3 , N o . 7 ( M a y , 1 9 5 4 ) , p p . 9 3 8 - 1 0 2 1 .

7 . S e e r e f e r e n c e s u n d e r f o o t n o t e 5 , c s p e c i a l l y B . a n d J. Ehrenreich's The Anrcrictrn Health limpire, C h a p t e r V I I , p p . 9 5 - 1 2 3 .

8 . D . M . G o r d o n ( E d . ) , P r o b l e m s i n P o l i t i c a l E c o n - omy: An Urban Iterspectiue, Lexington: D.C. H e a t h & C o . , 1 9 7 l , p . 3 1 8 .

9 . S e e , f o r e x a r n p l e , D . A . B c r n s t e i n , " T h e M o d i f i - c a t i o n o f S r n o k i n g B e h a v i o r : A n L , v a l u l t i v e l l e - view." Psych<tlogical Bulletin, Yol. 71 (June, 1 9 6 9 ) , p p . 4 1 8 4 4 0 ; S . F ' o r d a n d F . E d e r e r , " B r e a k i r r g t l . r c C i g a r e t t c H a b i t , " J o t r r n t t l o f ' A m e r - i c a n M e d i c a l A s s o c i a t i c t t t , 1 9 4 ( ( ) c t o b c r , 1 9 6 5 ) , 1 ' t y ' t . 1 3 9 - 1 4 2 ; C . S . K e u t z e r , e t a l . , " M o d i f i c a t i o n < r f S n r o k i n g B c h a v i o r : A R c v i e w , " P s y c h o l o g i c a l I l u l l e t i n , V o l . 7 0 ( D e c c r n b c r , 1 9 6 8 ) , p p . . 5 2 0 - - t 3 3 . M e t t l i n c o n s i c l e r s e v i c l c n c c c o u c c n r i n g r h e f o l l o w - i n g t c c h n i c l u e s f o r n r o d i f y i n g s r n , r k i n g b e h , r v r o r : ( 1 ) l r e h a v i o r a l c o n c l i t i o n i n g , ( 2 ) g r o u p c l i s c u s s i o n , ( . 3 ) c o u n s e l l i n g , ( 4 ) h y p n o s i s , ( . 5 ) i n t e r p e r s o r . r a l c o m r n u n i c a t i o n , ( 6 ) s e l f - a n a l y s i s . F { e c o n c l u d e s t h a t :

l l a c h o f t h e s e l p p r o : r c h e s s u l l l l c s t s t h a t s n r o k i n g b e - h a v i o r i s t h e r e s r r l t o f s o n r e f i n i t c s e t o f s o c i a l i r n c l p s y c h o l o g i c a l v a r i a b l e s , y e t n o n e h a s e i t h c r d e n r o n - s t r t r t c d l l n ) , s i g n i f i c a t r t p o r v e r s i n p r e d r c t r n g t h e s n r o k - i n g b c h a v i o r s o f a n i n d i v i c l u a l o r l e d t o t e c h n i q u e s o f s m o k i n g c o n t r o l t h ; r t c o l r s i d c r c c l ; r k r r r c , h a v c s i g n i f i - c a n t l o r r g - t c r n r e f f c c t r .

I n C . M c t t l i n , " S n . r o k i u g i r s B c h a v i o r : A p p l y r r g a S o c i a l P s y c h o l o g i c a l T h e o r y , " . l o t t r n a l o f H e a h h a n d S o c i a l B e h a u i o r , l 4 ( J u n e , 1 9 7 3 ) , p . 1 4 4 .

I 0 . l t a p p e a r s t h a t a c o n s i d e r a l r l e p r o g r o r t i o n o f a d v e r , t i s i n g b y l a r g c c < ; r p o r a t i o n s i s t a x e x e m p t t h r o u g h b e i r . r g g r a n t e d t h e s t a t u s o f " p u b l i c e d u c a t i o n . " L . r p a r t i c u l a r ; t h e e n o r m o u s r n e c l i : r c a n r p a i g n , w h i c h w t s r e c c n t l y w a g e c i b v m r r j o r o i l c < t r l p a n i e s i n a n :rttempt to preservc the pr"rblic myths they had so c a r e f u l l y c o n s t r u c t e d c o n c e r n i n g t h e i r a c t i v i t i e s , w a s a l r n o s t e n t i r e l y n o n - t a x a b l e .

I l . R c p o r t s o f t h e h i r r n r f u l n c s s a n d i n c f f c c t i v c n e s s o f c L - r t t i n p r t t d r t c t c a p p e e r a l t - u 9 s t w e e k l y i 1 t l - r e

e Prob- rouPs." ciado['

Vatson, :d Uni- FamilY sease.' 6AL P... t t h : 4 4 , 'les Qj ninous rne4tal nsidgr': |teidig

l l

tl:; ji lii 1i i,i

528 Toward Alternatives in Health Care

press. As I have been writing this paper, I have c o n 1 e a c r o s s r e p o r t s o f t h e l o w q u a l i t y o f m i l k , t h e u s e l e s s n e s s o f c o l d r e m e d i e s , t h e h e a l t h d a n - gers in frankfurters, the linking of the use of the aerosol propellant, vinyl chloride, to liver cancer. T h a t t h e F o o d a n d D r u g A d m i n i s t r a t i o n ( F . D . A . ) is unable to effectively regulate the manufacturers o f i l l n e s s i s e v i d e n t a n d i l l u s t r a t e d i n t h e i r i n e p t h a n d l i n g o f t h e w i t h d r a w a l o f t h e d r u g , b e t a h i s - tine hydrochloride, which supposedly offcrecl symptomatic relief of Meniere's Syndrome (an af- f l i c t i o n o f t h e i n n e r e a r ) . T h e r e i s c v e r y r e a s o n t ( ) t h i n k t h a t t h i s c a s e i s r r o t a t y p i c a l . F o r a d d i t i o n - ally disquieting evidence of how the Cigarette l-a- b e l i n g a n d A d v e r t i s i n g A c t o f 1 9 6 5 a c t u a l l y c u r - tailed the oower of the F.T.C. and other fedcral agencies frbm regr,rlating cigarette advertising and n u l l i f i e d a l l s u c h s t a t e a n d l o c a l r e g u l a t o r y e f - forts, see L. Fritschier, Smoking and Politics: Pol- icymaking and the Federtrl Bureaucracy, New York: Meredith, L969, and T. Whiteside, Selling Death: Cigarette Aduertising and Puhlic Heahh, N e w Y o r k : L i v e r i g h t , 1 9 7 0 . A l s o r e l c v a n t a r c C < r n g r e s s i o n a l Q u a r t e r l y , 2 7 ( 1 9 6 9 ) 6 6 6 , 1 0 2 6 ; a n d U . S . D e p a r t m e n t o f A g r i c u l t u r c , E c o n o m r c R e s e a r c h S e r v i c e , T o b a c c o S i t u a t i o n , W a s h i n g - t o r l : G o v e r n n r e n t P r i n t i n g O f h c c , 1 9 6 9 .

1 2 . T h e t e r m " c u l t u r e " i s u s e d t o r e f e r t o : r n u m b e r o f o t h e r c h a r a c t e r i s t i c s a s w e l l . f J o w e v e r , t h c s c t w o a p p e a r t o b e c o m m o n l y a s s o c i i r t e c l w i t h t h c c o n c c p t . S e e . f . B . M c K i n l a y , " S o m e O b s e r v a t i o n s o n t h e C o n c e p t o f a S u b c u l t u r e . " ( 1 9 7 0 ) .

1 3 . T h i s h a s b e e n a r g u e d i n . f . B . M c K i n l a y , " S o n r e A p p r o a c h e s a n d P r o b l e r n s i n t h e S t u d y o f t h c L l s e o f S e r v i c e s , " J o u m a l o f H c a l t h a n d S o c i a l B c h a t , - i o r , Y o l . 1 3 ( | u l n 1 9 7 2 1 , p p . 1 l - 5 - l - 5 2 ; a n d f . I 3 . M c K i n l a y a n d D . f ) u t t o n , " S o c i a l P s v c h o l o g i c a l F a c t o r s A f f e c t i n g I l e a l t h S e r v i c c U t i l i z r r t i o n , " c l r a p t c r i t C o n s u n t e r I n c c n t i u c s f o r H a a l t h ( . , a r c , N e w Y o r k : P r o d i s t P r e s s , 1 9 7 4 .

l 4 . R c l i a b l e s o u r c e s c o v e r i n g t h c s e a r e r s a r c a v a i l - a b l e i n m a n y g r r o f e s s i o n a l j o u r n a l s i n t h e f i e l c l s o f e p i d e r n i o l o g y , m e c l i c a l s o c i o l o g y , ; r r e v e n t i v e m e d - i c i n e , i n d u s t r i a l a n d o c c r - l p a t i ( ) n a l n r e c l i c i n c a n d public health. Usefr.ri refcrence s covering thcse a n d r e l a t e d . r r e a s a p p e a r i n f . N . M o r r i s , L l s c s o f Epidemiology, London: E. and S. I-ivingstonc' I r t d . , 1 9 6 7 ; a n d M . ' W . S u s s e r a n d W . W a t s o n , S o ciology in Medicine, New Yolk: Oxford Univer- s i t y P r e s s , 1 9 7 1 .

1 . 5 . D . Z w c r l i n g , " D e a t h f o r f ) i r . r n c q " T h e N c t u Y o r k R e u i e w o f B o o k s , V o l . 2 1 , N o . 2 ( F e b r u a r y 2 1 , 1 9 7 4 ) , p . 2 2 .

1 6 . D . Z w e r l i n g , " D e a t h f o r D i n n e r . " S c e f o o t n o t c 1 5 a b o v e .

17. This figure was quoted by several witnesses at the Hearings Before the Select Committee on Nutri- tion and Human Needs, U.S. Government Print- i n g O f f i c e , 1 9 7 3 .

1 8 . T h e m a g n i t u d e o f t h i s p r o b l e m i s d i s c u s s e d i n P . Wyden, The Ouerweight: Causes, Costs and C o n t r c , t l , E n g l e w o o d C l i f f s : P r e n t i c e - H a l l , 1 9 6 8 ; National Center for Health Statistics, Weight by Age and Height of Adults: 1960-62. Washington: Vital dnd Health Statistics, Public Health Servrce P u b l i c a t i o n # 1 0 0 0 , S e r i e s 1 1 , # 1 4 , G o v e r n m e n t P r i n t i n g O f f i c e , 1 9 6 6 ; U . S . P u b l i c H e a l t h S e r v i c e , C c n t e r f o r C h r o n i c D i s c a s e C o n t r o l , O b e s i t y a n d L l e a l t b , ' W a s h i n g t o n : G o v e r n m e r t t P r i n t i n g O f - fice. 1966.

1 9 . - I ' h i s a b o r t e d s t u d y i s d i s c u s s e d i n M . J a c o b s o n , Nutrition Scoreboard: Your Guide to Better Eat- ing, Ccnter for Science in the Public Intcrest.

2 0 . M . S . H a t h a w a y a n c l E . D . F o a r d , H e i g h t s a n d Weights for Adults in the United Srares, Washing- t o n : H o m e E c o n o m i c s R c s e a r c h R e p o r t 1 0 , A g r i - c u l t u r a l R e s e a r c h S e r v i c e , U . S . D e p a r t r n e n t o f A g r i c u l t t r r c , G o v e r n m c n t P r i n t i n g O f f i c e , 1 9 5 0 .

2 1 . l - l r i s i s c l i s c u s s e d b y D . Z w e r l i n g . S e e f o o t n o t e 1 6 .

22. Sce Hcarinpls Before the Sclect Cotnmittee on Nu- lrition ttnd Httntatt Needs, Parts 3 and 4, "T.V. A d v c r t i s i n g o f F o o d t o C h i l d r e n , " M a r c h 5 , 1 9 7 - l a n c i M a r c h 6 , 1 9 7 3 .

2 - i . I ) r . . f o h n U c l k i n , D e p a r t m e n t o f N u t r i t i o n , Q u e e n Eliz-ebcth Ci-rllcge, [.or.rdon LLriversity. See p. 225, Senate Ht:arings, footncltc 22 above.

2 4 . D . Z w e r l i n g , , " D e a t h f o r I ) i r " r n c r . " S e e f o o t n o t e l 6 i r b o v c , ; > a g c 2 4 .

2 . 5 . ' f h i s i s w c l l a r e u e d i n F . P i v e n a n d R . A . (llowarcl, llegulaiing the Poor: The Functions of Social \X/elfalc, New York: Vintage, 1,971; L. (ioodwin, Do the P<.s<tr 'Vlttnl to -W<trk?, Wash' i r r g t < r r r : l l r o o k i n g s , 1 9 7 2 ; H . . | . G a n s , " T h e P o s i - tive Fr-rnctions of Povcrty," American Journal of Sociltlog1,, Vrl. 78, No. 2 (September, 19721, pp. 275-28i; R. P. Roby (Fd.). Thc Pouerty Estab' l i s b m u r t , N e w J c r s c y : P r e r " r t i c e - H a l l , 1 9 7 4 .

2 6 . S c ' c , f o r . * a m p i e , j u i e s H e n r y , " A m e r i c a n S c h o o l - r o ( ) n r s : t , c o r r r i , r g i h e N i g h t n i a r . ' , " C o l u m b i a U n i ' t , c r s i t ) , F t n t n t z , - ( S p r i n g l 1 9 6 3 ) , p p . 2 4 - 3 0 ; - S e e elso ihc paper by

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ministratiue Science Quarterly, Vol. 14, No. 3 ( S e p t e r n b e r , 1 9 6 9 ) . p p . . 1 2 5 - 3 3 6 . T h e l i r e r a t u r e i n t h i s p a r t i c u l a r a r e a i s e n o r m o u s . F o r s e v e r a l g o o d r e v i e w s , s e e L . E . H i n k l e , " S o m e S o c i a l a n d B i o - l o g i c a l C o r r e l a t e s o f C o r o n a r y H e a r t D i s e a s e , " Social Science and Medi<:ine, Yol. 7 (19671, pp. 1 2 9 - 1 3 9 ; F . H . E p s t e i n , " T h e E p i d e m i o l o g y o f C o r o r r a r y H e a r t D i s e a s e : A R e v i e w , " l o u r n a l o f C h r o n i c D i s e a s e s , 1 8 ( A u g u s t , 1 9 6 5 ) , p p . 7 3 5 - 7 7 4 .

2 9 . S o n ' r e i n t e r e s t i n g i d e a s i n t h i s r e g a r d a r e i n E . N u e l . r r i r . r g a n d G . E . M a r k l e , " N i c o t i n e a n d N o r m s : T h e R e e m e r g e n c e o f a D e v i a n t l J e h a v i o r " S o c i a l P r o b l e m s , Y < t l . 2 1 , N o . 4 ( A p r i l , 1 9 7 4 1 , p p . - 5 1 3 - 5 2 6 . A l s o , J . R . G u s f i e l d , S y m b c ; l i c C r u - sade: Status Politics and the Atncrican T'emoer- a n c e M o u e m e n t , I J r b a n a , I l l i n o i s : U n i v e r s i t j ' , t f I l l i n o i s P r e s s , 1 9 6 3 .

3 0 . F o r a s t u d y o f t h e w a y s i n w h i c h p h y s i c i a n s , c l e r - g y m e n , t h c p o l i c e , w e l f : r r e o f f i c e r s , p s y c h i a t r : i s t s a n d s o c i a l w o r k e r s a c t z r s a g e n t s o f s o c i a l c o r l t r o l , see E. Curnning, Systems of Social Regulatiorr, N e w Y o r k : A t h c r t o n P r e s s , 1 9 6 8 .

3 1 . R . H . R o s e n m a n a n d M . F r i c d n r a n , " T h e R o l e o f a S p e c i f i c C ) v e r t B c h a v i o r P a t t e r n i n t l - r e C ) c c u r - r e n c e o f I s c h e r - n i c H c r t r t l ) i s e a s e , " C a r d i o l < t g i a P r a c t i c a , 1 3 ( 1 9 6 2 ) , p 1 t . 4 2 - 5 3 ; M . F r i e d m a n : r n r l R. H. Itosenntan, l'ype A Bchauior ttnd Your H e a r t , K n < t y t f , 1 9 7 . 1 . A l s o , S . . f . Z y z a n s k i a n c l C . D . J e n k i r r s , " l l i r s i c D i m e n s i o u s \ V i t h i n r n e C o r o r r a r y - P r o n e B e h a v i o r P : l t t c n t , " . l r x t m a l o f O h r L t n i c [ ) i s e t t s e s , 2 2 ( 1 9 7 0 1 , p p . 7 8 1 - 7 9 - 5 . T h e r e a r e , o f c o r l r s e , m a n y o t h e r i l l n e s s e s w l - r i c h h a v c a l s o b e e r - r r c l a t e d i n o n e w a y ( ) r a n ( ) t h e r f o c c r t i r l r p e r s o n a l i t y c h a r r r c t e r i s t i c s . H a v i n g f o u n d t h i s n e w t u r f , b c h : r v i o r r i l s c i c n t i s t s r v i l l m o s t l i k e l y c o n t i n u e t o p l a y i t f o r e v c r y t h i n g i t i s w o r t l r a r r c l t l - r c n , i n r h c i n t e r c s t s o f t h e i r o w n s t r r v i v r r l . r v i l l " d i s c o v e r " t l - r a t s o r n e t h i l r g c l s c i r r c l c c t l a c e o u n r s f o r w h a t t l r c y w c r e t r v i r r g t . , e x P l 3 i 1 1 . r n c l w i l l e v e u t u a l l y n r o v e o f f t h c r e r o f i n d r e n c w c d f : r n r e a n d f o r t u n e . F u r t h e r n r o r e , s e r i o u s r n e t h o c l o l o g i - c a l d o u b t s h a v e b e e n r : r i s e c l c o n c e r n i n q t h c s r i l c l - i e s o f t h e r e l a t i o n s h i p b e r w e c u p . . r s o n r r l i t y r r n c l a t - r i s k b c l . r a v i o r . S e e , i n t h i s r e g a r d , ( ; . M . H o c h b a u n r , " A C r i t i q u c o f P s y c l . r o l o g i c a l R e - s e a r c h o n S n r o k i u g , " p a p e r p r c s e n t e d t o t h e A r n e r i c a n P s y c h o l o g i c a l A s s o c i a r i o n , I - o s A n g e - l e s , 1 9 5 4 . A l s o B . l . e b o v i t s a n d A . O s t f e l d , " S m o k i n g a n d P e r s o n : r l i t y : A M e t h o d o l o g i c A n a l y s i s , " . l t t u n n l o f ' C h r o n i c / ) l s c a s e s ( 1 9 7 1 ) .

3 2 . M . F r i e d m a n a n d R . H . I l r s e n n r a n . S e e f o o t n o t c J l . .

3 3 . I n t h e N e w Y o r k T i n t e s < ' t [ S L r n d a y , M a y 2 6 , 1 9 7 4 ,

lcussmg Upstreatn: I he l'olltrcal L,conomy of Illness 529

t h e r e w e r e j o b a d v e r t i s e m e n t s s e e k i n g " a g g r e s s r v e s e l f - s t a r t e r s , " " p e o p l e w h o s t a n d r e a l c h a l l e n g e s , " " t h o s e w h o l i k e t o c o r n p e f e , " " c a r e e r o r i e n t e d s p e - c i a l i s t s , " " t h o s e w i t h a s p a r k o f d e t e r m i n a t i o n t o s o m e d a y r u n t h e i r o w n s h o w , " " p e o p l e w i t h t h e s u c c e s s d r i v e , " a n d " t a k e c h a r g e i n d i v i d u a l s . "

3 4 . A s p e c t s o f t h i s p r o c e s s a r e d i s c u s s e d i n J . B . M c K i n - l a y , " O n t h e P r o f e s s i o n a l R e g u l a t i o n o f C h a n g e , " in Thc Professions and Sociol Changc, P. Halrnos ( E d . ) , K e e l e : S o c i o l o g i c a l R e v i e w M o n o g r a p h , N o . 2 0 , 1 9 7 3 , a r . r d i n " C l i e n t s a n d O r g a n i z a t i o n s , " c h a p t e r i n | . R . M c K i n l a y ( F i d . ) , P r < l t : e s s i n g P e o - ple-Studies in Organizationa| B ehduior, London: H o l t , R i n e h a r t , a n d W i r r s t o : n , 1 9 7 4 .

. 1 . 5 . T l r e r c l r a v e b e e n a n u r n b e r o f r e p o r t s r e c e n t l y c o n c e r n i n g t h i s a c t i v i t y . Q u e s t i o n s h a v e a n s e n a b o u t t h c c o n d u c t o f r l r a j o r o i l c o r p o r a t i o n s d u r - i n g t h e s o - c a l l e d " e n e r g y c r i s i s . " S e e f o o t n o t e 1 0 . E q u a l l y q u e s t i o n a b l e n r a y b e t h e p u b l i c s p i r i t e d a c l v e r t i s e m e n t s s p o r ] s o r e c l b y v a r i ( ) u s p r o f e s s i o n a l o r g z r n i z i r t i o n s w h i c h , w h i l e c l a i n r i n g t o b e s o l e l y i r - r t h e i n t e r e s t s o f t h e p u b l i c , a c t u a l l y s e r v e t o e u - I t r r n c e b u s i n e s s i n v n r i o u s r . l . a 1 , s . F u r t h e r r n o r e , b y g r a n t i n g s p e c i a l s t a t u s t o l c t i v i t i e s o f p r o f e s s i o n a l g r o l r p s , g o v e n r n r c n t l g c r r c i c s l n t l l a r g e c o r p o r r t - t i o n s m a y e f f e c t i v e l y g a g t h e m t h r o u g h s o l - n c e x - y r e c f a t i o n o f r c c i p r o c i t y . F o r e x a t n p l e , l r o s t l r c a l t h g r o u l - r s , n o t r r b l v t h e A r n e r i c a n C e n c e r S o - c i c t y , d i c l ! r o t s u p p o r t t h e F . C l . ( 1 . ' s r c t i o n l l g r l i n s t s n r o k i r r g c o n r n r e r c i i r l s b c c a u s c t h e y w c r e f e r r r f u l o f a l i e n a t i n g f h e n e t w o r k s f r o u r w h o r l r t h e y r c - c c i v e f r e e a n n o l . l u c c l n c - n t s f o r t h c i r f r . r n d d r i v e s . l J o t h t h c A r " n e r i c : r n ( l a n c c r S o c i e t y e n c l t l r c " A m e r - i c : r n F l e a r t A s s o c i a t i o n l r r r v c b c e n c r i t i c i z e d f o r t l t c i r r c l u c t a n c e t o e n l l r r l a c i r r d i r c c t o r g , a n i z i r t i o n a l c o n f l i c t w i t h p r o - c i g r r r e t t c f o r c ( ' s , p i l r t i c r r l a r l y b c - f o r e t h e : r l l i a n c e b e t w c c n t h e t e l e v i s i < ' r n b r o a c l - c i l s t c r s a n c l t h c t o b l c c o i n d r r s t r y [ r r o k e d o w n . R r r t h r - r i t h c y h n v c d i r c c t e c l t l r e i r e f f o r t s t o t h e c l o w n s t r c - l r n r r c ' f o r n r < l f t [ r e s u r o k e r . S e c E . N u e h r i n g r r r c j ( i . F l . M a r l c l e , c i t e r l i n f o o t n ( ) t e 2 9 .

3 6 . l - . . N u c h r i n g

a n c i ( 1 . F l . M a r k l c , c i t e d i n f ( x ) t n o t e

3 7 . T h c r v a 1 , s i r . r w h i c h l r , r r g e - s c : r l c o r g : r n i z i t t i < l n s e n g i - n e e r a n c l d i s s e n r i n r r t e t h c s e n r y t h s c o n c e n r i n g t h e i r n r : r n i f e s t a c t i v i t i c s , w h i l e a v o i d i n g a n y r n e n - t i o n o f t h e i r r - r n r i c r l y i n g l a t c n t t c t i v i t i e s , a r e d i s - c t r s s e c l i n m o r e d e t a i l i n t h e t w o r e f e r e n c e s c i t e d i n f o o f n o t e 3 4 a b o v c .

. 1 8 . F o r a p o p t r l a r l y r v r i t t e n a n c l e f f e c t i v e t r e a t m e n t o f t h e r e l a t i o n s h i p b e t w e c n g i r n t c o r p o r e t i o n s a n d f o < t c l p r o d u c t i o n a n d c o r r s u m p t i o n , s e c W . R o b - birrs, T/re American Food Scttndal New York: W i l l i a r n M o r r o w a n d ( ' . < t . - 1 9 7 4 .

A C a s e f o r R e f o c u s s i n g U p s t r e a r n : T h e P o l i t i c a l E c o n o m y o f I l l n e s s