Book Review : ‘In Sickness’: Diagnosing U.S. Medical-Care System

In Sickness and in Wealth: American Hospitals in the Twentieth Century by Rosemary Stevens (Basic Books: $24.95, 432 pages)

The essential function of the American hospital is:

A. Making money.

B. Relief of human suffering.

C. Advancement of medical science and technology.

D. All of the above.

Rosemary Stevens suggests an answer to the multiple-choice question in her new book, “In Sickness and in Wealth,” an ambitious and impressive survey of a medical-care system that deserves to be called an industry.

“The essential historical dilemma for U.S. hospitals is that they are both public and private institutions; both necessary social organizations and icons of American science, wealth and technological achievement,” Stevens explains. “As multipurpose human repair shops, hospitals are affirming and defining mirrors of the culture in which we live, beaming back to us . . . the values we impute to medicine, technology, wealth, class and social welfare.”

Charity-Profit Tug of War

About 70% of America’s hospitals are “not-for-profit” institutions that “occupy the middle ground between government and commerce.” Stevens emphasizes that hospitals are virtually defined by the web of conflict in their identity and function, the “intertwining allure of technology, money and religion.” Thus, she explains, the hospital is tugged between charity and profit, private voluntarism and government regulation, technological innovation and humane care-giving, governance by both medical professionals and corporate bureaucrats, the “almshouse tradition” of the general hospital and the “conspicuous waste” of the private hospital.

Among the many ironies in Stevens’ book is the fact that an institutional health-care delivery system, however flawed, has emerged from the chaos and conflict of its own history: “The United States has a de facto national health system, although Americans are unwilling to recognize the fact and will indeed go to enormous lengths to deny it,” Stevens points out. And she calls for a clear and compassionate approach to health-care planning: “The quality of American medical care,” Stevens insists, “is, indeed, an index of American civilization.”

Turn of the Century

The “continuing dialectic” in the American hospital system, as Stevens puts it, reaches back to the turn of the century, when local private hospitals enjoyed both autonomy and subsidy by “avoiding the rigors and excesses of the marketplace through the privilege of tax exemption, government subsidy, and charitable donations, while also avoiding the leveling, regulation, and political scrimmages of government administration.”

Over the years, Stevens explains, the American hospital system has grown ever more complex and contradictory. With the standardization of medical education and medical practice, the advent of “scientific management” in the hospital setting, and the mobilization of national resources during World War I, the hospital system acquired the stature of a national industry (although without losing any of its local control). During the ‘20s, hospitals began courting the consumer, “including offering lines of credit that enabled Americans to purchase surgical operations or supervised deliveries as easily as they purchased . . . automobiles.”

Amid the economic upheavals of the Depression, hospitals “dusted their public-service image, disassociated themselves from ‘proprietary’ (for-profit) hospitals, and joined together under the banner of voluntarism.” By the end of World War II, Stevens writes, “there were general and open tensions--and an essential ambivalence--between the traditional ideology of the hospital as a quasi-public ‘charity’ . . . and the quasi-industrial character of the large institutions.”

Makings of a ‘Crisis’

Stevens catches up with the panicky and gloomy headlines of the late ‘80s, but she points out that the “crisis” in American medicine is at least three decades old. The infusion of federal money under Medicare was a response to the urgent problems of the American hospital as they were perceived back in the 1960s, and massive federal intervention prompted “a focus on capital expansion, an overtly profit-making nexus, huge industrial growth, and federal regulation.” And we are still living with reverberations: “The fruits of this process,” Stevens writes, “are the hospital system that we have today: opportunistic and unsettled; ebullient and nervous; politically attuned and market-oriented.”

Stevens is a former hospital administrator who went on to become a policy analyst and historian; today, she is a professor of history and sociology at the University of Pennsylvania. Her scholarship is quietly impressive--she is a temperate but tough-minded historian, a probing intellect with a sense of balance and proportion, and she delivers her poised historical narrative in graceful and lively prose.

Despite its rather contrived title, “In Sickness and in Wealth” is neither a lurid medical melodrama or a whiz-bang “investigation” of medical scandal; instead, it is a serious and significant study of the American hospital in the 20th Century. The book deserves--and I’m sure it will find--an appreciative, if specialized, readership.