It has been nearly forty years since sociologist Paul Starr’s Social Transformation of American Medicine (1983) won the Bancroft Prize and became the dominant narrative for the history of American medicine.Footnote 1 In it, Starr portrayed American medicine, largely defined by the American Medical Association (AMA), as driven by a steady agenda of self-serving professional goals such as building a veneer of infallibility around codes of silence and, by the twentieth century, leveraging medical professionals’ prestige, political influence, and claims to scientific medicine to dominate the health-care marketplace. Peter A. Swenson’s Disorder seeks to rescue professional medicine’s historical reputation. Suitable for an educated lay audience and upper-division undergraduates, Disorder may prove to be a necessity for graduates in the field. It rejects the idea that the nature of professional medicine has been entirely self-serving and highlights a progressive, reformist tradition that sought to prioritize public good over the accumulation of professional power. The history of American medicine, Disorder seems to suggest, may be more of a pendulum swinging between political poles rather than a steady, conservative march toward monopolistic professionalism.
Rooting its evidence in primary sources, especially the proceedings and journals of professional medical societies—the AMA is at the center of Swenson’s analysis, as it was in Starr’s—Disorder paints a picture of a fragmented community of physicians in the late nineteenth century who came together for a common purpose. Following popular currents, this joint purpose was progressive and focused on the betterment of society. Swenson defines this progressive “medico-political era” with three areas of reform: fighting against the threat of so-called patent medicines; engaging in public health initiatives (including with political, religious, corporate, and union groups); and improving medical education by weeding out inferior medical schools. These reforms resulted in marked improvements to the overall health of Americans, according to Swenson. Mosquitoes were identified as vectors of yellow fever and lives were saved. Turn-of-the-century public health campaigns brought down tuberculosis rates. Congress established the Food and Drug Administration in 1906 to protect Americans from food-born illness and pharmaceutical addiction. Even battles lost by the progressive AMA, such as the failure to create a national department of health with the Owen Bill, are nevertheless evidence of a progressive impulse.
Manifesting in 1920, according to Swenson, was a reactionary turn against medical progressivism. In many ways, this shift paralleled the decade’s larger conservative turn, but when American politics shifted leftward during the Great Depression in the 1930s, the AMA continued to take professional medicine into “ultra-conservative” territory, much to the social disadvantage of Americans. This reactionary turn was the product of a few ideologically driven physicians, including Journal of the American Medical Association (JAMA) editor Morris Fishbein, who were able to capitalize on lingering resentment within the medical community against progressive reform. At this point Swenson’s narrative largely follows the trajectory of Starr’s. Medicine’s reactionary turn brought the profession into questionable relationships with the drug and tobacco industries, which in turn led to profits that the AMA used to lobby politicians and influence public opinion against public health and national health care plans that AMA leadership feared would compromise physicians’ influence within the health-care marketplace. The result has been a disastrous tangle of for-profit insurance companies and “action-biased” physicians that contribute to a culture of overtreatment and medical malfeasance.
But all is not lost. According to Swenson, recent developments within medicine, including the AMA support for the Affordable Care Act (signed into law in 2010) and physicians joining together during the COVID epidemic to support public health directives in the face of impassioned conservative opposition, point to how the profession may be on the verge of another pendulum swing back to its progressive roots. In this context, Swenson is ultimately writing for the medical profession itself, encouraging physicians to reimagine the AMA as a vehicle for reform.
That Swenson is a political scientist (and Starr a sociologist) is not surprising, as historians rooted in the humanities may be uncomfortable with Disorder’s sweeping master narrative. The AMA at the turn of the twentieth century adopted Jim Crow segregation with their reform spirit, a move that W.E.B. Du Bois argued turned the AMA into a barrier to, rather than a vehicle for, progressive reform. Disorder acknowledges but downplays tensions over race, just as it acknowledges but downplays tensions over women within the profession during its progressive medico-political era. Also, its depiction of historiography—an argument that little has been written on professional medicine’s progressive spirit and reactionary turn—misses the opportunity to connect more robustly to previous histories that document dynamics between reformers and conservatives within the profession, such as John Harley Warner’s classics The Therapeutic Perspective (1984) and Against the Spirit of System (1997).Footnote 2 But Swenson is not writing for historical nuance so much as he wants to advance the master narrative of the history of the American medicine from where Starr left it in 1983, a goal that Disorder may very well accomplish.
