Critical Medical Theory.

Identity politics and other themes in the culture war are beginning to infect the health professions. A major preoccupation of schools of public health, institutions of medical training and research, and the Department of Health and Human Services is the phenomenon of group-based differences in health status. African Americans, for example, have higher morbidity and mortality for most conditions: cancer, heart disease, stroke, infant mortality, and so on, compared to whites. About that, there is no dispute.

Why these disparities exist and what we should do to reverse them are subjects of legitimate interest. But whether they are the products of racial discrimination in the health care system or in society in general (as the U.S. Commission on Civil Rights, among others, has suggested) is far from clear. Efforts to portray these disparities as the result of bias and to remedy them through civil rights activism are gaining momentum. I call this paradigm Critical Medical Theory. Just as critical legal theory ridicules the idea that color-blind justice could ever flow from a system of laws devised by white men, critical medical theorists believe that health "equality" is impossible to achieve in the current system which was designed by (and presumed to cater to) the majority. There are two manifestations of critical medical theory: oppression theory as it is taught in schools of public health, and affirmative action (racial preferences) in medical schools.

My interest in these disparities began on the morning of 24 October 1996. I literally woke up to a story on National Public Radio about high blood pressure and African Americans. The focus was a study that had been done at the Harvard School of Public Health and that had appeared in the peer reviewed American Journal of Public Health. The authors, Nancy Krieger, an epidemiologist, and Stephan Sidney, a physician, had hypothesized that African Americans were more likely to suffer from hypertension than whites--they do indeed have about twice the risk of high blood pressure--because of the stress of being discriminated against. They hypothesized that racial discrimination causes psychological stress, which in turn leads to constriction of the blood vessels and, ultimately, to high blood pressure.

Certainly, we know that stress can have physiological effects, that is not in dispute, but the Harvard study used weak methods. For example, they asked groups of blacks and whites (patients at a Kaiser-Permanente clinic), "Have you ever been discriminated against in your life? Never? One or two times? Three or more?" The responses were then compared with a blood pressure reading on each subject.

If Krieger and Sidney's hypothesis--that blood pressure increases with discrimination--were correct, then the pressure readings would have increased with reported episodes of discrimination. Yet, no such relationship was found. In fact, black working class men and women who reported zero episodes had higher pressure than those reporting one or more. Also, black professional women who reported one or two episodes of discrimination had lower blood pressure readings than those with none or with three or more. And exactly the opposite was found for professional men; that is, men with one or two episodes of discrimination had higher readings than those with none or three or more. In other words, the results were all over the map. When faced with results that show no pattern, scientists normally conclude that no correlation exists. But Krieger and Sidney were creative. They rationalized that some of the black subjects must have under-reported experiences of victimization or that they had "internalized" their oppression--in other words, they were so beaten down they believed they deserved any poor treatment they got.

Once published, the study received enormous media attention. "Study: Discrimination May Cause Hypertension in Blacks," declared the Washington Post. National Public Radio broadcast a lengthy report in which a psychologist who was interviewed about the study said, "We now have concrete data showing that what society does to you affects your health." Brent Staples, an editorial writer at the New York Times, wrote a column titled "Death by Discrimination: Of Prejudice and Heart Attacks." Three years later, he was still commenting, going so far as to remark that "the medical system has yet to list 'racism' as a cause of death [even though] some social scientists now see tension related to discrimination as a health hazard on par with smoking and a high fat diet."

I soon discerned that the Krieger-Sidney paper exemplified a major new trend in public health research: the doctrine that sickness is a product of power arrangements in society. This genre of research even has a special name: the social production of disease, and is devoted to the study of forms of social oppression (e.g., classism and sexism) as major contributors to disease. Social productionist researchers like Krieger posit that social disenfranchisement leads to infirmity and shorter life expectancies via two pathways. One is immediate: through the psychological stress of oppression. The other is ultimate: through material disadvantage, which takes the largest toll on the poor and minorities in our society. To be sure, it is a well-known fact that people who are further down on the socioeconomic ladder are, on average, less healthy and shorter lived than those above them. But is people's health utterly at the mercy of social forces?