Medical diploma mill
PROFESSIONAL VICTORY
The “regulars” were still in no condition to make another bid for medical monopoly. For one thing, they still couldn’t claim to have any uniquely effective methods or special body of knowledge. Besides, an occupational group doesn’t gain a professional monopoly on the basis of technical superiority alone. A recognized profession is not just a group of self-proclaimed experts; it is a group which has authority in the law to select its own members and regulate their practice, i.e., to monopolize a certain field without outside interference. How does a particular group gain full professional status? In the words of sociologist Elliot Freidson:A profession attains and maintains its position by virtue of the protection and patronage of some elite segment of society which has been persuaded that there is some special value in its work.
In other words, professions are the creation of a ruling class. To become the medical profession, the “regular” doctors needed, above all, ruling class patronage.
By a lucky coincidence for the “regulars,” both the science and the patronage became available around the same time, at the turn of the century. French and especially German scientists brought forth the germ theory of disease which provided, for the first time in human history, a rational basis for disease prevention and therapy. While the run-of-the-mill American doctor was still mumbling about “humors” and dosing people with calomel, a tiny medical elite was travelling to German universities to learn the new science. They returned to the US filled with reformist zeal. In 1893 German-trained doctors (funded by local philanthropists) set up the first American German-style medical school, Johns Hopkins.
As far as curriculum was concerned, the big innovation at Hopkins was integrating lab work in basic science with expanded clinical training. Other reforms included hiring full-time faculty, emphasizing research, and closely associating the medical school with a full university. Johns Hopkins also introduced the modern pattern of medical education—four years of medical school following four years of college—which of course barred most working class and poor people from the possibility of a medical education.
Meanwhile the US was emerging as the industrial leader of the world. Fortunes built on oil, coal, and the ruthless exploitation of American workers were maturing into financial empires. For the first time in American history, there were sufficient concentrations of corporate wealth to allow for massive, organized philanthropy, i.e., organized ruling-class intervention in the social, cultural, and political life of the nation. Foundations were created as the lasting instruments of this intervention—the Rockefeller and Carnegie foundations appeared in the first decade of the twentieth century. One of the earliest and highest items on their agenda was medical “reform,” the creation of a respectable, scientific American medical profession.
The group of American medical practitioners that the foundations chose to put their money behind was, naturally enough, the scientific elite of the “regular” doctors. (Many of these men were themselves ruling class, and all were urbane, university-trained gentlemen.) Starting in 1903, foundation money began to pour into medical schools by the millions. The conditions were clear: conform to the Johns Hopkins model or close. To get the message across, the Carnegie Corporation sent a staff man, Abraham Flexner, out on a national tour of medical schools—from Harvard right down to the last third-rate commercial schools.
Flexner almost singlehandedly decided which schools would get the money—and hence survive. For the bigger and better schools (i.e, those which already had enough money to begin to institute the prescribed reforms), there was the promise of fat foundation grants. Harvard was one of the lucky winners, and its president could say smugly in 1907, “Gentlemen, the way to get endowments for medicine is to improve medical education.” As for the smaller, poorer schools, which included most of the sectarian schools and special schools for blacks and women—Flexner did not consider them worth saving. Their options were to close, or to remain open and face public denunciation in the report Flexner was preparing.
The Flexner Report, published in 1910, was the foundations’ ultimatum to American medicine. In its wake, medical schools closed by the score, including six of America’s eight black medical schools and the majority of the “irregular” schools which had been a haven for female students. Medicine was established once and for all as a branch of “higher” learning, accessible only through lengthy and expensive university training. It’s certainly true that as medical knowledge grew, lengthier training did become necessary. But Flexner and the foundation had no intention of making such training available to the great mass of lay healers and “irregular” doctors. Instead, doors were slammed shut to blacks, to the majority of women, and to poor, white men. (Flexner in his report bewailed the fact that any “crude boy or jaded clerk” had been able to seek medical training.) Medicine had become a white, male, middle-class occupation.
But it was more than an occupation. It had become, at last, a profession. To be more precise, one particular group of healers, the “regular” doctors, was now the medical profession. Their victory was not based on any skills of their own: The run-of-the-mill “regular” doctor did not suddenly acquire a knowledge of medical science with the publication of the Flexner Report. But he did acquire the mystique of science. So what if his own alma mater had been condemned in the Flexner Report; wasn’t he a member of the AMA, and wasn’t it in the forefront of scientific reform? The doctor had become—thanks to some foreign scientists and eastern foundations—the “man of science”: beyond criticism, beyond regulation, very nearly beyond competition.
OUTLAWING THE MIDWIVES
In state after state, new, tough, licensing laws sealed the doctor’s monopoly on medical practice. All that was left was to drive out the last holdouts of the old people’s medicine—the midwives. In 1910, about 50 percent of all babies were delivered by midwives—most were blacks or working class immigrants. It was an intolerable situation to the newly emerging obstetrical specialty: For one thing, every poor woman who went to a midwife was one more case lost to academic teaching and research. America’s vast lower class resources of obstetrical “teaching material” were being wasted on ignorant midwives. Besides which, poor women were spending an estimated five million dollars a year on midwives—five million dollars which could have been going to “professionals.”
Publicly, however, the obstetricians launched their attacks on midwives in the name of science and reform. Midwives were ridiculed as “hopelessly dirty, ignorant, and incompetent.” Specifically, they were held responsible for the prevalence of puerperal sepsis (uterine infections) and neonatal ophthalmia (blindness due to parental infection with gonorrhea). Both conditions were easily preventable by techniques well within the grasp of the least literate midwife (hand-washing for puerperal sepsis, and eye drops for the ophthalmia.) So the obvious solution for a truly public-spirited obstetrical profession would have been to make the appropriate preventive techniques known and available to the mass of midwives. This is in fact what happened in England, Germany, and most other European nations: Midwifery was upgraded through training to become an established, independent occupation.
But the American obstetricians had no real commitment to improved obstetrical care. In fact, a study by a Johns Hopkins professor in 1912 indicated that most American doctors were less competent than the midwives. Not only were the doctors themselves unreliable about preventing sepsis and ophthalmia but they also tended to be too ready to use surgical techniques which endangered mother or child. If anyone, then, deserved a legal monopoly on obstetrical care, it was the midwives, not the MD’s. But the doctors had power, the midwives didn’t. Under intense pressure from the medical profession, state after state passed laws outlawing midwifery and restricting the practice of obstetrics to doctors. For poor and working-class women, this actually meant worse—or no—obstetrical care. (For instance, a study of infant mortality rates in Washington showed an increase in infant m
ortality in the years immediately following the passage of the law forbidding midwifery.) For the new, male medical profession, the ban on midwives meant one less source of competition. Women had been routed from their last foothold as independent practitioners.
THE LADY WITH THE LAMP
The only remaining occupation for women in health was nursing. Nursing had not always existed as a paid occupation—it had to be invented. In the early nineteenth century, a “nurse” was simply a woman who happened to be nursing someone—a sick child or an aging relative. There were hospitals, and they did employ nurses. But the hospitals of the time served largely as refuges for the dying poor, with only token care provided. Hospital nurses, history has it, were a disreputable lot, prone to drunkenness, prostitution, and thievery. And conditions in the hospitals were often scandalous. In the late 1870s a committee investigating New York’s Bellevue Hospital could not find a bar of soap on the premises.
SHE BECOMES A TRAINED NURSE
If nursing was not exactly an attractive field to women workers, it was a wide open arena for women reformers. To reform hospital care, you had to reform nursing, and to make nursing acceptable to doctors and to women of “good character,” it had to be given a completely new image. Florence Nightingale got her change in the battlefront hospitals of the Crimean War, where she replaced the old camp-follower “nurses” with a bevy of disciplined, sober, middle-aged ladies. Dorothea Dix, an American hospital reformer, introduced the new breed of nurses in the Union hospitals of the Civil War.
The new nurse—“the lady with the lamp,” selflessly tending the wounded—caught the popular imagination. Real nursing school began to appear in England right after the Crimean War, and in the US right after the Civil War. At the same time, the number of hospitals began to increase to keep pace with the needs of medical education. Medical students needed hospitals to train in; good hospitals, as the doctors were learning, needed good nurses.
In fact, the first American nursing schools did their best to recruit actual upper-class women as students. Miss Euphemia Van Rensselear, of an old aristocratic New York family, graced Bellevue’s first class. And at Johns Hopkins, where Isabel Hampton trained nurses at the University Hospital, a leading doctor could only complain that:Miss Hampton has been most successful in getting probationers [students] of the upper class; but unfortunately, she selects them altogether for their good looks and the House staff is by this time in a sad state.
Let us look a little more closely at the women who invented nursing, because, in a very real sense, nursing as we know it today is the product of their oppression as upper-class Victorian women. Dorothea Dix was an heiress of substantial means. Florence Nightingale and Louisa Schuyler (the moving force behind the creation of America’s first Nightingale-style nursing school) were genuine aristocrats. They were refugees from the enforced leisure of Victorian ladyhood. Dix and Nightingale did not begin to carve out their reform careers until they were in their thirties, and faced with the prospect of a long, useless spinster-hood. They focused their energies on the care of the sick because this was a “natural” and acceptable interest for ladies of their class.
Nightingale and her immediate disciples left nursing with the indelible stamp of their own class biases. Training emphasized character, not skills. The finished product, the Nightingale nurse, was simply the ideal Lady, transplanted from home to the hospital, and absolved of reproductive responsibilities. To the doctor, she brought the wifely virtue of absolute obedience. To the patient, she brought the selfless devotion of a mother. To the lower level hospital employees, she brought the firm but kindly discipline of a household manager accustomed to dealing with servants.
But, despite the glamorous “lady with the lamp” image, most of nursing work was just low-paid, heavy-duty housework. Before long, most nursing schools were attracting only women from working-class and lower-middle-class homes, whose only other options were factory or clerical work. But the philosophy of nursing education did not change—after all, the educators were still middle and upper-class women. If anything, they toughened their insistence on lady-like character development, and the socialization of nurses became what it has been for most of the twentieth century: the imposition of upper-class cultural values on working-class women. (For example, until recently, most nursing students were taught such upper-class graces as tea pouring, art appreciation, etc. Practical nurses are still taught to wear girdles, use make-up, and in general mimic the behavior of a “better” class of women.)
But the Nightingale nurse was not just the projection of upper-class ladyhood onto the working world: She embodied the very spirit of femininity as defined by sexist Victorian society—she was Woman. The inventors of nursing saw it as a natural vocation for women, second only to motherhood. When a group of English nurses proposed that nursing model itself after the medical profession, with exams and licensing, Nightingale responded that “ . . . nurses cannot be registered and examined any more than mothers.” [Emphasis added.] Or, as one historian of nursing put it, nearly a century later, “Woman is an instinctive nurse, taught by Mother Nature.” (Victor Robinson, MD, White Caps, The Story of Nursing). If women were instinctive nurses, they were not, in the Nightingale view, instinctive doctors. She wrote of the few female physicians of her time: “They have only tried to be men, and they have succeeded only in being third-rate men.” Indeed, as the number of nursing students rose in the late-nineteenth century, the number of female medical students began to decline. Woman had found her place in the health system.
Just as the feminist movement had not opposed the rise of medical professionalism, it did not challenge nursing as an oppressive female role. In fact, feminists of the late-nineteenth century were themselves beginning to celebrate the nurse/mother image of femininity. The American women’s movement had given up the struggle for full sexual equality to focus exclusively on the vote, and to get it, they were ready to adopt the most sexist tenets of Victorian ideology: Women need the vote, they argued, not because they are human, but because they are Mothers. “Woman is the mother of the race,” gushed Boston feminist Julia Ward Howe, “the guardian of its helpless infancy, its earliest teacher, its most zealous champion. Woman is also the homemaker, upon her devolve the details which bless and beautify family life.” And so on in paeans too painful to quote.
The women’s movement dropped its earlier emphasis on opening up the profession to women: Why forsake Motherhood for the petty pursuits of males? And of course the impetus to attack professionalism itself as inherently sexist and elitist was long since dead. Instead, they turned to professionalizing women’s natural functions. Housework was glamorized in the new discipline of “domestic science.” Motherhood was held out as a vocation requiring much the same preparation and skill as nursing or teaching.
So while some women were professionalizing women’s domestic roles, others were “domesticizing” professional roles, like nursing, teaching, and, later, social work. For the woman who chose to express her feminine drives outside of the home, these occupations were presented as simple extensions of women’s “natural” domestic role. Conversely the woman who remained at home was encouraged to see herself as a kind of nurse, teacher, and counselor practicing within the limits of the family. And so the middle-class feminists of the late 1800s dissolved away some of the harsher contradictions of sexism.
THE DOCTOR NEEDS A NURSE
Of course, the women’s movement was not in a position to decide on the future of nursing anyway. Only the medical profession was. At first, male doctors were a little skeptical about the new Nightingale nurses—perhaps suspecting that this was just one more feminine attempt to infiltrate medicine. But they were soon won over by the nurses’ unflagging obedience. (Nightingale was a little obsessive on this point. When she arrived in the Crimea with her newly trained nurses, the doctors at first ignored them all. Nightingale refused to let her women lift a finger to help the thousands of sick and wounded soldiers until the doctors gav
e an order. Impressed, the doctors finally relented and set the nurses to cleaning up the hospital.) To the beleaguered doctors of the nineteenth century, nursing was a godsend: here at last was a kind of health worker who did not want to compete with the “regulars,” did not have a medical doctrine to push, and who seemed to have no other mission in life but to serve.
While the average regular doctor was making nurses welcome, the new scientific practitioners of the early-twentieth century were making them necessary. The new, post-Flexner physician was even less likely than his predecessors to stand around and watch the progress of his “cures.” He diagnosed, he prescribed, he moved on. He could not waste his talents, or his expensive academic training in the tedious detail of bedside care. For this he needed a patient, obedient helper, someone who was not above the most menial tasks, in short a nurse.
Healing, in its fullest sense, consists of both curing and caring, doctoring and nursing. The old lay healers of an earlier time had combined both functions, and were valued for both. (For examples, midwives not only presided at the delivery, but lived in until the new mother was ready to resume care of her children.) But with the development of scientific medicine, and the modern medical profession, the two functions were split irrevocably. Curing became the exclusive province of the doctor; caring was relegated to the nurse. All credit for the patient’s recovery went to the doctor and his “quick fix,” for only the doctor participated in the mystique of Science. The nurse’s activities, on the other hand, were barely distinguishable from those of a servant. She had no power, no magic, and no claim to the credit.
Witches, Midwives, and Nurses Page 5
