Radical Journal of Health 1987 Vol. 2, Nos. 1-2, June – Sep.: Issues in Medical Technology
Item
- Title
- Radical Journal of Health 1987 Vol. 2, Nos. 1-2, June – Sep.: Issues in Medical Technology
- Date
- September 1987
- Description
-
Work, Ideology and Science: The case of Medicine
On surrogate motherhood: The baby ‘M’ case
Impact of Medical Technology in Neurology
Politics of Contraceptive Technology in New Zealand
How safe is the workplace?
Strengthening the cuckoo’s Next? - extracted text
-
COMMUNITY HeXTH 2 ~LL
♦7/t. (First Floor; St. Marts Roa
Ban#a!8re - 560 001.
Work, ideology and Science: The Case of Medicine
On Surrogate Motherhood: The Baby ‘M’ Case
Impact of Medical Technology -in Neurology
?' /c.5 of Contraceptive Technology in New Zealand
How Safe is the Workplace?
lengthening the Cuckoo's Nest?
June and September 1987
Nos 1 and 2
Working Editors:
Volume II
Amar Jesani, Manisha Gupte,
Padma Prakash, Rarzi Duggal
ISSUES IN MEDICAL TECHNOLOGY
1
Editorial Collective:
Editorial Perspective
TECHNOLOGY IN MEDICINE
Ramana Dhara, Vimal Balasubrahmanyan (A P), Imrana Quadeer,Sathyamala C (Delhi), Dhruv Mankad
(Karnataka), Binayak Sen, Mira Sadgopal (M P), Anant
Phadke, Anjum Rajabali, Bharat Patankar, Srilatha
Batliwala (Maharashtra) Amar Singh Azad (Punjab),
Smaraiit Jana and Sujit Das (West Bengal)
All Correspondence:
Radical Journal of Health
C/o 19 June Blossom Society,
60 A, Pali Road, Bandra (West)
Bombay-400 050 India.
Printed and Published by
Amar Jesani .for
Socialist Health Review Trust Registered
Address: C-6 Balaka, Swast*k Park, Chembur,
Bombay 400 071.
Printed at:
Bharat Printers, Shiv Shakti,
Worli, Bombay.
3
DEVELOPMENT OF MEDICAL TECHNOLOGY
THE EXAMPLE OF NEUROLOGY
Bindu T Desai
14
POLITICS OF CONTRACEPTIVE TECHNOLOGY
DEPO PROVERA IN NEW ZEALAND
Sally Washington
18
WORK, IDEOLOGY AND SCIENCE
THE CASE OF MEDICINE
Vicente Navarro
32
THE BABY 'M' COURT CASE IN THE US
Cindy Jaquith
36
UPDATE; News and Notes
39
WOMEN'S HEALTH CARE IN BRAZIL
Carmen Barroso
Book Reviews
42
EXPLOSION OF ALTERNATIVE INFORMATION ON DRUGS
Annual Subscription Rates:
43
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SYSTEMS APPROACH TO PROBLEM SOLVING
Dialogue
44
MEDICINE IN USSR. ANALYSIS LACKS RIGOUR
Anant R S
45
POLITICS OF MCH
Padma Prakash
(All remittance to be made out in favour of Radical
Journal of Health. Add Rs 5/- on outstation cheques)
47
Index to Vol I
Editorial Perspective
Technology in Medicine
SOMETHING is tearing apart the noble mask of medical
practice. A gigantic force is shaking its traditional indepen
dent status. Some say that machines are the culprits—they
have made medicine invasive, costly and impersonal. Some
are concerned about new the organisational set-up—
bureaucracy is the devil, large size is wasteful, so ‘small is
beautiful’. Undoubtedly, the introduction of new machines
in medical care has not only made medical technology visi
ble, but also made it an independent issue for discussion and
for evolving alternative practices. They have also widened
the scope of discussion by naturally making it open to peo
ple other than doctors. Ironically, while monopoly capital
has introduced them into medical care, they have made a dent
in the monopoly of doctors to discuss medicine.
Medical technology, to use a broad definition includes
drugs, devices and medical and surgical procedures used in
medical care, and organisational and support system within
which such care is provided. This definition is applicable to
all systems of medicine. We, however, restrict ourselves to
allopathy. For allopathy is the dominant medical system in
ternationally, it has an organic link with capitalism—the
dominant socio-economic system—and above all, we have
insufficient information to correctly understand the role and
nature of technology and emerging trends of technological
change in the context of capitalist development in other
systems of medicine.
While discussing new and recently-developed medical
technology—for that matter all such technologies-*— we need
to recognise that most of them are not developed by the applicatipn of advances in the basic sciences in one field. New
medical technologies are not only founded on the
developments’in the basic sciences in medicine alone, but also
on the combination of this with developments technologies
in other fields. For example, the cardiac pacemaker was
developed by using advances made in solid state physics,
developments in vaccum technology, electrical engineering
as well as in anatomy and cardiac physiology, and surgical
techniques and development of silicon rubber and epoxy
resins.
Though on the face of it a technology seems to develop
out of the accumulation of scientific and technological
knowledge and skill, this accumulation is encouraged,
discouraged and selectively manipulated in the socio
economic context. Further, the diffusion for widespread use
of any technology is determined by these forces. In the case
of medicine, the flow of capital into the medical service sec
tor and the concommitant organisational maturity of medical
care system provided an objective basis for widespread dif
fusion of new medical technology in the advanced capitalist
countries.
Penetration of Capital into Medical Services
Medical care is predominantly organised as (1) individual
and group medical practice which has its roots in the petty
commodity production in which the physician owned his/her
skills as well as essential tools, (2) organised hospital-based
June-Sept 1987
medical care which has traditionally been charitable, statefinanced or owned, or nonprofit voluntary. Historically,
though health care particularly, its public health component
was recognised as an essential economic function as early
as the mid-nineteenth century, the penetration of private
capital and consequent capitalist industrialisation of
technological components of medical care took place much
later. This was due to the specific place of the service sector
in the capitalist economy. Services of all kinds, including
medical service, rendered as a commodity or otherwise, are
essential to capital to revitalise, reproduce and even improve
labour power. But they do not in the process of actual
rendering of services, produce surplus value. Capital on the
other hand, flows naturally into the surplus-value produc
ing sectors of economy.
Therefore, the initial penetration of capital into the medical
service began into those technological components of
medical care—notably the tools of the physician—which
could be converted into commodities containing surplus
value. Thus, the physician who was a petty commodity pro
ducer gathering herbs, chemical, etc, and compounding them
into medicine to dispense it to the patient, was gradually
alienated from these tools. The doctor became dependent
on the supply of that tool (medicine) from capital. The doctorl no longer remained an independent petty commodity
producer, although he/she did retain the character of the in
dividual private medical practitioner. The latter characteristic
was not radically affected because the doctor retained the
exclusive knowledge and skill of prescribing drugs produced
by the industry. The doctor still remains indispensible for
sale of (and realisation of the use value of) the commodity
drug. Therefore, doctors are the most important target in
capital’s market strategy. For this purpoe it is necessary that
the doctors identify with the interest of capital. The common
method used for such purpose by the industry is ideological,
combined with material incentives. In the situation of in
tense competition, the industry consciously promotes irra
tional use of drugs and the use of useless drugs. This interest
of the industry is well-reflected in the doctors irrational
prescription practices. Indeed, once the doctor became the
last executor of capital’s market strategy, irrationalism was
bound to dominate medical practice.
The rise of monopoly capitalism and the changes in its
dynamic during and after the second world has provided ob
jective basis for further technological changes in medical
practice. In late monopoly capitalism there is a continuing
compulsion to increase the rate of surplus value, to valorise
the excess capital by investment in any possible area (such
as armament, services, etc) and to lower cost of production
through mechanisation and automation. In this situation,
one of the best ways to preserve monopoly market is to
accelerate technological innovation and consequent rapid in
troduction of new products in the market. This creates a
situation of permanent technological and product renewal.
This also creates a permanent need to dispose of obsolete
technology and the product to the less developed countries
(hence the slogan of technological transfer, albeit in neo
1
colonial ways). It is this characteristic that is primarily at
the root of continuous introduction of new drugs, devices
and hosts of other things, irrespective of actual medical needs
and priorities of the people, into medical practice.
Mirror effects of these developments are also seen in a third
world country like India, due to neocolonialism as well as
due to the needs of indigenous capital. The economic
backwardness of the country puts certain limits on the ex
tent to which capital can penetrate medical services sector
and new medical technologies can be brought to widespread
use. However, these limits are not absolute. Nevertheless, the
forceful entry of new medical technologies has created forces
which are transforming individual medical practice as well
as hospital care much more extensively than the propor
tionate economic value of such technologies.
cant development. Capital for the first time showed interest
in going beyond the production of drugs and devices to
organising hospital based medical care in line with industry
on a large scale. Investor owned or corporate hospitals have
concerned significant proportion of hospitals in developed
capitalist countries while in India the process has barely
started with the Apollo hospital in Madras.
With this, discussion on proletarianisation of doctors is
no longer academic. Doctors seeking employment is not new.
What is new is the logic of corporate for-profit hospitals,
absolute control by the capitalists, continuous introduction
of new technologies, inevitable need to use them at high price
to realise investment and earn profit etc. That is profit is no
longer incidental or one of the parts of a doctor’s medical
practice. Medical practice is now incidental to the organisa
tion primarily devoted to profit.
Recent Technological Changes
Social and Ethical Issues
Since the late 1960s after making its initial impact on the
production of drugs, the logic of late monopoly capitalism
started affecting other medical technologies. Within a decade
it unleashed a massive assault on medical care with a plethora
of new diagnostic and treatment devices. Not only have new
technologies entirely taken over the essential functions of
doctor in a medical care but aids him/her in performing
those functions. (They also create new functions.) In the pro
cess each function becomes a specialised one as it needs the
aid of a special, complicated and costly machine. Thus a
rapid division of diagnostic and treatment functions takes
place. These changes in medical care also accelerated certain
changes in the way medical care is traditionally organised.
In the sector of individual private medical practice many
new private practitioners with technological spaciality were
added. Indeed we have come a long way from X-ray clinics
to CT scan centres. The proliferation of diagnostic centres
run by individuals, institutions or companies has lengthen
ed the route which the patient travels in order to get
diagnosed and treated.
The accelerated fragmentation of functions has further impersonalised medical care. The business nexus of generalists,
specialists (medical), specialists (equipment), diagnosticians
and what not have expanded the naked play of market forces
(with the attendent corruption and irrational medical prac
tices) in medical care. No wonder all these escalate the cost
of medical care.
In hospital-based medical care too far-reaching changes
have unfolded. Fragmentation has increased the number of
departments. New equipment and procedures have led to a
new- division of labour inside the hospital. The need to co
ordinate all such activities has given rise to such
bureaucratisation that even many old styled but businessoriented doctors have started feeling uncomfortable. The
costly requirements like controlled environment for equip
ment, posh premises to match the high cost of services, etc,
make hospitals a huge investment. Thus the gradual conver
sion of traditional non-profit and charitable hospitals to forprofit and fee-for services hospitals is inevitable, though this
is at different stages and in countries where state services
are there, it is generating powerful forces for privatisation.
These changes are also accompanied by another signifi
2
The production and sale of irrational and useless drugs
with doctor’s prescription over-the-counter and even selling
prescription drugs directly by the chemists are well-known
to us. We do not elaborate on it here as it forms a separate
subject for discussion. However, it should be noted that by
the time new' equipment based medical technology made its
entry, the doctors had sufficiently encouraged the technology
culture (capsule and injection) amongst people or section of
people that matter for it to build further upon.
Since the new technologies are very expensive and in short
supply, it has to be rationed. In the market economy, this
rationing does not take place according to need but accor
ding to the capacity to pay. This is not a new ethical issue.
But earlier it did not confront the doctors so blatantly as
it does today with new' technologies.
The doctor is also confronted with legal problems, more
of them where medical insurance has taken roots. Witholding
a diagnostic procedure or delaying treatment with certain
equipment invite a spate of litigations in many advanced
capitalist countries. Doctors pay huge sums as premium to
insurance companies to protect themselves from bankruptcy.
In the US they have now even agreed to allow their colleagues
to review or assess their competence. This has accelerated
the production of literature on medical ethics to equip them
with enough knowledge of law and pitfalls in practice. In
our country this aspect is yet to become major issue.
Despite the high cost and legal issues, the fast use of such
technologies is an absolute need for capital. To generate quick
demand from the people, more elaborate methods are used
than just enlisting doctors, support. So it goes beyond the
doctor, directly informing people. This is one of the reasons
why in our country import of a nuclear magnetic imaging
makes front page news. In this way unnecessary use of such
equipment is systematically organised.
As said earlier, technological obsolescence being a major
problem, the traditional methods of assessing technology
before its introduction are waived. Most of these new
technologies are accepted on the basis of description of their
excellence, but not tested through careful trials. Neither com(( 'antuuted (in /Hl.t’C 35)
Radical Journal of Health
Development of Medical Technology
The Example of Neurology
Hindu t desai
The brain has remained an enigma through millenia despite the fact that the vast progress in medical technology has
helped to visualies it and for its functions to be studied directly and indirectly. This article traces the impact of medical
technology on our current understanding of the brain and its role in the developments in neurology. It points out that
tohile some innovations in different branches such as physics, electronics, etc definitely aided the physicians’ understan
ding, often tools which have evolved have ended up being overused. Moreover, even its nectary use has come to be
confined to the class which can afford to pay the fancy prices that are charged. Medical technology is thus neither value
neutral in its evolution nor in its use.
THE explosion of medical technology in the last century,
especially the past 25 years has irreversibly changed the face
of medical practice all over the world. This phenomena,
greatly accelerated by the advent of the transistor and
miniaturised electrical gadgets was rooted in the Cartesian
school with the question of mind and soul separated from
the body, dealing with the latter as a machine to be
understood and treated as a sum of its parts. If its
philosophical origins are found in Descartes its ability to
discover, probe, explore, remove, and sometimes cure illness
is almost wholly due to the enormous advances in human
understanding and knowledge about the nature of the electro
magnetic spectrum.
Medical technology is no more value neutral than any
other technology. It arose in the dynamic expanding world
of an aggressive, confident European mercantilism. Today
it is still only available at a price and with priorities set by
the successors of those merchants. It has benefited from the
European Renaissance, the scientific revolutions of the 17th
and 18th centuries and the atomic age. This article will review
at some length the history of the development of medical
technology emphasising its philosophical origins. It will
comment on the impact of modern medical technology on
diagnosis and treatment, and discuss the advantages as well
as problems accruing from its ascendency. I shall use the ex
ample of neurology for two reasons; first being a neurologist
I felt competent to comment critically on the development
and impact of technology on neurologic practice; secondly,
the nervous system has presented medical technology with
its geatest challenge as this organ system has been virtually
inacessible to human manipulation until a few decades ago.
Also the correlation between structure and function of the
brain is rudimentary compared to other organs like the heart,
liver or kidney.
While a review of development of technology in many im
portant aspects of the neurosciences has been attempted
some topics like neurophysiology and neuroradiology have
been covered extensively, others like neurosurgery rather
cursorily. This uneveness, partly due to personal interest in
the early history of the discovery and investigation of elec
tricity and its role in neurology, reflects the difficulty of
reviewing such a vast topic except at inordinate length.
Development of Neuroscience
The function of the brain, its effect on consciousness and
limb movements must have been evident to hunters even in
the Paleolithic age. The first recorded description of the brain
June-Sept 1987
and its coverings are found in Egyptian papyri written around
500 BC (McHenry 1969, p e). In ancient Greece, Pythagoras
(582 BC-500 BC) taught that the brain was concerned with
reasoning. His discovery of mathematical principles underly
ing music and the three sides of a right angled triangle for
which he is renowned represent the first examples of the
human mind’s ability to give theoretical concepts a reality
of their own (Bergland, 1986, p 10). A student of Pythagoras,
Alcmaeon performed one of the earliest recorded dissections
of the human body (sixth century BC) and described the
optic nerves. Further progress about knowledge of brain
structure and function took a tortuous course. Some of the
prominent authorities on brain function like Aristotle
(384-322 BC) and later Galen (130-200 AD) seem not to have
dissected a human brain (Spillane, 1981). Their ideas of the
brain as a cooling organ (Aristotle) or as the transformer
of the quintessence of life or pneuma into an animal spirit
which in turn was carried through the tubular nerves to the
body (Galen) may have arisen because of their ignorance of
its structure. Dissecting the human body was frowned on at
various points in history in Greece (Spillane, 1981, p 7), in
India (Basham 1967), and later by the Catholic Church
(Bergland, 1986 p 54). However many observers were aware
that the brain was the seat of intelligence, dreams and
thought. Hippocrates of Cos (400-370 BC) wrote:
Men ought to-know that from the brain, and from the brain only,
arise our pleasures, joys, laughter and jests, as well as sorrows, pains,
griefs, and tears. Through it... we... think, see, hear, and distinguish
the ugly from the beautiful, the bad from the good, the pleasant from
the unpleasant. (Bergland, 1986, p 28).
hrasistratus of Chios (circa 310 to 250 BC) was struck by
the greater number of convolutions in the human brain com
pared to animals. He related this difference of the superior
intelligence of humans. But for nearly two centuries the heart
was considered the organ of rational thought in Europe and
curiously also in India (Basham 1967; Winter 1975). In
Europe, Aristotle’s views reigned supreme: pneuma from
heaven came to the heart via the trachea and lungs. The brain
was a cooling gland that regulated the temperature of the
pneuma brought to it by the arteries.
In addition to mistaken ideas about brain function,
knowledge of brain structure was limited by the peculiar
biologic properties of the organ. The brain is extremely soft
and friable with its components easily distorted or destroyed
unless the organ is frozen or hardened by the addition of
a fixative like alcohol or formalin. (EScourolle and Poirier,
1973). Only in the eighteenth century was the technique of
fixation of brain tissue by alcohol developed which allowed
3
adequate dissection of brain tissue (Spillane, 1981, p 18).
Thus neuroanatomy illustrates a feature common to all
aspects of neuroscience and even science in general: the obser
vation of Thomas Kuhn regarding the dependency of creative
thought on technological advancs (Kuhn, 1962). Prior to the
fixation of the brain by additives one can only speculate on
the reactions of observers to brain tissue “oozing like por
ridge from the skull in a battlefield or even when delivered
promptly with the severed head from an executioner”.
Covered by membranes, full of convolutions and cavities it
must have appeared “ a most mysterious’object of explora
tion” (Spillane, 1981, p 18).
Along with countless other branches of knowledge,
medical science grew by leaps and bounds with the coming
of the Renaissance (1440-1540 AD). Printing allowed
technical advances to be disseimated rapidly and effectively.
Andreas Vesalius’ (1515-1564), De Humani Corporis Fabrica
(The Fabric of the Body)— the most complete and accurate
description of the human body was published in the same
year (1543 AD) as Nicolas Copernicus’ De Revolutionibus
Orbium Coelestium (on the Revolution of the Celestial Orbs).
Earlier Leonardo da Vinci (1452-1519 AD) had drawn an
outline of the ventricles of the brain. He had first inserted
a needle in the ventricles, filled them with melted wax and
used the casting techniques of bronze sculptors to delineate
the shape of the cavities of the brain. Vesalius’ anatomical
studies led him to question Galenic physiology though he
refrained from criticising Galen. Later, in 1629, William
Harvey; a student of the School of Medicine at Padua
founded by Vesalius, discovered the pump-like function of
the heart, described the circulation of blood and helped over
throw Galenic concepts of the pneuma and other mysterious
spirits. In the opening year of the seventeenth century
Giordano Bruno (1548-1600) was burnt to death for his vision
of an infinite universe. When the century ended science had
come of age, Galileo (1564-1642) had displaced the earth to
its modest position in the solar system, Aristole had been
dethroned, his dynamics discarded.
The phenomena of magnetism was described at length by
William Gilbert (1544-1603) in De Magnete published in 1600.
Gilbert was a court physician to Elizabeth I. Magnets, he
showed, possessed the virtue of attraction. Force could be
exerted by material bodies which were not in contact with
one another. Gilbert exemplified the experimenter scientist
who Francies Bacon (1561-1626) deemed necessary for the
advancement of learning. Speculation was to be replaced by
observation, vitalism by mechanisms. Magic lost its hold as
an explanation for natural phenomena in the seventeenth cen
tury as science unravelled some of these mysteries. It was
the era of mercantile capitalism, of the formation of the
Bank of Amsterdam in 1609, the Bank of England 85 years
later, of the Dutch and British East India Company, of the
horrific Middle Passage which for over three centuries car
ried some 13 million African slaves to the New World. With
the development of trade over long sea routes to the
Americas, India, China and Indonesia came the imperatives
of more accurate navigation charts, skilled shipbuilding, of
better implements of war, of a union between merchant and
scientist, of education no longer under the aegis of the church
4
but of new colleges which quickly became centres of science.
Gresham College, in London, founded in 1579 with monies
provided by the will of Thomas Gresham, a financial agent
to the Crown and founder of the Royal Exchange, was where
the Royal Society first met (Bernal, 1971, p 459). The scien
tific revolution had begun, everywhere old dogmas crumbled.
Descartes’ (1596-1650) Discourse on Method (1637) discussed
a new system which “exhibited that individual arrogance
which was one of the great liberating feature' of the
Renaissance, the same arrogance that expressed itself in the
great navigators, in the conquistadores, in all the defiances
of authority that characterised the end of the feudal period
and the beginning of one of individual enterprise” (Bernal,
1971, p 443). “I think therefore I am”—mind became more
certain than matter, Aristotle’s three souls were dispensed
with, only one, the rational soul existed and that too only
in the human. It resided in the pineal gland. Descartes’
philosophy completed the dualism of mind and matter. Later
Cartesians dropped the emphasis on the pineal gland and
sought to explain living organisms by the laws of physics.
“If all movement of matter were determined by physical laws,
mental events must be equally determinate” (Russell, 1945).
Even the soul was composed of atoms, thought came from
the movement of atoms. Descartes also commented on the
conditioned responses that would be described by Ivan
Pavlov (1849-1946) over 200 years later. “If you whip a dog
five or six times to the sound of a violin he would begin to
howl and run away as soon as he heard that music again”
(Brazier, 1984, p 24). Descartes recognised the need to explain
how the contraction of one muscle must be accompanied by
the relaxation of its opponent. His legacy was the
mechanically operating model of the human body, a model
very influential in medical science even today.
Antoni van Leeuwenhoek (1632-1732 AD) opened the
world of small things with his microscope just as Galileo
had uncovered some secrets of the stars with the telescope.
His study on nerves, hampered by lack of hardening or stain
ing techniques, left him a convinced Galenist—nerves were
little canals which carry humor. So the first use of the
microscope did not clarify nerve structure. Indeed the issue
remained unresolved even a century later (Brazier, 1984, p 37).
Arguments continued about the release of spirits down the
nerves, spirits that led to muscle contraction. Outstanding
physicians like William Croone (1633-1684) and Thomas
Willis (1621-1675) did not “confront the problem defined by
Nicolaus Steno (1635-1686); The (muscular) heart continued
to beat when taken out of the body, cut off from its nerves
and blood supply (and from the soul)” (Brazier, 1984, p 62).
Giovanni Borelli (1608-1679) found that when an animal was
submerged in water, and its muscles were slit open no bubbles
appeared in spite of vigorous muscle contraction by the strug
gling animal. Therefore he felt, muscle contraction could not
be due to gaseous spirits. As the Seventeenth Century drew
to a close science had become organised in the manner sug
gested by Bacon. Powerful scientific societies replaced groups
meeting in private homes, scientific journals were started and
publishing houses were established that brobght out only
science related books.
The eighteenth centurv established science as an indispen
Radical Journal of Health
sable feature of what was to become the Industrial Revolu
tion. Capitalism was transformed from a “phase dominated
by merchants and small manufacturers to one dominated by
financiers and heavy industry’’ (Bernal, 1971, p 503). The
age of European colonisation was about to begin. The history
of America, Africa and Asia would now reflect indelibly the
consequences of those ships that had come to their shores
over 200 years ago. For Europe would discover from this cen
tury onwards the principles governing essential properties of
matter like electro-magnetism, it would harness the power
of steam and achieve its dominance of other continents aided
by the knowledge of these powerful forces in nature. In ad
dition, the seventeenth century had seen the first revolution
in Europe; the Civil War and the execution of Charles I of
England. These were only the most dramatic manifestations
of a world in ferment. In the ideas of the Levellers and the
Diggers the seed of a society equal and free from exploita
tion was eloquently expressed by Gerard Winstanley:
Freedom is the man that will turn the world upside down, therefore
no wonder he hath enemies. . . the earth should be made a common
treasury of livelihood to whole mankind, without respect of persons”
(Hill, 1975).
These revolutions would recur in America and France in the
eighteenth century, the questions raised and problems faced
by them continue to confront us today, from general societal
issues to the availability, relevance and effectiveness of
modern medical technology.
The intellectual advances of the eighteenth century made
that period famous as the Age of Enlighenmeni. Theories
about brain function changed and the nervous system could
be explained without the existence of a soul. D'Alembert
(11717-1783) one of the co-editors of the Encyclopedia shared
John Locke’s (1632-1704) view of the nervous system; all
knowledge was derived from sense experience, hence the
sciences should be based on actual perception. The relation
ship of the brain to the spinal cord was still a puzzle. The
function of the nerve roots that were attached to the cords
was unkown. Jacques-Benigne Winslow (1669-1760) introduced
the concept of a ‘sympathetic’ system made of ‘small brains’
or ganglia that were centers for communication between the
nerves and various organs. Jiri Prochaska (1749 1820) pro
posed a purpose for unconsciously initiated movements—
preservation of the individual. Such a purpose made the
teleological significance previously ascribed to these
movements irrelevant.
Discovering Electricity
Many experiments began investigating the new and
mysterious phenomena of electricity. Perhaps it was related
to nerve conduction. By the early 18th century it was already
known that the human body could be charged electrically
if it was insulated from the ground. At first it was thought
that a layer of air had to be present between the subject and
the ground. The characteristics of conductors and non
conductors were only beginning to be understood (Brazier,
1984, p 176). More knowledge about the nature of electricity
was necessary before its action on an animal’s body could
be studied. Also if animal tissue itself produced electricity,
the current produced would be very small and need exquisitely
June-Sept 1987
sensitive instruments to detect it. These gadgets designed
crudely at first by Alessandro Volta (1745-1827) would be
modified later by Waller (1887) and Einthoven (1903),
(Cooper, 1986), Adrian (1929) and Berger (1929), (Licht, 1971)
to herald the use of electrocardiography, (EKG), elec
tromyography (EMG) and electroencephalography (EEG)
respectively.
These developments came slowly. Initially a technique for
sorting an electric charge had to be discovered. It happened
accidentally to Petrus van Musschenbroek (1962-1761) at the
University of Leyden. Musschenbroek had been trying to
conserve electricity in a conductor and delay the loss of its
charge to the air. He thought electricity was a fluid and tried
at first to fill an empty glass jar, then one filled with water
with this fascinating effluvium. He charged the water with
electricity with a wire leading from an electrostatic machine,
but to no avail. The electricity dissipated once the elec
trostatic machine stopped running. One day, his assistant,
Andreas Cuneas picked up the jar containing charged water
in one hand and at the same time reached out to remove the
wire from the electric machine with the other hand. On
touching the wire he got an electric shock—his hand had
formed one ‘plate’, the charged water another, and the glass
jar the intervening dielectric. A condenser was born (Brazier,
1984, p 180). The Leyden jar as it was called later contained
no water, instead it was coated on its inner and outer sur
face by a tin foil. The jar became a source of entertainment.
The Abbe Nollet (1700-1770) used it for a spectacular
demonstration of electrical power. He lined up a human
chain of 180 soldiers at Versailles for the benefit of the King
of France. The entire line of soldiers leapt into the air when
the men at each end touched the poles of a Leyden jar. The
Abbe repeated this experiment for the Monks of Chartreuse
this time using a human chain 3 kilometers long! (Skilling,
1948). The Leyden jar was used by all kinds of ‘medical’ men
to treat a variety of nervous ailments. John Wesley, the
Methodist-reformer who wrote a pamphlet on the subject
said that he was “firmly persuaded there is no remedy in
nature for nervous disorders of every kind, comparable to
the proper and consistent use of the electrical machine”
(Schiller, 1982, p 4). Electrotherapy persists today in many
forms as ECT or electroconvulsive therapy for some
psychotic disorders, as trancutaneous and spinal cord
stimulation for relief of pain and for relaxing spastic mus
cle and the EEG’is used in biofeedback therapy. The scien
tific basis of these therapies are unclear, their usage
sometimes as in the case of ECT, being based on the er
roneous observation that since epilepsy and schizophrenia
never occurred in the same patient, convulsions might result
in elimination of the symptoms of that psychosis (Solomon
and Patch, 1974).
Meanwhile, in the eighteenth century research began on
the torpedo fish whose power to shock was known to
fishermen and whose ability to cause pain was thought by
Ibn Rushid (Averroes) (1126-1198) to be similar to the effect
of a lodestone. In 1972 Abbe Lazzaro Spallanzani studied
the anatomy of the torpedo in terms of its ability to shock.
He was convinced the shock was electrical, a fact which Luigi
Galvani (1737-1798) later confirmed. Galvani cut the nerve
5
supply to one side of the electric organ of the torpedo and
found that this side failed to discharge. On svering the head
of the fish the discharge was destroyed even though the heart
was intact. The mechanism of electrical discharge thus was
independent of the circulation. Electric fish aroused sustain
ed scientific interest for here was an animal that produced
electricity. But was animal electricity similar to the one
physicists studied? Was it triggered by the brain? Michael
Faraday (1791-1867) gave an ambivalent answer to the first
question, he was not convihced that nervous fluid is only
electricity. The second question remained unanswered for a
century because there were no instruments to detect the
passage of small currents.
Galvani’s Commentary on the Effects of Electricity on
Muscular'Motion was published in 1791. Although Galvani
was only one of several individuals like Caldini and Fontana
who had directly stimulated nerves with electricity, and his
discovery came about accidentally like the Leyden Jar, his
commentary enabled the science of electricity and physiology
to come together and ‘each took a great leap forward’
(Spillane, 1981, p 147). On 20th September 1786 Galvani had
dissected out a nerve-muscle preparation of a frog and placed
it on a table on which an electrically charged frictional
machine lay at some distance. In Galvani’s words “when by
chance one of those who were assisting me gently touched
the point of a scalpel” to the exposed nerves of the frog
“immediately all the muscles of the limbs seemed to be so
contracted that they appeared to have fallen into violent tonic
convulsions. But another of the assistants, who was on hand
when I did electrical experiments, seemed to observe that the
same thing occurred whenever a spark was discharged from
the conductor of the machine” (Spillane, 1981, p 146). An
electrical charge had been transferred to the insulated nerve
muscle preparation by induction from the machine nearby.
Galvani then studied ‘atmospheric’ electricity lightning in a
thunderstrom to excite frog legs. The lightning conductor was
invented by Benjamin Franklin in 1753. Interestingly
Franklin’s rebel tendencies had irritated George III who in
sisted that the lightning conductors at his palace should have
round knobs instead of the sharp points Franklin had sug
gested! (Bernal, 1971, p 602). Galvani attached one end of
a frog’s leg to an iron wire antenna under the roof of his
house and to the other end a wire that led to the water of
a nearby well. When lightning flashed in the sky the frog
muscles contracted. Later he found that frog muscles con
tracted when hung on iron gratings by bronze hooks that
penetrated the spinal cord, irrespective of atmospheric con
ditions (O’Leary and Goldring, 1976). Though Galvani was
aware that the muscle contraction arose because of contact
between dissimilar metals he saw it as proof of animal elec
tricity. In 1975 Volta showed that the frog leg merely served
as an electroscope. Volta produced electricity without any
animal at all, he simply put two plates of metal one of cop
per, the other zinc with liquid between them and invented
the first electrical battery.
Galvani and Volta differed in their attitudes to Napolean
who was then the first consul of France. Napolean conquered
the area of Lombardy coverting it into the Cisalpine Republic
with himself as its president. Galvani refused to take the oath
6
of allegiance to the Republic and lost his position at the
University of Bologna, while Volta supported Napolean and
was honored with medals, and a title (Brazier, 1984, p 215;
Skilling, 1948, p 44).
The French Revolution resulted in the formation of the
Ecole de Medicine and the Ecole Polytechnique which
became models for scientific teaching and research. Only the
most eminent scientists were employed as salaried professors.
The gentlemen amateur and the patronised client scientists
of the past were thus replaced. In the Napoleanic period the
first counsul turned emperor took a personal interest in
science. He saw the utility of science for industry and war.
With the nineteenth century came revolutionary advances
in the knowledge of electricity. In 1820 Oersted (1757-1851)
accidentally found that electric current deflected a magnetic
compass needle at a right angle to the current. Ampere
(1775-1836), Gauss (1777-1855) and Ohm (1787-1854) studied
the magnetic fields produced by currents. Faraday showed
that a magnet moved near an electric conductor produced
a current, a discovery of enormous practical significance
because electricity could be produced by mechanical action
and used to operate machines. The science of electromagnetism
was born. It is striking that the Leyden Jar, Galvani’s animal
electricity and Oersted’s observation of magnetic deflection
were accidental discoveries. Thomas Kuhn has commented
that the difficulty in science is not in making a discovery,
but to know one has made it (Kuhn, 1962). This is parti
cularly true when existing theory cannot explain or predict
phenomena. The people who are likely to succeed are
generally “sufficiently broadminded, and sufficiently critical
or ignorant of orthodox theories to make the discovery” (Ber
nal, 1971, p 608). The belief that electricity is the ‘stuff of
thought’ began with Benjamin Franklin who wondered
whether it was rhe unseen force that extended through our
universe. The study of brain electricity was pursued from
Galvani onwards. It has helped to understand some aspects
of brain function but has been sadly ineffective in solving
the problems of brain disease (Bergland, 1986).
The first half of the nineteenth century saw an increase
in knowledge about the internal structure of the brain.
Johann Reil (1759-1818) studied the lobes of the cerebellum,
and by soaking the brain in specific salt solutions was able
to separate bundles of nerve fibers that carry specific
messages from the body to the brain and vice versa. Luigi
Roland (1773-1831) described the cerebral convulutions,
Charles Bell (1774-1842) demonstrated that the anterior nerve
roots of the spinal cord carried messages that led to
movements of muscles, while Francois Magendie (1783-1855)
showed that the posterior nerve carried sensation of pain,
pressure, heat and cold. The laminated structure of the brain
with six layers of nerve cells was recognised by Robert Remak
(1815-1865), who besides showing continuity of the axons
(nerve fibers) with neurons or nerve cells of the spinal cord,
also noted that some nerve fibers were not white (myelinated)
but grey (unmyelinated). Camrillo Golgi (1843-1928)
developed a silver chromate method of staining neurons
which gave the first pictures of the architecture of these cells.
Silver salts for reasons yet unknown bind only to the sur
face of nerves. Theodore Schwann (1810-1882) who describRadical Journal of Health
cd (he myelin sheath that surrounds most nerve fibers was degrees by which the amount of current in the coil could be
much influenced by Rudolph Virchow’s (1821-1902) cellular measured by the deflection of the spot of light reflected from
basis of disease. Virchow wrote “every animal is a sum of the mirror. The mirror galvanometer was to be used by Hans
vital units, each of which posscses the full characteristics of Berger in recording the first EEG in 1928. DuBois Reymond
life. The character and unity of life cannot be found in one (1818-1896) who had built a galvanometer with more than
definite point of the higher organisation for example, in the 4000 turns of wire described the resting current seen in ex
brain of man, but only in the definite, constantly recurring cised nerves and muscles and postulated on electromotive
disposition shown individually by each single element” force that preexisted in tissues. Edward Hitzig (1828-1907)
(Bergland, 1986, p 64). Schwann while accepting Virchow’s and David Ferrier (1843-1928) used electrical stimulation to
idea that organisms consisted of individual cells which func localise the control of body movement by the cerebral cor
tioned symbiotically argued that brain cells had to know what tex. As the recording of electrical potential of the nerves con
their neighbours were up to. He conceived of the brain as tinued Claude Bernard (1813-1878) who demonstrated the
a gaint spider web with every neuron directly connected to paralysing action of the poison curare selectively on motor
every other neuron. His microscopic methods did not allow nerves, spoke of the nervous system as the highest expres
him to see the synapses (Greek: to clasp) later described by sion of the mileu interior “which inter-connects all the tissues
Ramon y Cajal (1852-1934). Cajal, using Golgi’s stains, found of the organism and makes them react one upon the other”
that every nerve fibre was seperate, ending in liny bulbs (Spillane, 1981, p 265).
(boutons terminaux) rather like little hands that were con New Tools and Techniques
tiguous with similar bulbs from other axons but lacking any
continuity between them. But Cajal’s discoveries did not
The latter half of the nineteenth century saw the inven
lessen the belief in the notion of the brain as a giant-circuit tion of many tools and techniques now considered essential
in medical diagnosis and treatment. Needles and syringes
of nerve cells.
More attention was placed on the electricity that flows were invented in 1865 (Bergland, 1986, p 39). Herman
along the surface of cells than in the activity that went on Helmholtz (1821-1894), who measured the velocity of the
inside the cell. The synapses became circuit-breakers. Charles nerve impulse, invented the opthalmoscope in 1851. It was
Sherrington (1856-1952) who had learnt Virchow’s cellular now possible to look into the eye, the Shakespearean ‘win
theory in Berlin, continued the work begun by Stephen Hales dow of the soul’. The swelling of the optic nerves that oc
(1677-1761) 200 years before. Hales had found that the hind curred with brain tumours was observed within a few years,
legs of a decapitated frog would move if the cut end of the haemorrhage and pallor of the optic discs were also noted.
spinal cord was compressed—a type of reflex action. Inciden Lister’s aseptic surgery and the use of chloroform accelerated
tally Hales made the first direct measurement of arterial the use of surgical techniques; the pocket thermometer was
blood pressure. Marie Flourens (1794-1867) correctly placed introduced in 1896; Pasteur and Koch established the
the vital centers of breathing in the medulla, and noted that microbial basis of many diseases and in 1895 Wilhelm
the cerebral hemispheres received and controlled sensation Roentgen (1845-1923) discovered the x-ray (De Jong, 1982).
The flowering of clinical neurology also took place during
while the cerebellum co-ordinated body movements. Marshall
Hall (1760-1857) showed that reflex action consisted of three that half-century. In France Guillame Duchenne (1806-1875)
parts: a nerve leading from the irritated part to the spinal who had no formal appointment to any hospitals in Paris,
cord, the cord itself and a nerve going from the cord to the but was allowed to visit outpatient clinics, made major con
involved body part. Sherrington, known as the father of tributions to modern neurology (Dubowitz, 1982). He used
modern neurophysiology, outlined the sensory nerve supply electrical methods to study muscle disease, introduced biopsy
of the body in terms of the appropriate level of the spinal as a technique in clinical medicine, designed an ingenious
cord to which the nerve conveyed information about sensibili needle for muscle biopsy, and described several muscle
ty, and performed several experiments that demonstrated the diseases for the first time including the dystrophy that car
nature of the tone that is present in normal muscle at rest. ries his name. Jean Charcot (1825-1893) founded clinical
Meanwhile in 1825 C L Nobili’s astatic galvanometer in neurology and psychiatry came into use in the decade of the
1860s when Charcot began his work in earnest. The history
creased the sensitivity of measuring electric current by a
multiplier effect. Increasing the number of turns made by of the Saltpetriere itself serves to highlight the intimate con
coil of wire increased the deflection of a magnetic needle nection between the larger society and the medical world.
when the wire carried electric current. The astatic galvano It was built in 1603 as an arsenal, deriving its name from
meter was further refined by William Thompson—later Lord saltpeter, the principal ingredient of gunpower, that was once
Kelvin—in 1858 into the mirror galvanometer used to receive manufactured at the site. In 1656 it was converted into a
telegraphic signals. A tiny steel piece, smaller than a sewing asylum for infirm and abandoned women, in the eighteenth
needle was suspended by a single fibre. It was a permanent century it housed the ‘infirm and insane’. Pinel and Esquirol
magnet hung at the center of a coil of many turns of wire. conducted their psychiatric studies on these hapless victims
When current flowed this tiny magnet swung to one side or of France’s industrialisation. At the end of the eighteenth
another depending on the direction of flow of current. The century its inmates were described by Coguel as “madwomen
magnetic force required to turn this needle was very small. seized with fits of violence—chained like dogs at their cell
A small mirror attached to the needle reflected a beam of doors and separated from keepers and visitors alike by a long
light thrown on it onto a screen. The screen had a scale of corridor protected by an iron grille; through this grille is pass
June-Sept 1987
7
ed their food and the straw on which they sleep; by means
of rakes part of the filth that surrounds them is cleaned out”
(Foucalt, 1965). In McHenry’s laudatory version, “Charcot,
who took charge in 1862, saw this motley collection as a
veritable mine of neurological material. Containing some five
thousand inhabitants of whom three thousand were neurotic
paupers and epileptics, the Saltpetriere offered Charcot a
source of case material that was unique in the history of
neurology’’ (McHenry, 1969, p 284). Indeed it did. Charcot
described the lesions of multiple sclerosis, motor neuron
disease and an inherited nerve disorder now known as
Charcot-Marie-Tooth’s disease. Charcot is notorious for his
role as the charlatan of the Saltpetriere in his preoccupation
with hysterical seizures, which according to him occurred ex
clusively in woman, and which he claimed to cure by com
pressing their ovaries with his own invention: an ovarian
compressor (Veith, 1965, p 232).
In England, Hughlings Jackson (1835-1911), William
Gowers (1845-1915) and Charles Brown-Sequard (1817-1894)
laid the foundations of clinical neurology at the National
Hospital for the Paralysed and epileptic. Jackson is re
membered for his seminal work on epilepsy which he defined
as “sudden, excessive, temporary discharge” of neurons. He
pointed out that lesions of the brain produced a duality of
symptoms; loss of function like loss of speech, movement,
consciousness and positive symptoms like increased muscle
tone, increased reflexes, or uncontrolled motor activity
(McHenry, 1969, p 309). Jackson argued for a hierarchical
manner of functioning within the nervous system, being
heavily influenced by Herbert Spencer’s picture of organis
ed societies where primitive lower orders (the spinal cord and
nerves and muscles) were kept in their place by the more
highly developed upper echelons (the brain). Recent research
however reveals that the brain though highly organised does
not have a command post at the apex. When Jackson lec
tured on cerebral function he would draw a pyramid to repre
sent the hierarchy he considered present in the brain. Modern
analysis of visual function however shows that neurons of
the cerebral cortex operated in parallel not in series. There
is no master decision-maker and the brain it seems functions
in a democratic and interactive fashion (Ferry, 1986). William
Gowers was like Jackson a clinician but differed from the
latter’s analytical and physiological approach. Gowers was
a keen observer of symptoms and signs and described many
entities for the first time including myotonic dystrophy, sleep
paralysis, and palatal myoclonus.
American neurology began with studies of Injuries to
Nerves and their Consequences by S Weir Mitchell
(1829-1914) who had followed with interest the cases of nerve
damage brought forth in such large numbers by the civil war.
Mitchell’s study of gunshot wounds published in 1864 is but
one of a long line of publications and advances in medicine
that have occurred through history by the close alignment
of the medical profession with the services required of them
and rendered by them to the state. As Bernal states “much
medical knowledge and pratical treatment was learned in the
hard world of the military surgeon” (Bernal, 1971, p 393).
From the shaman of yore ordering the rain or sun for the
welfare of the tribe to Ambroise Pare (1510-90) unlettered
8
writing in coloquial French about gunshot wounds, Weir Mit
chell is but one link in a chain. The United States’ Public
Health Services’ connection with US imperia! policy overseas
and racism at home is well-documented in Walter Reed’s
(1851-1902) typhoid and yellow-fever related research follow
ing the US occupation of Cuba after the Spanish-American
War of 1898 (Bean 1983; Lyons and Petrucelli 1978) and the
scandalous study of the natural history of syphilis exclusively
in black men, a study that ended only in 1970. (Jones, 1981).
Developments in Physics
As the twentieth century dawned. James Maxwell’s
(1831-79) electromagnetic theory established a unity between
light, electricity and magnetism. Electromagnetic oscillations
gave rise to waves in a hypothetical ether, similar to those
of light but with much lower frequencies. In 1881 michelson
and Morley proved the non-existence of ether. Soon light
itself was explained as a low-energy photon or a packet of
energy virtually massless moving at an incredible but definite
speed. Thomas Edison’s (1847-1931) discovery in 1884 of the
Edison effect that a glowing filament of an electric bulb
could retain a positive but not a negative charge, i e, current
would flow only one way from a heated metal plate to a fila
ment, led to the invention of the electronic valve. Electricity
could travel without any wires through empty space. In 1905
Lee de Forest (1873-1961) mounted a piece of a zig zag wire
between the filament and plate. This electric screen when
negatively charged would repel electrons which could not get
past this grid. However when the grid was positive or neutral
electrons could flow on through to the metal plate. A very
small current could change the voltage of the grid—a weak
current could control a relatively strong current. The triode
was born and with it the revolutionary possibilities of
amplification and of power based on information. Radio and
television, high-tension vacuum and valve techniques that
followed integrated physics and electricity into the new ap
plied science of electronics.
Cathode ray oscilloscopes provided electronic amplifica
tion of very weak signals even very tiny such as occurred bet
ween synapses. The Cathode ray tube in which a beam of
electrons flashed across a tube on a horizontal axis could
be used for on-line recording of a signal on a vertical axis.
The string galvanometer, used by Richard Caton (1842-1926)
in 1875 to directly record currents from the surface of the
brain and 60 years later by Hans Berger, was replaced. It is
noteworthy that Berger’s publications were initially dismissed
as artefacts and his records though carefully assembled were
met with “monumental indifference, disbelief or even hosti
lity” (Gloor 1971). Berger’s work was ignored for several
reasons. Neurophysiologists held a deeply felt belief in the
brain as a highly complex neural network. Surely brain ac
tivity could not be the simple, regular waves Berger
demonstrated. Also, Berger’s reticent personality, and his
refusal to cooperate in building Hilter’s New Order unlike
the bulk of the German medical establishment, (Light, 1985)
forced him into retirement in 1938 and suicide three years
later. Equipment to record EEG was further improved in the
United States. Using a recorder developed by Western Union
Radical Journal of Health
for writing on a ticker tape with an ink stylus, replacing its tury would palpate, and percuss the part of the body con
magnets with more powerful ones of nickel, aluminium and sidered involved in disease. However the brain is inaccessible,
cobalt alloy and by providing stiffer springs, it was possible being surrounded by the rigid bony skull, to the senses of
to electrically record the human brain’s normal background sight, hearing, smell, or feeling, and it is very fragile.
rhythm called alpha waves with frequencies of 8-13 per se Palpating the brain, where there is no skull, would irrever
cond at a paper speed of 3/8th of an inch per second. Brain sibly destroy brain tissue! Thus the skull which protects the
waves would now be recorded easily; the action potentials brain from mechanical insults also prevents it from being
of individual muscle fibres, and the velocity of nerve impulse reached by the physician. Table 1 indicates the presently
could also be studied by using amplifiers and cathrode ray available means of imaging the brain. Even a quick glance
at this table reveals the intimate connection between
oscillographs.
These advances in neurophysiology made possible by the neuroimaging techniques and usage of some part of the
improved radio and amplifying equipment, oscilloscopes and electro-magnetic spectrum (See Table 2). Neuroimaging has
computers forged in “the furnace of human conflict” during advanced because of contributions from many fields of
the two world wars, (Walter 1971) were instruments designed science: necrology, neurosurgery, clinical radiology, radia
for destruction transformed in neurology for more benign tion and nuclear physics, engineering, mathematics, com
purposes. EEG has contributed to knowledge about epilepsy, puter science, mechanical engineering and biochemistry to
sleep disorders, brain tumors and altered states of con name a few.
Progress in neuroimaging though rapid was often accidensciousness. But the test has not been anyw'here as helpful as
the volume of words written about it, well over ten million
Table I: Neurological Imaging Techniques’
in the Journal of Electrophysiology and Clinical
Neurophysiology alone, would suggest (Williams, 1974). Procedure
Image
of
brain
that
results
Used indiscriminately to bolster physicians incomes, the EEG
and EMG have been aptly described as wasteful, and preten Neurological consultation Imaginary construct of possible pathology
tious (Menken and Sheps, 1984); or that as “most single Electroencephalogram
Surface electrical activity below 80 Hz
records would best be reported thus: this record departs Skull films
Distribution of crystallized calcium in head
slightly from accepted standards of normality; nobody knows Ultrasound midline
Position of 3rd ventricle
what this means” (Matthews, 1973). Similar caution has been Isotope scan
Distribution of blood-brain barrier
expressed about the overuse of evoked potential techniques Pneumoencephalogram Location of cerebrospinal fluid compartment
(Eisen and Cracco, 1983). This technique uses computers to
Cerebral agiogram
Location of blood compartment
store many elicited responses, averaging them and enabling Computerized tomogram Distribution of tissue radiodensity
one to record signals as small as one-hundredth of back
Positron tomogram
Distribution of brain metabolism and
ground activity. The electrical route of studying brain func
blood flow
tion which began in the eighteenth century has done very Nuclear magnetic
Distribution of brain water
little for patient care (Bergland, 1986, p 76). Structural ab resonance imaging
normalities of the brain are more easily and accurately un
(from Oldendorf, 1980)
covered by radiological techniques to the development of
which we now turn.
Noie * All of the special neurodiagnostic procedures mentioned can be
considered ways of imaging the brain. Each produces images
As far back as 1838 Faraday had observed a luminous glow
of the brain in a unique way, isolating some more or less restricted
which (William Crookes (1833-1919) in 1876 called cathode
characteristic of the brain and constructing an image from it,
rays, as they seemed to consist of particles torn out of the
thereby providing a restricted conceptualisation of the structure
cathode or negative end of a highly evacuated glass tube.
and function of the brain.
Nine years later Wilhelm Roentgen noticed something hap
Table 2: The Electro- Magnetic Spectrum and Neuroimaging
pening outside such a tube. It could fog photographic plates,
pass through sheets of rubber, through human skin and flesh,
Wavelength Photon Energy Frequency Neuroimaging
but not through bone. Roentgen had discovered x-rays—a
Technique
(Hertz)
(centimeters) (electron \olts)
scientific discovery with a vengeance (Bernal, 1971, p 73).
MRI. Ultra0.00001
10’10"
10-10'
It unlocked doors in medical diagnosis, and many branches Radio
sound
VHF)
of physics. X-rays are photons with an energy level greater (upto
0.00001 to
Microwave 0 01 +10
than 100 electronvolts (eV). (For comparison visible light
10h,-l0:"
0.1
10p-10u
photons have energies of 2 to 3eV). X-ray machines spread Infra red
0.0001 toO.Ol 0.1 to 1
10,4-10''
2x 10 ' to
I to 6
rapidly in Europe and the US as the high voltage generators Visible
10 4
and evacuated bottles necessary to produce x-rays were
l0,6-10'
6 to 1000
10 ’ to
Untra
already available in many laboratories. It socn became clear violet
2x10 '
Skull xrays
10,s-10:“
that x-rays were useful only in differentiating gas from soft Xrav
1.000 to
10 M to 10
Computerised
100.000
tissues and bone. They could not reveal useful structural
tomography
details in most soft organs like the brain.
Radioactive
102,-10"
100.000
10 9
Gammarav
The brain posed special problems to clinical medicine.
Isotope
Generally physicians like to visualise the structures they deal
with. In addition to vision, physicians till the nineteenth cen- (modified from Oldendorf 19S0; Weinberg 1977; Young 1984)
June-Sept 1987
9
tai. In 1912, an x-ray taken of a man with a skull fracture
showed air in the cavities or ventricles of the brain. Six years
later, Walter Dandy (1886-1946) “made the quantum intellec
tual jump from the clinical observation of air in the head
resulting from head trauma... to its deliberate injection for
diagnostic purposes” (Oldendorf, 1980, p 15). The pneumoencephalograph or PEG, used for over 50 years did not
show the brain directly. Air injected between the middle
(arachnoid) and inner (pia) layers of the coverings of the
brain filled the ventricles of the brain and by comparing dif
ferences with a normal outline one could infer something
about the size and shape of surrounding structures.
A Parisian neurologist Jean Sicard (1872-1929) had been
using Lipiodol, an iodized oil for treating back pain. He in
jected the substance into the lumbar muscles and found that
it was well tolerated and produced no serious side effects.
He had noticed that Lipiodol was excellent x-ray material
and used it to outline the bronchial tree in the lungs. One
day one of his pupils injected Lipiodol into the lumbar
muscles and was horrified when he found he was withdraw
ing cerebrospinal fluid (CSF) as he drew back the plunger
of the syringe. He rushed off to Sicard, who asked how the
patient was and on being told the patient was well, decided
to look at the lumbar region on a flourescent screen. Sicard
first screened the patient standing up and saw that the
Lipiodol had dropped to the bottom of the cavity surroun
ding the spinal cord (the spinal subarachnoid space). He then
had the brilliant idea of tilting the patient head down and
seeing the movement of Lipiodol (Bull, 1982). The techni
que of myelography was born, one which has proven very
useful in diagnosing diseases of the spinal cord’like tumors
and protruded intervertebral discs. In 1926 Egaz Moniz
(1874-1955) performed the first cerebral angiogram in a living
patient. A substance opaque to x-rays was injected in the
carotid arteries that supply blood to most of the brain. This
technique, still in use today, delineates tumors, hemorrhages,
blood clots and vascular malformation of the brain. Research
now concentrated on the development of a non-toxic
contrast-agent. These agents had to confront the blood-brain
barrier (BBB) which depends upon certain characteristics of
the capillaries in the brain. A capillary, a tube with a diameter
of 0.1 mm, length of about 1 mm has a wall of single flat
endothelial cells that are about 0.001 mm thick. Blood and
soluble substances in the plasma can pass through the walls
of non-neural capillaries or diffuse through the intercellular
clefts, or pores between two endothelial ceils. Molecules up
to 40,000 molecular weight can pass through these pores.
Pinocytosis is another way of bloodcell exchange. Here the
inner walls of the endothelial cell breaks, a small amount
of blood enters the cytoplasm and is transported through
the width ot the cell and dumped into the extracellular space
immediately surrounding the capillary. In neural capillaries,
on the other hand, there is no intercellular cleft, the en
dothelial cells form ‘tight junctions’, and pinocytosis is vir
tually absent. Thus the blood and brain can exchange
material only through the capillary cell. The tight junctions
exclude molecules with molecular weights as low as 2000.
Water-soluble polar compounds, i.e. those substances which
have an electric charge at each end of the molecule, are
10
mostly excluded while lipid-soluble compounds rapidly and
easily enter the brain. Paul Ehrlich (1854-1915) had discovered
the BBB in 1885 when he noted that aniline dyes injected
into an animal stained its body but not the brain or spinal
cord. The BBB is ‘lost’ when the brain suffers any kind of
insult like infection, trauma, or a stroke.
The contrast-agents that became widely used were
iodinated organic compounds because they were the least tox
ic, stable in water-solution, with a high molecular weight,
but low- osmolarity, (1.5 osmolar solution only five times the
0.3 osmoles of brain capilary endothelial cells). Also the
iodine atom’s innermost shell of electrons (the k-shell) has
a binding energy of 33 Kev. Incoming x-rays in computerised
tomography have an energy level of 60 to 80 KeV. These rays
can be captured by the k-shell electrons of iodine, deleting
the x-rays and increasing the radiodensity of the tissue that
contains it.
The second world war which sparked the development of
nuclear physics resulted in many artificial radioactive
substances being avaialble by the mid-40s. In 1947 George
Moore then an intern in surgery discovered that radioactive
iodine injected intravenously emitted gamma rays which
could be detected by a Geiger counter. Radioactive isotope
imaging was refined in the next two decades using a thalliumactivated sodium iodide crystal photo multipliers. The small
amount of thallium breaks up the regularity of the sodium
iodide crystals so that they scintillate or generate visible light
photons when struck by gamma rays. These photons are
amplified by the photomultiplier and the amplitude of the
voltage thus produced measured electronically. Radioisotope
scanning did not produce sharp images of the brain as at
tempts to sharpen the image by collimation resulted in many
emitted rays being uncounted. Also Compton scatter or
deflection of gamma rays by atoms in their path made the
rays appear to have a different origin when they reached the
detector, these ‘incorrect’ locations further contributing to
a fuzzy image.
Visualising the Brain
By 1971, though the brain could be visualised indirectly
by angiography, ultrasound, radioisotope scanning, PEG etc,
these tests were either cumbersome, time consuming or very
uncomfortable to the patient. W H Oldendorf around 1960
and G N Hounsfield in 1967 independently developed the
technique of computerised axial tomography (tomos = a slice)
based on tissue specific gravity. The fascinating story of the
development of computerised tomography is recounted in
Oldendorfs book The Quest for an Image of Brain. In 1960,
Oldendorf applied for a patent for a device that produced
a radiographic cross-section of the distribution of tissue
structures based on regional radiodensity. A narrow col
limated beam of high energy photons passed through the
head and were counted after they emerged from the head
by means of a detector fixed in relation to the photon source.
Several points on a particular plane of the head were scann
ed using rotational and translational motions. The observ
ed counts of photons were then processed by a computer
which reconstructed the distribution of radiodensities within
Radical Journal of Health
the plane. Oldendorf was granted a patent in 1963 but found
none of the major x-ray manufacturers interested in the
device. As he ruefully remarks “their lack of interest was a
matter not so much of technical unfeasibility (since they had
more information than I had as to whether the idea was
workable), but more of economic promise. A letter from one
of the world’s major x-ray manufacturer ended—even if it
could be made to work as you suggest, we cannot imagine
a significant market for such an expensive apparatus which
would do nothing but make a radiographic cross-section of
a head” “Oldendorf, 1980, p 85-6). Success came to Gor
don Hounsfield who worked in the research laboratories of
EMI Ltd. Hounsfield decided to use sodium iodide crystals
rather than the photographic plates used for 50 years in
radiology, because the crystals being 100 times more sensitive
than the plates, allowed better differentiation of soft tissue
density. As his device took five minutes to produce a pic
ture he was advised to study the brain which did not move
rather than the chest or abdomen as images produced of
these regions would be blurred since no patient could hold
his breath for five minutes. Today a picture can be produc
ed in seconds allowing any part of the body to be scanned.
EMI pursued the development of the CT scanner as Olden
dorf explains, being previously uninvolved in medicallyoriented research they were not aware that the limits of
technology had already been explored. The production of
the CT Scanner illustrates a feature common to technological
and scientific advancement under capitalism. The large xray manufacturers behaved in a manner similar to wireless
manufacturers: too intent on immediate profits to indulge
in expensive development (Bernal 1971, p 717) whereas the
unorthodox approach of the inexperienced musical company
led it to market one of the truly revolutionary diagnostic
techniques in medicine. Tvo other brain imaging techniques
have become available since 1971. They are positron emis
sion tomography (PET) which measures regional metabolism
of glucose or oxygen and magnetic resonance imaging (MRI)
in which the magnetic property of hydrogen atoms is utilis
ed. The hydrogen atoms of the brain are made to resonate
in a strong magnetic field. They partially align themselves
with the field and absorb energy which is subsequently
reradiated. Images of hydrogen density and relaxation time
allow striking pictures of the brain and spinal cord making
virtually all parts of the central nervous system accessible
to the human eye without tissue ionisation, injection of con
trast material or radioactive substances being involved
(Oldendorf, 1984).
C T and MRI scans have proliferated in the US, the
number of C T scanners rising from none in 1973 to 800 in
1978 representing a capital investment of 400 million dollars
(Oldendorf, 1980), while MRI scanners rose from none in
1978 to about 200 in 1985 leading the industry’s two dozen
firms collectively looking to annual sales worth 2500 million
dollars worldwide in 1988 {Lancet 2:1169, 1984). Separate
buildings, each costing as much as 1.5 millions dollars, have
been constructed to ‘contain’ the magnetism surrounding the
MRI equipment financed by ‘venture-capital’ groups who
see them as tax shelters or investment opportunities
(Goldsmith, 1984).
June-Sept 1987
So the high-tech revolution in medical diagnostics :s ex
pensive, becomes obsolete rapidly and by virtue of the finan
cial stakes involved, available at a stiff price therefore largely
only to the affluent (see Table 3). Though the technology
provides diagnosis more accurately at a crucial early stage
of some diseases, and the greater precision of pinpointing
lesions leads to a reduction in other tests (see Table 4) it is
cost-effective in a rather narrow sense: to those able to get
the test done. The issues of cost-effectiveness deserves a full
discussion on its own.. Suffice to say here that in the US cor
poratisation of health care promotes the use of capital in
tensive technology while ignoring the question of access to
these services by the 35 million Americans who are either
under and uninsured.
Improvements in neurodiagnosis aided the growth of
neurosurgery. Injury to the head had been regarded as a
surgical problem since antiquity (Flamm, 1982), but removal
of tumors of the brain and spinal cord was first attempted
only about a century ago. Victor Horsley (1857-1915) a
pioneer who contributed to many neurosurgical techniques
Table 3: Costs of Various Neurodiagnostic Procedures in Relation to
Discomfort to Patient, and Information Obtained
Procedure
Discomfort Information
Cost
form
Obtained (US Dollars)
Procedures
—
Neurologic Consultation
—
Skull xrays
—
EEG
—
Ultra-sound (midline ECHO)
++
Pncumoencephalogram
Caroled angiogram
4- 4Digital Subtraction Angiography +
—
Radioisotope Scan
—
C T scan (head)
—
C T scan (spine)
—
MRI scan (head)
MRI scan (spine)
-
+ -r *r 4- +
44- 4-
+
4- 4-
4-4-44- 44-4-4-
4- 4- 4- 44- 4- 4- 44- 4- 4- 44- 4- 4- 4-
80-100
55- 75
75-150
25- 50
300-500*
550-1200*
300-400
150-250
300-500
325-600
600-800
600-800
Note-. * If costs of hospitalisation are included these procedures would
me much more expensive—daily room charges vary from
S 175-250 1 day.
(modified from Oldendorf 1980; Gunby 1983)
Table 4: Effect of Various Procedures AT Dent Neurological Institute,
Buffalo, N Y
Procedure
Echoencephalograms
Pncumoencephalogram
Isotope brain scan
Lumbar punctures
EEGs
Angiograms
Hospital admissions
Patients seen in ER
Office consultations
1973 (pre-CT)
189
39
579
425
1,047
111
355
222
668
1976 (post-CT)
0
5
157 (16)*
167
731
87
351
291
1,087
Note: * Sixteen tests were required by neurosurgeons and neurologists.
The numbers below the line indicate that, despite the reduction
of tests, the total clinic work load increased between 1973 and
1976.
(from Oldendorf 1980)
11
including decompressive surgery for brain tumors, laminec
tomy for removal of spinal cord tumors, nerve section for
relief of exquisite facial pain (tic doloureux), etc deserves
mention for his championing of social causes. He was an
aovwed agnostic who worked for Votes for Women (the Suf
fragette Movement) demanded equality for women in
medicine, sought proper recognition for the nursing profes
sion and urged health legislation that would benefit the poor
(Cooper, 1982). He was disliked by the British medical
establishment who feared his socialism ('Riylor, 1986). A
remark of William Osier’s illustrates the attitude of the
medical establishment then (and I suspect it would not be
very different today) to Horsley’s politics: “What demon
drove a man of this type into the muddy pool of politics?’’
(Osler, 1916). Horsley though appointed to the staff of the
National Hospital in 1886 was given no beds of his own in
the thirty years he worked there.
Neurosurgery progressed rapidly in the twentieth century
keeping pace with developments in neuroradiology. Harvey
Cushing (1864-1939), a leader in modern neurosurgery, in
vestigated the role of the pituitary gland and established that
it secreted growth hormone. He linked the brain with en
docrine function, a link that appears increasingly important
as the number of neuropeptides discovered grows, their ac
tions playing a pivotal role in memory, emotions, sleep, and
the perception of pain. Indeed Bergland (1986) argues that
we have come full circle. The brain may be what the Greeks
imagined it to be: a hormonally modulated gland with the
“stuff of thought’’ being large molecules or peptides and not
electricity. The discovery of neuropeptides would have been
difficult without a simple and safe technique to examine
cerebrospinal fluid (CSF). Such a technique was invented by
Heinrich Quincke (1841-1922) who was searching for a way
to remove CSF from children with hydrocephalus. He in
serted a needle with a stylet in the lumbar intervertebral place
and removed CSF. He used the lumbar puncture to examine
the constituents of CSF and described the changes in the
latter in purulent meningitis (McHenry 1969, p 366).
The role of special chemicals or neurotransmitters that
conveyed messages across a synapse was first described by
Henry Dale in the 1930’s. Acetyl choline, released by the
vagus nerve which supplies the heart, slowed the rhythm of
the heart. Soon other neurotransmitters were discovered and
by 1975 it was known that the brain produced morphine like
substances or endorphans. Presently over 45 neuropeptides
are known and their effects on degenerative diseases of the
brain like senile dementia and Parkinson’s disease under ac
tive study. Tools used in peptide research include radioimmunossay, immunocytochemistry and complementary DNA
probes. Usage of monoclonal antibodies, introduced in the
last decade, has made possible knowledge about the inter
nal structure of the neuron. Disciplines that were unknown
till the early seventies flourish in their own right today.
Neuroimmunology, molecular genetics and neuropeptide
research bring together branches of science outside the field
of clinical medicine. Advances in knowledge are depandant
upon a sophisticated and wide technological base. Often new
techniques are developed for reasons other than what they
are used for later. For instance monoclonal antibodies
12
developed out of Milstein and Kohler s attempts to learn
more about the genetic control of synthesis of antibodies
(Sattaur, et al, 1984). Presently brain function is accepted
as both hormonal and electric, without a brain-body dualism.
Both arc dependant on and influenced by the other. A basic
operation or function common to all areas is suspected but
the manner in which integration of thought and behaviour
occurs is unknown. Neither are we able to correlate struc
ture and function at the level of a single cell (Philips et al,
1984).
Conclusion
The brain then remains the enigma it has been through
millenia. It can however be visualised, directly and indirect
ly, its functions studied and modified by chemical, electrical,
and surgical means. Progress in medical technology and
knowledge about basic biologic structure and function, which
permit these interventions in the nervous system, records even
more spectacular advances in other organs—the heart, the
liver, the kidney and bone marrow can be transplanted.
Machines can do the job of the heart, the lungs and the
kidney. No part of the gastrointestinal tract remains hidden
from the human eye with the use of fibre-optics. Setting
broken bones, stitching up torn arteries, controlling bacterial,
fungal and parasitic infection, these are but some of the
techniques taken for granted by a majority of the citizens
of Europe and North America. But the availability and
relevance of this technology to a large section of humanity
remains tied in to the social, philosophical and economic
realities which govern our planet. Flowering first in Europe,
and later North America, medical technology has concen
trated on a cellular and clockwork like approach to the body.
Preventive measures have generally received scant attention
particularly those that focus on industrial pollutants as likely
carcinogens or of individual habits like smoking that are pro
moted by big corporations. Prevention by innoculation
against disease no longer has universal applicability.
Recently developed hepatitis and malaria vaccines are
enormously expensive and intended only to aid soldiers of
the “free world’’ as they are called to save democracy in
tropical and equatorial climes. The electronic razzmatazz
available at the beck and call of physicians follows the road
of most commodities—the more, the better! Marketed ex
pertly by companies out to make quick and big profits much
of the application of medical technology is prohibitively pric
ed and even unnecessary (Angell, 1985). Certainly it is dif
ficult to account for the number of intensive care units, CT
scanners, coronary artery bypass grafts in the United States
without considering the links between medicine and the
health care industry.
A society that cares neither for adequate prenatal care,
nutriton, education, housing, and old-age security exhibits
sudden concern for end-stage renal disease and elderly
patients when government programmes assure physician,
hospitals and biotech industries of sustained high income.
A modern intensive care unit reflects uncannily the society
from which it has emerged. Notwithstanding the underly
ing disease, modern death bed rituals are mounted. Every
index of body function is tracked and treated without any
Radical Journal of Health
attempt at considering the patient’s prognosis or the futility
of these costly heroic efforts. Blood gases, body pH, elec
trolytes, urine output, continuous electrocardiographic
monitoring and arterial blood pressure recording, respirators,
nothing is ignored in this relentless pursuit of information.
Macabre though it may sound, patients die, but not before
they are made biochemicaly and haematologically normal!
The same system of hospital based technological intensive
medicine is sought worldwide, an acknowledgement in part
of its limited, but definite success in combating disease and
relieving suffering. The control of infection proudly acclaimed
as an achievement of medicine probably has more to do with
better nutrition, sanitation and hygiene (McKeown, 1976).
The efficacy of antibiotics has depended on the integrity of
the body’s defence mechanisms against disease. They are in
effective in infections such as the AIDS virus, which derives
its lethal nature from its ability to destroy the immune system
of the body. The AIDS epidemic illustrates the complex
multifaceted nature of modern medicine. Though the medical
establishment is baffled by the disease and presently unable
to help its victims adequately, a remarkable amount of
knowledge has been acquired in the five years since the
disease became known. The medical profession not parti
cularly noted for its compassion towards those society re
ject*: or ignores, has been free of panic and prejudice while
AIDS high risk groups consisted largely of drug addicts and
male homosexuals. In fact, it has campaigned against
hysterical and unwarranted measures such as quarantine very
effectively. Medical technology helped uncover the human
immunogenic virus as the cause of AIDS and may give us
a vaccine in the next decade. Yet AIDS illustrates the limita
tions of modern medicine. It concentrates on treating disease
not in learning more about why only a few acquire it. In any
epidemic the disease affects a much larger proportion of the
populace than is cither incapacitated or killed by it. Factors
that protect most individuals are only now' beginning to be
studied.
Finally and very importantly comes the question of
resource allocation. It would cost a fraction (about 30 billion
dollars) of the amount spent on arms (800 billion dollars
a year) to feed, clothe and educate every person on earth.
CT scanners and MRI equipment co-exist w'ithin a stone’s
throw of people scouring through garbage cans for food.
Drugs that can save human lives are controlled by corpora
tions notorious for overcharging poor countries. As Martin
Ryle put it in a letter written several months befor his death
in 1984: “The benefits of medical research are real, but so
are the potential horrors of genetic engineering and embryo
manipulation. We devise heart transplants, but do little for
the 15 million who die annually of malnutrition and related
diseases. Our cleverness has grown prodigiously—but not our
widsom” (Ryle, 1985).
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Medical Association, 254: 1203-1207, 1985.
Basham A L, The Wonder That Was India, Fontana-Collins, London,
1967, p 50.
Bean W B, Walter Reed and Yellow Fever, Journal of the American
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June-Sept 1987
Bergland R, The Fabric of Mind, Viking, Great Britain, 1986.
Bernal J D, Science in History, Volumes 1-4, The MIT Press Cambridge,
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Brazier M A, A History of Neurophysiology in the 17th and 18th cen
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Bull J W, The history of neuroradiology, In Historical Aspects of the
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1982, p 255-264.
Cooper J K, Electrocardiography 100 years ago. New England Journal
of Medicine, 315:461-464, 1986.
Cooper I S, Sir Victor Horsley: Father of modern neurological surgery.
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Dejong R D, A History of American Neurology, Raven Press, New York,
1982.
Dubowitz V, History of Muscle disease. In Historical Aspects of the
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Eisen A and Cracco R Q, Overuse of evoked potentials: Caution,
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Flamm E S, The decline of osteology and the rise of surgical neurology
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Elsevier, Amsterdam, 1971, Vol 1, p 4.
Goldsmith M F, NMR & CT: Questions of cost, complexity and efficacy.
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Gunby P, Scanning the field of neuroradiology. Journal of the American
Medical Association, 249: 857-867, 1983.
Hill C, The World turned Upside Down, Penguin Books England, 1975.
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New York, 1981, p 272.
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Lancet. The big business of NMR scanners, 2:1169, 1984.
Licht S, History of electrodiagnosis in Electrcdiagnosis and Elec
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Light D W, Values and structure in the German health care systems,
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N Abrams, New York, 1978, p 559.
McHenry Jr L C, Garrison’s History of Neurology, Charles C Thomas,
Springfield H 1969.
McKeown T, The Role of Medicine: Mirage or Nemesis, London, Nuf
field Provincial Hospital Trust. 1976.
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(Continued on p JSj
13
Politics of Contraceptive Technology
Depo-Provera in New Zealand
sally Washington
The development and dissemination of injectable contraceptives provides a good illustration of the politics of contracep
tive research and its international dimensions. It is also an example of (he capitalist patriarchal control over women’s
fertility. The article throws light on the S six million clinical trial which was conducted in New Zealand bv Upjohn,
the sole manufacturer of the contraceptive. Needless to say a majority oj women on whom the drug was tried were
black and working class as well as Maori women. The New Zealand trial was extremely important to the manufacturers
for several reasons and moreover there were several conditions in the country which made it convenient for Upjohn.
Not surprisingly women’s struggles against these trials have been determinedly put down.
IN the patriarchal mode of reproduction, women lose their
social power at the moment of conception when the work
of reproduction begins. There is no right time to become
pregnant because in this mode, sex, procreation and the
socially necessary work of parenting are inextricably linked
and all occur under male control. (Trainer, 1986). In theory
however, contraception allows individual women to plan
when they will confront this process. Female control of fer
tility is therefore an essential condition of women’s self deter
mination and is an important site for gender struggles.
Women do not make real choices about when or whether
to reproduce. It is a misnomer to talk about ‘free choices’
when the means of contraception (the pill, injectables, intra
uterine devices [IUDs] etc) are not primarily developed ac
cording to women’s needs, but are determined by the forces
of the capitalist patriarchy mediated by the state, the medical
establishment and the multinational drug corporations.
In this article I examine the patriarchal means of con
traception to discover the real relations behind their develop
ment and dissemination. I shall use the example of the in
jectable contraceptive Depo-Provera as one of the most hor
rific examples of the capitalist patriarchal control of women’s
fertility, and one that has special relevance for New Zealand
women. I shall also attempt to link this discussion to the cur
rent struggle by Indian women to have a similar (progestogen
based injectable) contraceptive, Net-Oen, banned in their
country.
A Patriarchal Industry
Men dominate the contraceptive industry at every level;
in research and development, as manufacturers and suppliers,
and as regulatory authorities. Male dominance means that
the contraceptive cafeteria reflects patriarchal needs to con
trol female fertility. Common features of ‘modern’ contracep
tives, are that they control female rather male fertility. The
form that their administration takes, is that birth control is
a female responsibility. Virtually no research has gone into
male contraception. The repertoire is currently limited to con
doms and sterilisation, as patriarchy could not tolerate
tampering too much with male fertility.
Birth control is also a commodity. The forces of patriarchy
determine that contraceptives should be aimed at female fer
tility, but the detailed decision about which contraceptives
will be developed are determined by the forces of capitalism.
The bulk of research money pours into IUDs, the pill and
methods of ‘reversible’ sterilisation including injectables,
while barrier methods receive minimal investigation. Barrier
methods have limited profitability whereas chemical methods
14
are •‘amongst the most profitable of all pharmaceuticals”
(Bunkie, 1983).
Chemical method^ are presented as more ‘effective’ but
the real reason why they are given such priority is because
they are administered by medical professionals, not controlled
by the women who use them. Chemical methods are typically
dangerous so women must be kept ignorant of their
functioning.
The patriarchal monopoly of contraceptives and con
traceptive information means that women must either ‘ac
cept’ whatever is developed and offered by patriarchy and
risk dangerous side effects, or ‘fall’ pregnant and face a possi
ble lifetime of domestic drudgery. The social conditions of
our lives and the wider political system in which we live in
fluence the extent of risk we will take as well as the awareness
of that risk. In countries like India, a women’s ability not
to become pregnant often means better access to housing,
schooling for their children and health services: all typical
family planning incentives, (Balasubrahamanyam 1986).
While modern contraceptives appear to give women some
choice about when they' reproduce, the real structures at work
are patriarchal and hence, do not serve women’s needs.
Capitalist corporations require that contraceptives maintain
profitability, imperialist nations require effective population
control weapons and the medical profession demands that
contraceptives are monopolised so that only medical ‘experts’
can administer them. Under these criteria, Depo-Provera and
its injectable cohorts are ideal contraceptives.
Depo-Provera in New Zealand
Depo-Provera works by inhibiting ovulation and is ad
ministered by injection once every three months. It is however,
a temporarily irreversible drug which cannot be purged from
the bloodstream once injected. Those women then, who suf
fer severe side effects from it must endure these for at least
three months. Millions of women are using Depo-Provera
worldwide which given its dubious safety record, amounts
to a massive experiment on women, (Bunkie, 1985). Since
the patent on DMPA, the progestogen used in Depo, expired
in 1984, other brands of injectable contraceptives have
flourished. One of these is Net-Oen. Given that the active
agent in progestogen-based injectables is similar if not iden
tical to Depro-Provera, it could logically be argued that the
side-effects will also be similar. Certainly the means by which
multinational corporations have ‘tested’ and disseminated
their particular brands have been surprisingly similar.
America’s Upjohn Corporation took over the development
of Depo in the 1960s. The drug had been used in the 1950s
Radical Journal of Health
but had been cast aside because it caused disease of the uterus g) cervical, endometrial and breat cancer: Depo users have
revealed three to nine fold increases above normal rates
(Unity, 1982). In 1965 Upjohn researches began human ex
periments on Thai women using three monthly doses of Depo
of cervical cancer (Neal, 1979).
h) A New Zealand study found that several women had
which were later increased to six monthly doses.
serious anaphylactic reactions which were almost fatal
In 1969 Upjohn applied to the American Food and Drug
Administration (FDA) for a licence to sell the drug as a
(Bunkie, 1983).
human contraceptive. A year later, the seven year study on ii) Immediate and short-term effects include:
beagle dogs and the eleven year monkey study required by a) abdominal discomfort
the FDA began. In New Zealand the Health Department ap b) dramatic weight gain or loss
proved Depo Provera for use as a contraceptive before the c) depression: progestogen is a well-known depressive drug.
results of both studies were released. The results revealed in d) loss or suppression of sexual desire and/or orgasm: Depo
creases in both benign breast nodules and breast cancer.
is used in two American clinics to chemically castrate
Meanwhile, other unsuspecting women were participating in
rapists. Supressing libido is an ironic property for a
trials of Depo in Bangladesh as were black women in South
contraceptive.
Africa and what was then Rhodesia.
e) headaches, dizziness and nausea.
In 1974 the FDA allowed the ‘restricted’ sale of Depo for
f) vaginal discharge
‘patients’ who knew the drug could make them sterile; who g) breast discomfort and abnormal growth
were unreliable users of contraceptives; who could not use h) menstrual abnormalities are suffered to some extent by
other forms of contraception; or who had a history of con
all women on Depo.
traceptive failure. In 1978, after three Congressional Hear
One
respondent to a New Zealand survey was bled every
ings the FDA rejected Upjohns’s application to market the
day for three years and eventually had a hyserectomy, while
drug in the USA.
A year later, the rhesus monkey study revealed that two about one Depo user a week is admitted to Auckland’s Na
out of the twenty high dose animals had cancer of the uterus tional Women’s hospital with uncontrollable bleeding. Yet
and three had breast lumps. But Upjohn’s enthusiasm was Upjohn medical director, Norman McLeod, dismisses this
by saying “Anyway, bleeding is more of a nuisance than a
not dampened by these results.’
Many developed countries including Australia, Britain health problem and can be easily dealt with’’ (The Press,
(temporarily) and the USA have banned Depo pending pro 1985) apparently by administration of controversial estrogen
of of its safety. Evidence is still being gathered from millions pills probably also produced by Upjohn.
Depro-Provera was not primarily designed to help women
of female ‘guinea pigs’ who still use it: essentially the poor
in Jamaica, Thailand, Mexico, Sri Lanka and New Zealand. control the reproductive lives, so why do millions of women
In countries where it is banned for general use disadvantaged still use it? Probably the main reason why women still use
sections of the population are also using it, in particular: drugs like Dempo, despite their dubious safety records, is
West Indian and Asian women in Britain, aboriginal women that they are not aware of the risks or the alternatives. We
in Australia and Chicano and Black women in America. assume that whatever medical professionals and ‘specialists’
Similar trials of other injectables with less of an international prescribe has been adequately tested and proved safe. This
reputation then Depo are also being conducted, such as the assumption could be fatal.
Net-Oen trials in India.
The carcinogenity of Depo has been the main issue in the Scientifc Evidence
debate over its safety. Other side effects are relegated to
The FDA ban on Depo effectively closed the US market
‘minor’ or ‘irrelevant’ status, which women are expected to to Upjohn and worse still meant the US ‘aid’ agencies could
put up with. What are the effects of Depo use?
not supply it overseas. Upjohn has campaigned hard to have
i) Long-term risks include:
this situation reversed. The most effective strategy in this
a) anemia
campaign has been to produce •scientific evidence’ that the
b) diabetes
drug is safe. It has spent millions a year (S 6 million on a
c) temporary or permanent infertility
New Zealand stud) alone) on research designed to produce
d) uterine disease and permanent damage to the ovaries, pan the desired results. Investigations into the safety of Depo have
creas, liver and adrenals
therefore centred on its carcinogenity (which is difficult to
e) lowered resistance to infection because of its negative ef prove anyway) while its more immediate side effects have
fects on the production and distribution of antibodies:
been ignored.
particularly damaging to poor women.
Upjohn’s control of the information about Depo allows
f) child abnormalities: Depo is especially recommended for it to brush asise any evidence that questions its safety. In
breast feeding mothers on the assurance that there are no the first seven-year beagle study for example, Upjohn dismiss
negative effects on the production of breast milk. Yet
ed the findings that 18 of the 20 dogs receiving Depo died,
Depo has been found in breast milk, and discovered in
by claiming that beagle dogs were especially prone to breast
the fact tissues of breast fed children of Depo mothers.
tumours.
The drug also cannot be discontinued if a women finds
The results of the rhesus monkey study were similarly
she is pregnant which means it could act on the fetus for dismissed by saying they were dose related. Upjohn’s claim
several months.
that Depo “is probably the safest harmonal contraceptive
June-Sept 1987
15
drug available" is therefore totally unproven (Bunkie, 1983).
So while medical practitioners may prescribe it in good faith,
their decisions are based on mis-information produced and
controlled by the company that stands to profit.
And profit it has. The first Reagan administration passed
the Drug Regulations Act which rendered impotent the FDA
ban on Depo sales to the Third World. Drugs judged unsafe
for Americans can now be exported provided they are re
quested by the foreign government. Apart from Upjohn’s
profits, the assault on Third World women has other
advantages:
“Population explosion, unless stopped would lead to
revolutions: population control is required to maintain the
normal operations of US commercial interests around the
world... without our trying to help these countries with their
economic and social development, the world would rebel
against the strong US commercial presence. The self interest
thing is the compelling element" (Ehrenreich, 1980).
Government applying for loans from organisations like
the World Bank (with heavy US presence) are usually re
quired to show that they are addressing their ‘population pro
blem’. Sterilisation programmes and campaigns of DepoProvera and other injectables are pushed because they are
immediately effective with long-term results.
Why New Zealand?
US imperialism concentrates Depo’s three-way assault of
racism, patriarchy and capitalism. Like other weapons in this
armoury, Depo has been aimed at women in New Zealand.
In 1968, the Nev/ Zealand Health Department approved
Depo for use as a contraceptive, before the study on its ef
fects were complete and despite its ban in the US. Moreover,
it is offered as “one of the many available choices" (Bonito,
1980) rather than approached conservatively.
There are several reasons why Upjohn has chosen to study
women in New Zealand:
First, they reveal the highest rate of Depo use for a popula
tion whose social and ethnic composition resembles that of
the US, where the company ultimately hopes to market the
drug.
Second, the subsidised health system here is a great boon
because it relieves the company from having to pay for any
medical treatment required by women involved in the study.
Third, the ACC (Accident Compensation Corporation)
Act absolves Upjohn of all damages suffered by the women.
Drug companies have had to pay millions of dollars in the
US in damages for the effects of drugs like Depo.
Fourth, since the New Zealand Medical Association
monopolises and the state regulates the dissemination of con
traception, the company does not have to seduce a wide
variety of organisations.
That the power brokers—state and medical—are united
in supporting the Upjohn study means the assault on New
Zealand women will continue. But the Depo-Provera assault
is not distributed evenly. There are definite targets.
In New Zealand, Depo is administered mainly to women
who have the least access to contraceptive information;
women for whom informed consent has little relevance. For
16
example:
1) One survey revealed that 42 per cent of Maori women
and 11 per cent of Pakeha (European) women had used Depo
while another concluded that the injection was the only
contraceptive method used by a higher proportion of Maori.
women than European women, (Bunkie, 1982; Trlin and
Perry, 1981). This reveals racist attitudes on the part of white
middle class medical practitioners who view Maori women
as unreliable users of contraception.
2) Working class women—one study discovered that the
injection had been used by a higher proportion of women
without school certificates and by women whose partners
were in the ‘lower’ status category (Trlin and Perry, 1981).
3) Maternity patients and breast-feeding mothers—one
study found that some women were given Depo as routine
medication before leaving the maternity hospital and were
assured that it would not alter the milk supply. Many were
not told what they were being given until it had been adminis
tered but being in unfamiliar surroundings and subject to
hospital rules they were not in a position to resist or complain.
4) Mental patients and intellectually handicapped women
are given Depo on the excuse that menstruation is a ‘pro
blem’ for hospital staff. This totally ignores the fact that in
stead of losing their periods some women ‘flood’ while on
Depo. In addition a women admitted to a psychiatric institu
tion, perhaps suffering from some form of depression,
“should not be subjected to a drug known to cause depres
sion" (Clark, 1980).
Depo is also given to young women who are considered
‘sexually irresponsible’; to immigrant women especially if
they are of an ‘undersirable’ type (i e, non-European); and
to post-abortion women.
But by far the largest group using Depo-Provera however,
are Black and working class women. Health professionals
say this is because these women like Depo and cannot or will
not use other forms of contraception. The reality is that
women do not make choices about their reproductive lives
under conditions that they control.
Black and working class women are under great preassure
to accept stronger and more dangerous methods of birth con
trol because an extra child could have quite disastrous ef
fects on the quality of the lives of existing family members.
When family planning incentives and dis-incentives are in
stitutionalised as they are in some countries like India these
pressures are even greater.
In a capitalist society doctors set up in areas where they
can earn most, which means that women living in working
class areas see doctors who are typically overworked. Quite
apart from any decision those doctors may make about the
contraceptive competence of any individual woman, they
simply do not have the time to explain various contracep
tive methods adequately.
Women are dependent on those who control th<' goods and
the information. One New Zealand study found that 82 per
cent of Depo users should not have taken it had they known
the evidence against it (Amas, 1984). In India a Net-Oen
camp was disrupted when half the women left after hearing
about the dangers of injectable contraceptive use (Nair and
Balasubrahmanyam, 1985). Women appear to ‘consent’, to
Radical Journal of Health
using dangerous contraceptives but what appears as consent
is really submission.
Iheir ‘decisions’ are largely determined by the material
conditions of their lives including their access to abortion
facilities, their ability to support another child and by the
limited information they receive from the birth controllers.
Contraception is an important area for gender struggles
because as long as men control women’s fertility, female
sexuality and the work of reproduction will be inextricable
linked. What forms have women’s struggles against injec
table contraceptives taken and how effective have they been?
Women's Struggle Against Injectables
dissemination of similar injectables marketed once the pa
tent on Depo was lifted. The same was true of the Daikon
Shield debate: other potentially dangerous IUDs were left
with their reputations intact.
It is also important that women share information across
international boundaries and link our struggles so that get
ting rid of a dangerous contraceptive in one country does
not mean that the problem is simply exported to more
vulnerable women in some other country.
Perhaps the most effective strategy, and one that has
ramifications for women outside the birth control arena, is
to empower individual women or groups of women to stand
up to the birth controllers. Empowering women means pro
viding them with information to challenge the ‘wisdom’ of
doctors, medical ‘experts’, technicians working in contracep
tive camps and ‘scientific evidence’. Information is power and
both must be shared for women to take some control of their
reproductive lives.
The campaign against Depo was an attempt by New
Zealand women’s health groups to have the Upjohn study
stopped and Depro-Provera banned in New Zealand. By
publicising the side-effects of Depo use it was hoped that
women could resist being manipulated into participating in
References
the study and or using the drug. But the feminists who cam
paigned against Depo have been verbally attacked, threatened Amas, Raewyn, Depo-Provera—voluntary choice? unpublished
undergraduate paper, Department of Women’s Studies, University
with libel suits, or dismissed as ‘emotional’ and ‘hysterical’.
of Waikato, 184, p 3.
Upjohn was not about to waste the $ 6 million it had pledged
Balasubrahmanyam, Vimal. A Bizarre Medley of Carrots, Women’s
for the study.
Global Network of Reproductive Rights, January-March 1986, p 7.
The study’s essential aim is to produce data that will ex
Reprinted from SHR.
tend the Depo-Provera stranglehold. Not long after the study Bunkie, Phillida. National Women’s Health Conference Report, Broad
began Upjohn was claiming the success of its New Zealand
sheet, November 1982, p 10.
study and claiming that it proved the drug’s safety for use Bunkie, Phillida. Draft paper presented to ANZSEARCH (Australia and
New Zealand Society for the Epidemiology and Research in Com
in America.
munity Health), Wellington, New Zealand, May 1983.
And while even statisticians and demographers criticised Bunkie, Phillida. Calling the Shots? The International Politics of Depo
the study’s protocol they have never been given the oppor
Provera In Test TUbe Women, ed Rita Arditti et al, Pandora, Lon
don 1983, p 168.
tunity to back up their arguments with the data from the
study because this has never been made public {The Press, Bunkie, Phillida. As above p 179.
Bunkie, As above cites Upjohn Corporation p 169.
1983). Completed questionnaires go straight to Upjohn’s New Bonita, Ruth. Contraceptive Research: For Whose Protection? Broad
Zealand headquarters then directly, without being opened,
sheet, January-February, 1980, p 7.
to Michigan, USA, where data is stored on their company Clark, Heather. Letter to Broadsheet, June 198C, p 3.
computer. Only Upjohn scientists have access to that data. Ehrenreich, Barbara et al. Contraceptive Dumping, reprinted in Broad
January-February, 1980, p 7.
The ‘facts’ that are concluded from the study will reflect the Nairsheet,
Sumathi and Vimal Balasubrahmanyam, Manushi, no 28, Maymale-dominated and profit-oriented structures that created
June, 1985, p 35.
them. The opinions of lay women have no status alongside Neal, Sue. Only Women Bleed, Broadsheet, December, 1979, p 13.
those of the country’s medical experts. The $ 6 million Up The Press. In Depo Provera, A Drug on Trial, July 8, 1983.
john was prepared to pay for the study is equivalent to the The Press. Depo Project will Involve 7,500 women in three samples, July
8, 1983.
entire budget of the New Zealand Medical Research Council Trlin A and P C Perry. Manawatu Family Growth Study, Management
and must have been an irresistible attraction to those experts.
Services and Research Unit, Department of Health, Special Report
60, Wellington. 1981, p 25.
For women’s groups, the struggle was diverted to the more
immediate and probably winnable Daikon Shield crisis. The Unity. Dangerous Contraceptive Freely Prescribed. No 13, October 1982, p 6.
anti-Depo campaign essentially failed, alongside rumours
SUBSCRIPTION RENEWALS
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cesses of our India sisters in the struggle to ban Net-Oen in
Foreign subscriptions: US S 20 for US, Europe and Japan
their country. Perhaps this is because in contraceptive camps
US S 15 for all other countries
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(special rates for developing
that drug alone, but can stand together for a collective refusal
countries)
as in the example of the Net-Oen camp described above.
Life^subscription.- Rs. 500/But despite the success and failures there are several points
D.D.S, cheques, IPOs to be made out to Radical Journal
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of
Health. Bibay. Please write your full name and correct
Women should struggle against all ‘types’ of contracep
address legibly. And please don't forget to add Rs. 5/- on
tives rather than certain brands. The adverse publicity created
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about Depo had no effect on the development, trials and
June-Sept 1987
17
Work, Ideology and Science
The Case of Medicine
vicente navarro
This article discusses (he nature of work, ideology and science in Western capitalist societies. It analyses how capitalist
or bourgeois ideology reproduces capitalist dominance in the spheres of production (Section I), politics (Section ll),
and science and medicine (Section HI). Also, this article explains how the working class responds to that capitalist
dominance through a continuous process of class struggle. Sections I, II and III show how class struggle affects bourgeois
dominance in the processes of production, politics, and science and medicine, respectively. Special focus in Section
III is on the analysis of (A) how bourgeois dominance appears in science and medicine; (B) how bourgeois ideology
appears and is reproduced in medical knowledge; and (C) how class struggle determines the nature of scientific and
medical knowledge. In this section, an alternative mode of production of scientific and medical knowledge, different
from the prevalent bourgeois one, is presented and discussed. In all three sections, medicine and medical knowledge
are chosen as the primary points of reference.
The article is reproduced from Social Science and Medicine, Vol 14, C no 3, 1986.
become part of that one-dimensional society [3]. Witness,
"The docs keep telling me there’s nothing wrong with the place where
I work, 1 guess they are supposed to know it all because they have
for example, a most recent publication edited by a leading
had a lot of education and everything. I’m no expert like they are,
radical in this country who, in covering the changes in the
but 1 sure as hell know there’s something wrong in that mill and other
cultural meaning of medicine, refers in his introduction to
guys arc saying the same thing. One thing I know for sure—that place
the impact of blacks’ and women’s struggles in the redefini
is killing us’’— Cancer patient and steelworker from the Bethlehem
Steel Corporation mills, Baltimore, Maryland, USA, 1978.
tion of health and medicine, but not once does he refer to
THERE is a concern among the centers of power in the the struggles which are taking place at the sites of work in
Western capitalist world that something is going wrong with the Western capitalist societies [4], struggles which I believe
the nature of work in that world. Editorials in the daily press, are among the most important ones in changing the nature
articles in scholarly papers, reports of powerful foundations, of our society, including the definition of health and
expose programmes on television, and even more recently,
medicine. Just in the United States alone, millions of workers
some commercial films have focused on different dimensions were involved in strikes last year which had to do primarily
and components of what has been called the ‘crisis at the with work conditions and health. From the wildcat strikes
work place’ in contemporary society. Part of this crisis is the among steelworkers in Ohio who asked to change conditions
rebellion of the working populations against their conditions of work and medical regulations which applied in their work
of work, rebellions which appear in different forms such as ing places, to the coal miners who struck for three months—
absenteeism, turnover, or just plain sabotage. These have threatening, as President Carter indicated, the stablity of the
reached such proportions as to become a cause for major economy, i e, US capitalism—for the right to strike for health
alarm by the establishments of those societies. An example and safety conditions and for the right to retain some form
of this concern and alram is one of the reports of the power of control over their health plans, many instances show that
ful Trilateral Commission. A major recommendation of that major struggles are taking place at the work place question
Commission, which includes representatives of the power ing the meaning of work under capitalism and its effects on
structure of the lop capitalist developed societies [1], is that the health and well being of our working populations.
“a major intervention is required in the area of work in our Health-related issues have been triggering points in many of
societies” to attack workers’ discontent and alienation at its those struggles, and health-related movements have had an
roots since, otherwise, those rebellions can threaten the whole important impact on changing the nature of political and
survival of the Western economic system—a euphemistic social institutions, including labour’s own institutions. A
term which is used to define Western capitalism. The most recent example is the key role played by the Black Lung
representatives of the bourgeoisie or capitalist class, or, to movement in creating Miners for Democracy. That move
use a more American term, the corporate class, as the most ment rallied the majority of coal miners around the issue
class-conscious of all classes, tend to perceive quite clearly of democratising their union, the Union Mine Workers, and
from where they sit where trouble may come from, i e, from overthrowing the corrupt leadership of Boyle [5]. A very im
the working class rebellion against the main column on which portant issue—a key one—in that fight was a health related
the entire capitalist system is built: the nature and the con issue, i e, the need to recognise and compensate black lung
as an occupation related condition, and the right to strike
ditions on which basis work is extracted from the workers [2].
On the other side of the ideological fence, progressive for safety conditions. The miners fought a tough battle to
forces in the United States have only recently begun seeing redefine health and medicine, showing—against the verdict
signs of that potential storm. Many, however, still seem to of coal companies, state and federal legislative bodies and
be stuck in that scenario so widely emphasised by ideologists agencies, and even large sectors of the academic
of capitalism and radicals alike that the working class has community—that coal mining was indeed a very unhealthy
practically disappeared as agents of change, and, instead,
occupation in our society.
has been absorbed into society, becoming part of the larger
The history of the working class in the United States, and
consuming and undifferentiated masses. According to some other countries as well, is punctuated by a continuous strug
radical theorists, other groups are supposed to have taken gle to redefine the nature of work and health. And these
over that task of carrying on the much needed struggle for struggles have heightened to such an extent that, as the
change. The working class, however, has been ‘lost*, and has Trilateral Commission indicates, they are threatening the cur
18
Radical Journal of Health
rent international capitalist order.
In summary the fight for the realisation of health is very
much at the center of the conflict between capital and labour
which takes place at the work place and heightens in
moments of crisis like the current one. The struggle which
occurs at the places of work in our Western societies is a most
important one, since it questions the very basic social power
relations of capitalism [6].
Nature of Work under Capitalism
Let us analyse the conditions of work of the working class,
that class by whose sweat and pain the goods and services
in our society are produced. A primary characteristic of work
is that its controllers increasingly shape the nature of work
to optimize their pattern of control over (1) the productive
process; (2) the individual producers; and (3) the collectivi
ty of producers—the working class [7]. By means of this pro
cess, the workers are: (a) compartmentalised into increasingly
narrower tasks; (b) hierarchicalised by a division of labour
which reproduces the class relations in society; and (c) ex
propriated from all possibility of controlling, influencing or
having a say in the design or development of the work pro
cess of the products they create.
The outcome of this process is a set of relations which
cannot be defined as less than totalitarian. Democracy, the
capacity of individuals to control their own lives, stops at
the gates of the working places. This set of authoritarian rela
tions where one class—the bourgeoisie—controls that pro
cess of production and work, and the other—the working
class—doesn’t, is what Marx called the dictatorship the
bourgeoisie, understanding as such not a specific political
form of government but rather an overwhelming dominance
and control which the bourgeoisie has over the means and
process of production. Nowhere for the millions of workers
does that dictatorship appear more clearly than at the place
of work. Michael Bosque, in his usual vivid way, puts this
quite clearly when he invites the reader to
Try’putting 13 little pins in 13 little holes 60 times an hour, eight
hours a day. Spot-weld 67 steel plates an hour, then find yourself one
day facing a new assembly-line needing 110 an hour. F.it 100 coils to
100 cars every hour, tighten seven bolts three times a minute. Do your
work in noise ‘at the safety limit’, in a fine mist of oil, solvent and
metal dust. Negotiate for the right to take a piss—or relieve yourself
furtively behind a big press so that you don’t break '.he rhythm and
lose your bonus. Speed up to gain the time to blow your nose or get
a bit of grit out of your eye. Bolt your sandwich sitting in a pool of
grease because the canteen is 10 minutes away and you’ve only got
40 for your lunch-break. As you cross the factory threshold, lose the
freedom of opinion, the freedom of speech, the right to meet and
associate supposedly guaranteed under the constitution. Obey without
arguing, suffer punishment without the rieht of appeal, get the worst
jobs if the manager doesn’t like your face. Try being an assemble-line
worker 18].
But these characteristics of assembly line work are not uni
que to workers in the automobile industry or workers in
manufacturing alone. Many other studies have been done
showing how assembly line work where the individual worker
is carrying out predetermined tasks over which he or she does
not have much control, is also the most frequent type of work
among sales, clerical and large sectors of public service
workers. Indeed, that expansion of the atomised hierarchical
June-Sept 1987
and authoritarian division of labour growing rather than
diminishing in most areas of work in society, and is being
presented as needed to increase the efficiency and produc
tivity of the workers, i e, to extract as much work as possi
ble from the worker. But that demand by representatives of
the capitalist class is not made without misgiving about how
long the working class will tolerate those conditions of work.
As a leading exponent of the establishment put it, “How long
can our political system stand the seventy million who live
the majority of their working hours in an atmosphere which
is totalitarian?”[9]
In the following pages of this article, I will explain how
bourgeois ideology [by ideology, I mean, with Gramsci, the
ethical, juridical, political, esthetical, and philosophical ideas
about social reality as well as the set of customs, practices
and behaviours which consciously or unconsciously reflect
that version of reality] reproduces these dominant/dominated
relations in the sphere of production (Section I); in the area
of politics (Section II); and in the area of science (including
medicine) (Section III). Needless to say, dominance does not
mean complete control [10]. The working class does not re
main passive against that domination. A continuous process
of class struggle takes places where the working class also
wins most significant victories and determines changes in
the boundaries, means and instruments of that dominance
[11]. How this class struggle affects that dominance in the
world of production, of politics, and of science is also
covered in Sections I, II, and III, respectively. In all three
sections, I have chosen medicine and medical knowledge as
the primary points of reference.
I
Work, Market Ideology7, and the Reproduction
of Power Relations
How is class dominance being reproduced? By different
means. For example, the division of labour within the work
ing class, by dividing the labour force into different
categories, erodes a sense of class solidarity. Also, tending
to reproduce those dominant/dominated relations are the
conditions of work, highly hierarchical and authoritarian,
which tend to create a habit of submission and subordina
tion, further accentuated by a fear of unemployment or
dismissal which tends to produce an obedient body of
workers and citizens.
But besides these reasons, there are two others which ex
plain the reproduction of these relations. One, very impotant ideologically, is that this type of work is presented, not
as a result of specific power relations in soceity, but rather
as a logical, rational, and natural outcome of the unavoidable
and unchangeable industrialisation and technologisation of
the work process. Thus, the culprit of workers’ pains is seen
in the unchangeable industrialisation and technology of work
rather than in the social power relations which determine this
specific type of oppressive industrialisation and technology.
Needless to say, the absence in the current historical period
of models of alternative processes of production and work
strengthens the ideology that ours is the only logical, rational
and natural way of organising production. But dominant
19
ideology tries to impress on the worker that those relations
are not only natural but a\so fair. This dominant/dominated
relationship in the world of production appears as a fair ex
change in the labour market in which these exploitative rela
tions are veiled and mystified by making them appear as a
matter of free, unfettered and equal exchange between the
labourer who sells his labour and the capitalist who pays a
wage for it. Needless to say, bourgeois ideology may even
be willing to admit and accept that much work today is op
pressive and does not offer the possibility for self-fulfilment
to the worker. But this same ideology will quickly add that
the worker is compensated with a fair wage and that fair wage
will allow the worker to obtain the key to the door to his
self-fulfillment in the house of consumption. The worker,
denied the possibility for creativity and self-fulfillment in
the world of production, is said to be given that possibility
in the world of consumption. Moreover, while he has no con
trol over the work process, he is being told that he has con
trol over the product of that process where, not as a worker
but as a consumer, he can, through the free expression of
his wants in the market, allocate the resources in that socie
ty. Thus the sovereignty denied to the worker in the world
of production appears as the sovereignty of the consumer
in the world of consumption. In this scenario, the criteria
and discussion of fairness is not over the control of the pro
cess of work but, rather, on the price to pay and compen
sate the worker for his work so that he may reach a sense
of fulfilment, control, and pusuit of happiness in the world
of consumption.
Suffice it to say, it is of paramount importance for the
reproduction of the capitalist system that all struggles at the
point of production be shifted to the area of consumption.
with the focus of the struggle being the cost of labour
personal and social wages—rather than the control of the
process of production. The acceptance of this shift in the
struggle from the world of production to the world of con
sumption by the trade unions and their consequent focus on
the price of labour has been a primary reason for the
reproduction of capitalist relations. As Gramsci indicated
“trade unionism by organising workers not as producers but
as wage earners had accepted and submitted to the rationale
of the capitalist system where workers are merely sellers of
their labour power” [12]. The shift from workers to wage
earners is a key mechanism of reproduction of capitalist rela
tions and responds to the intrinsic need of capitalism to
separate the world of consumption from the world of pro
duction, focusing all areas of conflict on the former and not
on the latter. Capital, in its position within the class strug
gle, clearly perceives the correctness of Marx’s position when
he wrote in the Grundisse that, “. . .the important point to
be emphasised here is that whether production and consump
tion are considered as activities of one or separate in
dividuals, they appear as aspects of one process in which pro
duction forms the starting point and therefore the predomi
nant factor. ..” [13]. A predominant factor whose control
capital cannot allow to be questioned.
A consequence of that bourgeois ideological dominance
and acceptance of the unalterability of the process of work
(and shift of the struggle from the world of productioh to
the area of consumption) has been the acceptance by the
20
unions of damage created at the work place as being
unavoidable, and thus the champ de bataille has been on the
compensation for that damage. Consequently, occupational
medicine, a branch of forensic medicine in its beginnings,
had, as its initial task, to define for management the nature
and size of the damage which needed to be compensated.
Occupational doctors, still called company doctors in many
countries today, had as a primary function, to defend
management interests and obfuscate or veil the actual
damage created at the work place. The struggle was, and still
continues to be, between labour which demanded a higher
compensation, and capital (helped by occupational doctors)
who wanted to minimise that compensation, denying for as
long as they could that there was any relationship between
work, disease, and death. Let me add here that not only oc
cupational physicians directly employed by management, but
many in academe, medical schools and schools of public
health, supported directly and indirectly by grants or funds
from industry or industry financed foundations, contributed
to veil and mystify that relationship between work and
disease [14].
A further consequence of the separation between the
worlds of production and of consumption was that the
damage created at the work place, when and if recognised,
was perceived to be unrelated to the damage produced out
side the work context. Thus, a dichotomy was established
between the branches of medicine responsible for the defini
tion and administration of disease at the work place (occupa
tional medicine) and at the non-work place, in the world of
consumption (medical care). That dichotomy, production/consumption, is till present today and is being reproduc
ed in the structure of health services with different admini
strations responsible for those two separated branches of
medicine.
In summary, that shift erf the struggle around the work
place from (1) control of work to compensation for damage;
and (2) from the world of production to the world of con
sumption, has led to the establishement of occupational
medicine as a separate branch of medicine historically con
trolled by management in charge of defining damage and
compensation. Needless to say, the priorities within the social
system were higher for the medicine of consumption than
for the medicine of production, particularly considering that
a primary function for the latter—the one of policing the
labour force—was achieved under capitalism by other effec
tive means than occupational medicine.
All these struggles on compensation were, for the most
part, carried out under the supervision of the state institu
tions where capital was far more influential than labour,
which leads me to discuss the second area where those domi
nant/dominated relations are being reprodued, i e, in the
realm of the political institutions.
II
Work, Political Ideology and
Reproduction of Power Relations
In the same way that it is of paramount importance for
the reproduction of the dominant/dominated relations at
work to shift all struggles around the control over the pro
Radical Journal of Health
ccss of production to world of consumption, it is equally
important to shift those same struggles from the world of
work to the world of representative politics. Indeed, just as
the worker/subservient relationship is concealed at the
economic level of our society under the ideology of consumer
sovereignty, the worker/subservient situation is concealed at
the political level with the dominated worker being presented
as citizen/sovereign. According to bourgeois ideology, people
decide through the market what they consume and through
the political process what they want. A clear representative
of this position is Eli Ginzberg, Professor in the Business
School at Colombia University, who begins a book entitled
The Limits of Health Reform: The Search for Realism, with
the following sentence. “In our society, it is till the citizens
who, through their voice in the market place and in the
legislature, ultimately determine how their resources will be
allocated” [15]. According to this ideology, workers become
citizens, and as such, have the same rights as the controllers
of their work. The assembly line workers are supposed to
have the same rights as the controllers of their work. The
assembly line workers are supposed to have the same political
and juridical weight, according to legislative discourse, as
the Henry Fords of America. Both categories—bosses and
workers—are abstracted into a new category, the citizens who
decide, with equal weight, the major political decisions. In
the political - juridical realm, they are both equal. But is it
really true that they both have the same power to choose,
decide, and develop different political alternatives? Many
studies have been written showing that the Henry Fords of
America, or of any other Western capitalist country, have
far more power—an overwhelming power to shape the nature
of what is discussed, voted upon and presented in the political
debate—than the assembly line or other type of workers[16].
In order to consider them with equal political power, Ginz
berg and others with him have had to consider them as in
dividual citizens, an abstract category which levels off
everyone independent of their position in the world of pro
duction where goods and services are being produced. But
men and women under capitalism are not equal. That assum
ed equality in the realm of politics is continually shown as
inequality in the realm of production. Under capitalism, the
relations of production allocate men and women into dif
ferent social classes, defined by their differential access to
and possession of the means of production[17]. Agents
within those classes have, indeed, different political and thus
juridical power. The class which owns, controls and possesses
the means of work has a dominant hegemony in the political
- juridical apparatuses of the state and in the ideological cultural apparatus of society[18]. It goes without saying that
the intellectual representatives of that class deny this, dismiss
ing it as a simplification, tolerable for “ideologues” but not
for reasonable people. They present it as a matter of fact
that the political juridical institutions are an outcome of peo
ple’s will who, via the electoral process in representative
democracy, periodically elect those on whom authority is be
ing bestowed. Consequently bourgeois dominance in the ap
paratus of representation is denied by burgeois ideology in
which bourgeois domination is veiled and mystified as
representing the popular sovereignty and the voxpopuli. Ac
June-Sept 1987
cording to this ideology, the workers, regardless of how ex
ploited in the economic arena they may be, are still suppos
ed to be free and equal citizens who, by their will, have
chosen, and continue to choose, a system which reproduces
that system of exploitation. This is the most important
ideological legitimation of the bourgeois rule, i e, people
want it and choose it.
It is worth stressing that in this scheme of things, demo
cracy is not—as Lincoln said—government by the people—
but one occasionally approved by the people. Democracy is
thus defined differently from self-governance. In such a
democracy, governments come and go at the approval of the
people. In this respect, the government is assumed to repre
sent we, the people, and what happens in our societies is what
we, the citizens, want. As Etzione recently indicated in The
Washington Post, “we, in the United States, have decided
that we value production more than risk or damage at the
work place”[19]. And that we is supposed to mean, of course,
the American people who have expressed their political will
through their political institutions. We, the citizens, have
chosen to maximise production rather than safety at work.
It speaks of the overwhelming dominance which the
bourgeois position has in official and academic discourse,
that those authors such as Ginzberg, Etzione and many
others can consider these expressions as merely factual and
absent of ideological meaning. They would strongly deny,
of course, that they are bourgeois ideologists who reproduce
the scheme convenient and favourable to dominance of our
lives by the bourgeoisie. It is easy to predict that the bourgeois
theorists would dismiss as ‘rhetorical’ the interpretation that
it is not we, the American people, but the capitalist class
which primarily—although not exclusively—dominates the
state functions; and that it is not we, but the controllers of
work, who decide on the nature of production and consump
tion in society. They would, indeed, dismiss that as Marxist
“rhetoric”. But they do not realize, or want to realize, that
theirs is also a rhetoric and one which reproduces a pattern
ot class power relations where the minority and not the
majority makes the major decisions. In summary, each
ideological position has its own discourse dismissed as
‘rhetoric’ by its adversary. The untenability and incredibili
ty of bourgeois rhetoric which assumes that we, the American
people, decide on major issues in society, is increasingly clear
for all to see. The majority of American citizens who belong
to the working class and lower middle class know reality far
better than the bourgeois theorists. In many polls, they have
expressed their belief that the two major parties are controll
ed by corporate America and that the government institu
tions work principally for the benefit of Big Business—that
folksy term used to refer to the capitalist class[20].
In summary, then the dominant/dominated relations at
the work place are being reproduced by shifting struggles
from the world of production to the world of representative
politics where the bourgeoisie is the dominant force. It is of
paramount importance for the bourgeois order that a clear
separation be established between the economic class strug
gle confined within trade union battles (primarily concern
ed with the price of labour and compensation of work and
damage), and the political struggle carried out primarily by
COMMUNITY HEALi
47/1. (First Floor; St.'w^
Banwalore . 560 001.
the political parties in the realm of representative democracy’.
As many points in history, from the General Strike in Britain
in 1926 to the May events of France in 1968, show quite clear
ly, the shift of the place and focus of struggles from the place
of work to the arena of representative politics has had a most
important effect in diluting threats to the bourgeois order.
But why this dilution—this weakening of that threat when
the area of struggle shifts from the floor of the factory to
the parliament? One reason is that representative democracy
converts the process of participation from active to passive,
delegating popular power to elected and/or selected represen
tatives. These representatives, however well they may repre
sent the interests of the working class and popular masses,
have to conform to a set of rules and operate within a set
of state institutions where the bourgeois is, by definition,
dominant—a bourgeois dominance which gives its character
to those institutions, including the institutions of represen
tation and mediation[21]. Thus, it has always been in the in
terests of the bourgeoisie to demobilise the mass struggles
occurring in the places of production by shifting those strug
gles to the parliament or its equivalent.
The previous paragraphs should not be understood as shy
ing away from or slowing down the struggles which need to
be carried out within the state and organs of representative
democracy'. The class struggle carried out within the ap
paratuses of the state can lead to substantial victories for
the working class. The National Health Service in the United
Kingdom, for example, was, no doubt, a remarkable achieve
ment for the British working class. But it would be wrong
to consider the NHS as a socialist apparatus within a
bourgeois state [22], I have shown elsewhere how the NHS
is under the hegemony of the bourgeoisie, a hegemony which
appears in the ideology, composition and distribution of
medicine ip the UK [23]. Similarly, the occupational health
legislation which has appeared in the United States from the
late sixties and early seventies has to be seen also as a great
achievement for the US labour movement. But the fact that
these achievements have occurred within a state that is under
bourgeois dominance explains the limitations and the nature
of that progressive legislation. The consequences of
bourgeois dominance are many. One is that programmes
established by legislative mandates tend—in the absence of
continuous pressure from the working class—to be
manipulated by the components and strata of the bourgeoisie
which ara affected by that legislation. Lobbies of those
groups are “always there, close to the corridors of power’*
to limit and change the progressive impact and nature of
those programmes. But, more importantly, those program
mes have to operate within parameters which are defined by
the overall power relations in that society and which cannot
be touched upon by those programmes. For example, great
stress is made by all governments that occupational health
programmes cannot interfere with the overall pattern of
capital accumulation. Capital formation and the subsequent
class power relations which it sustains cannot be affected by
that type of legislation. And when it is, enormous pressures
are brought to bear on governments to assure that that situa
tion be reversed.
Last but certainly not least, another consequence of
22
bourgeois dominance in the apparatuses of the state, in
cluding those progressive programmes, is that the implemen
tation of those programmes is carried out within the
ideological framework convenient to the reproduction of the
bourgeois order. For example, the prevalent approach of state
regulatory agencies in occupational medicine is to protect
the worker against an environment! agent such as the toxic
substance which can harm the worker. Consequently, a strug
gle takes place around the allowable exposure of the worker
to that toxic substance [24]. This struggle is a very impor
tant and needed one. But it is still carried out within that
ideological dichotomy of worker versus environment which
assumes and independence and autonomy where the worker
is on one side of the working scene and the environment is
on the other. The dichotomy of patient or potential patient
versus environment characterises, as I will discuss later on,
the conception of risk and disease in bourgeois science. In
the s£me degree that the bacteria was perceived to be the ex
ternal cause of disease, the toxic substance is now perceived
to be the cause of that disease. In either case, however, such
a dichotomy is a faulty one. The social power relations which
determine the environment of exposures also determines the
nature of the work process and of the agents of that pro
cess, i e, the workers. The social power relations which deter
mine the working environment also determine how the
worker fits within that environment, relates to that environ
ment, and perceives himself or herself in relation to fellow
workers and to the controllers and managers of that environ
ment. In other words, by focusing only on a specific item
of that environment (the toxic substance) and by not touching
on the power relations which shape both the environment
and the worker, the bourgeois order is reproduced.
HI
Bourgeois Dominance, Ideology
and Knowledge in Medicine
In previous sections, I have discussed how bourgeois
dominance appears in the world of production and in the
political-juridical level of society, and how that dominance
has many implications in medicine as well. In this section,
I will focus on how that class dominance appears also in the
production of knowledge in medicine. Many studies have
been written showing how bourgeois dominance of our
research institutions including medical research institutions
has determined a set of priorities that, while presented as
apolitical, are, in fact, clear political statements which reflect
the class dominance of those institutions. Elsewhere, I have
discussed how that overwhelming class dominance of our
research institutions explains, for example, why most of
cancer research in Western capitalist countries has focused
on biological and individual behaviour, but not on other fac
tors such as carcinogens that exist in people’s work places
which could be threatening to the sections of the bourgeoisie
that have a major influence in the funding institutions for
cancer research [25].
It would be erroneous, however, to believe that those cancer
research priorities are merely a result of the influence of
Radical Journal of Health
powerful interest groups in the top corridors of power in fun
ding agencies. There is more to it than that. These groups
belong to a class—the bourgeoisie—which has an ideology
or vision of reality with an internal logic and consistency
which, in turn, leads to the support of some positions, con
clusions, and priorities and to the exclusion of others. This
bourgeois ideology is the dominant one under capitalism.
That it is dominant, however, does not mean that that
bourgeois ideology is the only ideology. In this regard, it has
to be stressed that each social class had its own vision of
reality and ideology. In other words, there is not under
capitalism, just a single ideology which is upheld by all
classes, races, and sexes. I stress this, because on both sides
of the ideological spectrum, there are ideological currents
which postulate that there is in any society just one
ideology—the dominant or ruling ideology—which has
resulted from that society’s choice, wills and wants (as the
bourgeois theorists believe), or from an overwhelming
dominance, tantamount to control, which the bourgeoisie
has in that society [26]. Agreeing with Marx, I believe that
classes have different ideologies which also appear in dif
ferent forms of culture.
Upon the different forms of property, upon the social conditions
of existence, rises an entire superstructure of distinct and peculiarly
formed sentiments, illusions, modes of thought and views of life. The
entire class creates and forms them through tradition and upbring
ing [27].
But one of them, the ideology of the dominant class is the
dominant ideology. As Marx and Engels indicated
. .the ideas of the riding class are in every epoch the ruling ideas,
i e, the class which is the ruling material force of society, is at the
same time its ruling intellectual force 1281.
But this ‘ruling’ does not imply that the working class
ideology is either non-existent or absorbed in the bourgeois
one. Nor does it imply that a clear-cut division exists bet
ween the two ideologies with a well delineated boundary bet
ween them. Class struggle is continuously taking place with
victories and defeats which influence both ideologies. For
example, I have already indicated in previous pages how
bourgeois values appear in the working class. An example
is when the working class accepts the belief that the nature
of work is determined by industrialisation. And vice versa,
the rhetorical (although not actual) acceptance by the
bourgeoisie of democracy as a part of dominant ideology
was forced by the working class on the bourgeoisie, when
the latter social class needed an alliance with the former in
its struggle against the aristocracy, then hindering the rise
to power of the bourgeoisie [29]. In other words, democracy
was not a set of values and practices spontaneously created
by the bourgeoisie, but, rather, an ideology forced on the
bourgeois ideology by the working class. The bourgeoisie has
always fought by all means the expansion of democracy, in
cluding the expansion of universal suffrage, freedom of
association, freedom of the press and many other freedoms
which the working class has had to win with great sacrifice
and not without heroic struggle.
In summary, there is, under capitalism, a' dominant
ideology which appears in all institutions including the in
stitutions of science and medicine.
June-Sept 1987
Class dominance in scientific medicine
How does the bourgeois vision of reality appear in science
and medicine? In many ways. Let us outline some of them.
Dichotomy of Science versus Ideology
An extremely important view within bourgeois ideology
is that there is a clear-cut dichotomy between science and
ideology. Actually, science was the creation of the nascent
bourgeoisie and was contraposed to religion (seen as the
ideological expression of aristocratic dominance) which it
was considered to transcend and supersede. Science was sup
posed to be a new global vision of reality which would ra
tionalise and legitimise the new bourgeois social system.
Galileo, one of the founders of the scientific revolution—
and who, incidentally, was working as an advisor to coal
owners on how to increase the rate of exploitation of coal
miners [30]—established the basis for the creation of new
knowledge based on what was called objective observation
and not on theology. And that dichotomy, objectivity ver
sus subjectivity, science versus ideology, has lasted
throughout the history of science. Science was thus perceiv
ed as a body of neutral and value free knowledge built in
a painstaking and. linear process in which each new scien
tific dscovery was built upon a previous one. Science and
technology'became part of the forces of production and as
such, their development was considered to be intrinsically
positive. According to bourgeois ideology, science and
technology’(and the process of industrialisation which they
determine) were forces of progress, determining, almost in
a fatalistic way, the nature and shape of society. The most
recent versions of those positions are the ones taken by Daniel
Bell [31] and others, who indicate that power has shifted from
the owners of the means of production to the managers of
the process of that production and, more recently, to the
producers—the scientists—of what is perceived as the most
important ingredient of production, i e, science and
technology.
It is worth stressing here that the bourgeois interpretation
of the value free character of science has also appeared within
the labour movement, particularly since Stalin [32]. As
Sweezy and Bettelheim [33] as well as Lecourt [34] have elo
quently indicated, the forces of production, including science
and technology, under Stalinism were perceived as neutral.
Their development was perceived to be a primary condition
for the achievement of a change in the relations of produc
tion at a later stage. That change in the relations of production
was perceived as needed, because they were retarding and
hindering the full development of the forces of nroduction.
[Social relations of production are the relations which exist
in a given process of production between the owners of the
means of production and the producers, a relation which
depends on the type of ownership, possession, capacity for
allocating and designing those means of production and the
use of the products of that process of production. Forces
of production are the forces, instruments, labour and
knowledge which are organised to produce goods and ser
vices in any society. How the forces of production are
organised, designed and related among themselves is deter
23
mined by the social relations of production.] In this
dichotomy—forces versus relations of production—the forces
of production were primarily understood as the instruments
of production, and their development was considered to be
the primary motor of history. The point that has to be stres
sed here, and Lecourt ignores it, is that instrumentalist
understanding of forces of production already appeared in
Lenin. Il was Lenin who believed that the Western forces of
production (including Taylorism) should be imported and
put to proper and better use by the Soviet revolution. Lenin
was an enthusiast of Taylorism. As Claudin-Urondo has indi
cated, Lenin conceived science and technology as neutral en
tities, rather like tools, the function of which can be chang
ed depending on the use being made of them [35]. It should
be pointed out that immediately after the October Revolu
tion, a massive democratisation in scientific institutions, such
as in the medical ones, took place with changes in the pat
tern of class control of medical schools and other scientific
institutions and with changes in the class origins of the
medical profession and other scientists. These changes had
quite an impact in redefining the nature of those institutions,
and in redefining the process of creating scientific knowledge.
That democratisation had a very significant impact in
redefining the nature of both scientific institutions and
science itself.
The priorities within medicine, for example, changed quite
substantially, and initial changes in the understanding of
medical knowledge started taking place. This process of demo
cratisation, however, was strongly reversed later on, in parti
cular under the Stalin regime. Class control of scientific insti
tutions and class origin of the scientists were reversed most
dramatically under Stalin, giving strong political weight to
the experts (scientists and technocrats) who became the con
trollers and administrators of scientific knowledge, closely
supervised by the party apparatus. In this scheme of things,
the development of the USSR meant primarily the fantastic
growth of the forces of production (including science and
technology) and the better redistribution of the product of
that process. But it did not change the process of production
and work nor those forces of production. The nature of
science and technology (and, as I have shown elsewhere,
medicine) did not change under Stalinism [37].
Foces of production are not neutral, however. They carry
with them the social relations of production which determine
them. In other words, a factory or a hospital is not a neutral
institution. It is a hearer of power relations which determine
how work in the institution is done, by whom, and with what
type of instruments. How the work process takes place in
these and other institutions in society is determined by the.
power relations existent in that society. It is not the process
and forces of production which determine the social division
of labour (as the theorists of industrialism postulate), but,
rather, it is the social division of labour, its concomitant
power relations and the ideological relations which those
power relations carry, which determine the forces of produc
tion including science and technology. The power relations
in society appear also within scientific knowledge, and the
bourgeois ideological dominance appears and is being repro
duced in the production of knowledge itself. The dominant
24
ideology reproduces itself in scientific knowledge. And this
reproduction takes place, not only by selecting the subjects
of inquiry, but also by choosing the method of inquiry, and
the relations which the researcher or inquirer has within the
overall process of production. Needless to say, this position—
that bourgeois ideology reproduces itself in science and thus
science is value loaded and not value free—is continuously
denied by scientists and other bourgeois theoreticians.
Science appears as the epitome of objectivity. And all series
of ideologies rush to be called sciences to gain legitimacy
and credibility in bourgeois society. Not only natural sciences,
but a long list of ideological positions appear with the sanction
of sciences, e g, business sciences, management sciences,
social sciences, political sciences, economic sciences. Sciences
become the newly accepted vision of reality which would
enable the citizenry to cope with the world in a better fashion.
All types of ideologies are thus made compulsory subjects
in our scholarly institutions, from schools to academe, pro
vided they are presented as sciences (i e, “value free and
neutral’’). In this way, while the parents of a ten-year old
child would strongly object to having him/her subjected to
compulsory classes of a certain religion or certain ideology,
they would not object, or would not be given the right to
object, if that subject were, or is, presented as a science, e
g, economic science. Science becomes that magic word which
allows the transformation of value loaded knowledge into
a value free one. Thus, the dichotomy of science/ideology
constitutes a most powerful ideology for the reproduction
of bourgeois relations.
Division Between Experts and Laymen
Once this dichotomy of science/ideology is established, then
we have to ask what is science? And the bourgeois response is
that science is an objectivejbody of value free, classless and
universal knowledge, based on testable observations of reality.
As such, the production and reproduction of scientific
knowledge takes place place in scientific institutions by indi
viduals who—in the overall social division of labour—have
been assigned the task of producing and reproducing that
knowledge, i e, the scientists. Science then becomes what
scientists—a small group of individuals in society—do. And
scientific medicine is what medical scientists and practitioners
do. Needless to say, all systematic knowledge which is pro
duced outside those institutions, and by individuals other
than scientists, is not considered science. According to this
criteria, the documents produced by research groups in occu
pational medicine that concluded in the thirties, forties, fifties
and even sixties in the United Slates that there was not a
relationship between black lung and coal mining were sup
posed to be “scientific documents and conclusions” and thus
trustworthy. On the other hand, the knowledge accumulated
by generations of coal miners—knowledge which appeared
in their culture as folk songs, popular writings, etc—that the
work in coal mines was destroying coal miners’ lungs was
dismissed as cultural, folksy, ideological and in summary un
trustworthy. Thus, knowledge is legitimised only and exclu
sively when it comes from the scientists. This dichotomy of
science/ideology then appears operationally as the dichotomy
of expert/non-expert in which the control of the definition
Radical Journal of Health
of science and expertise is delegated by the dominant bour
geoisie to another class, the petit bourgeoisie or professionals
who carry on that task, namely, the production of knowledge
under the hegemony of bourgeois ideology.
This last point of delegation raises the question of the
autonomy of science. Can science become autonomous from
the dominant ideology? My answer is yes and no [37]. Yes,
in the limited sense that once established, it has an internal
logic of its own, i e, the logic of that discipline or branch
of science. No, in the major sense that scientific knowledge
is continuously growing under the dominance of bourgeois
ideology. In other words, scientific knowledge and scientific
situations are under bourgeois dominance, and that reality
shapes the nature of that knowledge. For example, and as
1 will explain in the next section, bourgeois dominance in
medicine established a vision and an understanding of disease
in which that disease was seen as the lack of equilibrium
within the different parts—organs and humors—of the body.
This specific understanding of disease generated a medical
knowledge which developed autonomously. But the division
of labour within medicine—specialisation—developed
according to the bourgeois understanding of disease. Con
sequently, this internal logic of scientific medicine led to the
creation of specialities which follow organistic bases: cardio
logists, nephrologists, etc. Thus, medical knowledge
developed according to its internal logic given by that
bourgeois conception of disease. In other worlds, bourgeois
dominance always determines in the ultimate instance what
occurs in the realm of scientific knowledge\3%\.
How Bourgeois Ideology Appears
in Medical Knowledge
In the previous section, I indicated how the bourgeoisie’s
definition of science—knowledge produced by an elite, the
scientists—appears and is reproduced in our society. In this
section, I will discuss how that bourgeois ideological
dominance over science appears in the production of
knowledge. But, first, let us clarify what we mean by pro
duction of knowledge. It is the process whereby a percep
tion of reality is transformed into a specific product, i e,
knowledge, a transformation which in science takes place by
intellectuals whose primary instruments of work are the
theories and methods of science. Scientific theories in each
science consist of a group of concepts which belong to that
specific branch of science (e g, the law of gravity in physics).
Scientific method is the way in which those concepts are used.
Both theory, and method allow that intellectual—the
scientist—to transform this perception into knowledge [39].
Needless to say, this knowledge is being reproduced, not in
abstract but in specific institutions, subjected to class
hegemony and by scientists whose very specific visions of
reality are moulded by the ideology of the dominant class
(the bourgeoisie); their own social class (the petit
bourgeoisie); their race; their sex; their discipline; their
political position, among others. The scientist does not leave
all those ideologies outside the walls of the scientific institu
tions. The scientists carry those visions of reality in the pro
duction of knowledge as well. That production is submerged
June-Sept 1987
into and is part and parcel of those ideologies, of which the
most important one is the ideology of the dominant class
or bourgeoisie.
How does this bourgeois dominant ideology appear in
medicine? By the submersion of that medical knowledge into
the positivist and mechanistic ideology which typifies science
created under the hegemony of the bourgeoisie, and which
I would call bourgeois science. Actually, positivism and
mechanism appeared as the main ideologies of the
bourgeoisc in the nineteenth and twentieth centuries in
Europe with the works of Hume. Comte, and, later on,
Durkheim. According to positivism, science must focus on
specifics to build up the general, looking at social phenomena
as if those phenomena were natural, ruled by natural and
thus harmonious rules. As Durkheim indicated, positivism
reduces social phenomena to natural phenomena [40]. And
within that interpretation, causality was supposed to be ex
plained by association of immediately observable
phenomena.
Positivism appears in medicine in its definition of disease
as a biological phenomenon caused by one or several factors
which are always associated and observed in the existence
of that disease. For example, in one of the most widely used
textbooks on epidemiology in the Western world, MacMahon
describes epidemiology—the science of studying the distribu
tion of health and disease—as an extension of demography,
and he defines that distribution according to age, sex, race,
geography, etc, giving major importance to those individual
characteristics which are either biological or physical.
Moreover, in explaining causality, MacMahon quotes Hume
and indicates that causality can only be seen but not ex
plained, since we can only focus on the degree of associa
tions between several subsequent events [41].
A legitimate question at this point is to ask how that
positivist conception of medicine came about. To answer that
question, we have to go to the origins of scientific medicine
as we understand it today. And these origins appeared
primarily in the nineteenth and twentieth centuries during
the same time that science appeared as a recognised and
legitimised area of endeavour. Those were times of large
social upheavals and unrest in Europe. Capitalism was be
ing established, changing from a mercantile system to an in
dustrial one. Those changes had an overwhelming impor
tance in defining the nature of medicine as well as that of
health and disease. One version advanced by the working
class and by the revolutionary elements of the bourgeoisie,
such as Virchow, saw disease as a result of the oppressive
nature of existent power relations of society, and thus saw
the intervention in smashing (the revolutionary) or modify
ing (the reformist) those power relations. Epitomised by the
dictum that medicine is a social science and politics is
medicine in a large scale (Virchow), its best representative
was Engels whose work on the conditions of the working
class in England was a dramatic document showing the
political nature of the definition and distribution of disease.
His solution was written, with Marx, in the Communist
Manifesto, with his call for revolutionary change, where the
first steps included the actual democratisation of political,
economical, and ideological spheres in society. This version
25
of medicine, however, did not prevail. The bourgeoisie, once
it won its hegemony, supported another version of medicine
that would not threaten the power relations in which it was
dominant. The bourgeois social order was considered from
then on as the natural order where its class rules would be
veiled and presented as rules of nature. Accordingly, disease
was not an outcome of specific power relations but rather
a biological individual phenomenon where the cause of
disease was the immediately observable factor, i e, the
bacteria. In this redefintion, clinical medicine became the
branch of scientific medicine to study the biologicalindividual phenomena and social medicine became that other
branch of medicine which would study the distribution of
disease as the aggregate of individual phenomena. Both bran
ches shared the vision of disease as an alteration, a
pathological change in the human body (perceived as a
machine) caused by an outside agent (unicausality) or several
agents (multicausality). This mechanistic vision of health and
disease is still the prevalent and dominant interpretation of
medicine. Witness a recent deifinition of health and disease
in Dorland’s Medical Dictionary in which health is defined
as “a normal condition of body and mind, i e, with all the
parts functioning normally”; and disease is defined as “a
definite morbid process having a characteristic strain of
symptoms—it may affect the whole body or any of its parts,
and its etiology, pathology, and prognosis may be known or
unknown” [42]. .From this mechanistic understanding of
health and disease, it follows that the division of labour
(specialisation) in medical knowledge and practice has evol
ved around component parts of that body machine, i e,
cardiology, neurology, etc.
A related point is that the mechanistic interpretation of
medicine was built upon knowledge which had been
generated previously (blood circulation by Harvey in 1628;
microscope by Van Leeuwencheck in 1683, and others). But
it would be erroneous to consider scientific medicine as a
mere linear evolution starting with those previous discoveries.
These discoveries did not lead to or create scientific medicine.
Rather, it was the victory of the industrial bourgeoisie which
established that positivist conception of science and of
medicine. The fact that those previous discoveries were used
and presented as the originators of scientific medicine was
due to the change in the correlations of forces and subsequent
victory of the bourgeoisie as the dominant class under in
dustrial capitalism. In this respect, scientific medicine was
not the linear growth of previous knowledge. Rather, and
to use a Kuhnian term [43], a shift of paradigm took place,
establishing a new paradigm which carried a new, a positivist,
vision of disease which added to what had already been built.
This point has to be repeated, because it is part of the
bourgeois understanding of scientific knowledge that this
knowledge evolves linearly with “new” discoveries based on
previous ones, as if these discoveries were the bricks on which
the scientific building was constructed [44]. According to this
understanding, science and technology grow and determine
the nature of power relations in our societies; and the history
of humanity becomes divided into stages determined by the
discovery of new technologies which shape the nature of that
historical stage, e g, industrial revolution, nuclear age, etc.
26
Science and technology thus appear as the “motor” of
history. But, as Braverman [45] among others, has shown,
the so-called “technological breakthroughs” were not the
ones which established new social orders—rather, the reverse
was the case, i e, a new correlation of forces used those
already known technological breakthroughs which were, later
on, presented as the actual cause of that change in the socia’
order. But those breakthroughs or scientific and techno
logical discoveries were used and put forward by new cor
relations of forces. The victory and subsequent hegemony
of the bourgeosie, for example, was the one which stimulated
science, including scientific medicine. It was this political
reality which determined the advancement of the positivist
and mechanistic conception of medicine, health, and disease.
In other words, the power relations which existed under the
bourgeois order were the ones which determined the form
ano nature of medicine. It lea to a scientific inquiry where
the aim of that inquiry was the discovery of the cause or
micro-organism, and the instrument of that inquiry was the
microscope. By focusing on the microcausality of disease,
however, science ignored the analysis of the macrocausality,
i e, the power relations in that society. Scientific inquiry in
medicine developed into a search for the cause: bacteria,
parasite, virus or, later on, the toxic substance. Consequently,
the strategy of intervention was the eradication of what was
supposed to be the cause of disease. Needless to say, that
interpretation of disease and of medical intervention was sup
posed to be presented and perceived only and exclusively as
scientific and certainly not political. The dichotomy of
science vs ideology was made quite clear and explicit. The
alternative explanation, i e, the assumed “cause” was a mere
intervening factor and the actual cause of disease resided in
the power relations of that society, was dismissed as political,
anti-scientific and in some circles perceived also as needing
“eradication”. In a report of The Rockefeller Foundation on
Health in Latin America, it was stressed that there was a great
need “to eradicate disease in vast areas of rural South
America, otherwise the virus of the tropics will soon attack
the metropolis, a virus that can be biological or, even woite,
political”^]. A clear call for scientific eradication of undersirable ideological explanations! The limitations of this
strategy of eradication based on the unicausal interpretation
of disease led to the later strategy of control instead of
eradication. But, most importantly, that unicausal explana
tion was, and is, increasingly abandoned by the multicausal
explanation of disease. Disease was later on supposed to be
determined by several causes, some of which included socio
economic causes. But these socio-economic variables were
added to other causes as if they were independent variables,
independent of each other. Social class thus appears as one
more variable which may be indirectly associated with the
direct and most important explanatory variables. But this
limitation of the concept of causality to the immediately
observable association between disease (e g, cancer) and other
specific events such as smoking, occupation and others is
intrinsically limited since it leaves the key question un
explained, i e, how those different events are related. As a
recent report on cancer research published by the United
States government indicates, “a maior defect in most canr^
Radical Journal of Health
research in the Western world (and I would add other worlds
as well) is that most cancer research has been based on
looking for<a single or multiple cause, ignoring the inter
relations among those assumed causes”[47]. What this
report touches on is that the primary cause for our ignorance
of the causality of cancer has been a limited understanding
of causality, a limitation that comes from the positivist
understanding of knowledge which I have indicated. By
focusing on statistical association? positivists are touching
on the appearance but not on the reality of the phenomena.
In other words, what are presented as “causes” are not the
actual causes [48]. The epistemological problem thus created
cannot be solved either by indicating that those assumed
causes are intermediate causes, part of a network of
causalities whose linkage among, the knots (intermediate
variables) can be measured by statistical associations. The
actual way of studying disease in any society is by analysing
its historical presence within the political, economic, and
ideological power relations in that specific social formation.
And by this, 1 do not mean the analysis of the natural history
of disease but rather the political, economic, and ideological
determinants of that disease, determinants resulting from the
overall power relations which are primarily based on the
social relations of production. These power relations are the
ones which determine the nature and definition of disease,
medical knowledge, and medical practice. The understanding
of the evolution and causality of black lung in the United
States, for example, cannot come from an analysis of the
natural history of black lung. It has to come from an
understanding of the class power relations in the United
States and how the class struggle shaped both the scientific
definition, recognition, and knowledge of black lung in the
United States and the actual production and distribution of
that disease.
What I have said so far should not lead, however, to the
opposite conclusion that the inquiry should be limited to the
discovery of associations between specific power relations
and disease. In other words, it is not enough to establish an
association between specific forms of capital accumulation
or, say, economic cycles and certain diseases. It is not enough
to say that capitalism, for example, determines a certain
disease profile. It is necessary to research how those power
relations appear, how they are being reproduced, and how
they determine the nature of death and disease in society.
The different categories of analysis such as world of pro
duction, consumption, and legitimation need to be
understood in detail and related to the specific mediating
mechanisms that those sets of relations have with the ap
parent “causes” of disease. In other words, what is needed
is not th£ incorporation of the social as mere additions to
‘environmental’ variables which act on the individual; but,
rather, what is need is an understanding of how diseases
mediate social relations, i e, how the social power relations
determine both the social and physical environment and the
individual’s experiences within that environment, including
disease. Actually, there is an urgent need to break with that
new dichotomy of iudividual/environment which.is as false
as the old dichotomy of mind/body.
Consequently, the terms of the discourse have to be chan
June-Sept 1987
ged. Instead of using the dichotomy, individual/environment,
we should analyse how social power relations determine
disease. Taking black lung as an example, we have to under
stand how the social power relations defined and determined
the working and living conditions of the coal miners; how
the workers struggled against them: and how. in that con
text medical knowledge and medical practice came into being
to obfuscate or clarify the nature of the damage inflicted
on the coal miners. Needless to say, in the process of this
struggle, individuals and classes have different knowledge,
perception, and ideologies regarding their own experiences,
which leads me to the last point I want to stress, namely,
the existence of bourgeois science and working class science.
Bourgeois Science or Working Class Science: Utopia or
Reality?
Knowledge is accumulated, stored, produced, and
reproduced in the daily practice of people’s lives. And the
nature of that knowledge varies considerably, depending on
the social class practices. Each social class has its own prac
tice which appears in its own ideology and culture, i e. a
vision of reality; and vice versa, that ideology and culture
also appear as class practices. Thus, there is a bourgeois
ideology, culture, and knowledge given and reflected in
bourgeois practice. And there is a bourgeois knowledge and
a working class knowledge. Both classes have different prac
tices which generate different types of knowledge. The
knowledge (legitimised under the name of science) produced
by the bourgeoisie and reproduced in scientific institutions,
which denied, for example, that there was any relationship
between work and cancer, was bourgeois knowledge aimed
at reproducing bourgeois power and practices. The know
ledge (perceived in scientific discourse as ‘hot air’, ‘folklore’,
or populist culture) produced by the working class and
reproduced in its cultural forms, affirming that work was
killing them, was, and is, working class knowledge based on
experience. From this, I conclude that there can be two types
of sciences: a bourgeois science and a working class science,
each one based on different sets of knowledge and practice.
To deny the above dichotomy is to assume a classless nature
of knowledge, and thus a knowledge absent of practice. These
two different and even conflicting visions of reality, the
bourgeois and the working class visions, are not separated
by clear-cut boundaries without one influencing the other.
Through the process of class struggle, the working class
develops and imposes its own vision of reality on bourgeois
science: witness current interest in researching the relation
ship between work and cancer. This new development is due
to a large degree to working class and the general popula
tion’s outcry on the damage being created at the work place
But, still, the hegemony which the bourgeoisie has in all
scientific institutions explains the nature and bias of that
response, a bias reflected both in the choice of areas to be
researched and the means and ways of researching it. The
scientist does his/her job in institutions with the bourgeoisie.
In this respect, the scientist is, to use a Gramscian term, an
organic intellectual of the bourgeoisie who explains the
reality with and for the bourgeoisie. This relationship of
scientist/bourgeoisie is overwhelmingly clear in the United
27
States where most research is sponsored either by private
foundations or by the state where capital’s representatives
are extremely powerful and influential.
The alternative, the socialist alternative, would be to carry
on scientific inquiry with the working class, analysing reality
based on the extremely powerful knowledge given by the daily
practice of the working class, and under the direction of the
working class.
In this I see a great area of struggle: to democratise the
institutions and to change the patterns of accountability of
intellectual workers: and to work together with manual
workers until eventually that dichotomy of intellectual/
manual will be questioned and diluted. No doubt, this change
of accountability requires a tough struggle: the one of
democratising our institutions. In this respect, it was a great
victory for the Italian working class when it won the right
to control occupational health services at the factory level
and also when it won the right to undertake research
at the factory with the researchers chosen by the workers.
This is a clear example of how the struggle for democracy
and for knowledge are one and the same.
Let me finish by saying that I am aware that many
eyebrows will be raised when reading this section of my
article. The nightmare of the Stalinist distinction between
bourgeois science and proletarian science will undoubtedly
be remembered. And the case of Lysenko will be immediately
raised as a warning agains' those dichotomies. My answer
to that legitimate concern is that the Stalinist version of pro
letarian science was not the science developed by the working
class (which was not in power), but rather the version given
by the Stalinist leadership of the party which identified pro
letarian science with dialectical materialism as defined and
controlled by them. The fact that the agency of control was
mislabelled proletarian science did not make that science pro
letarian, nor does it make the whole concept of class bound
knowledge meaningless. That is the mistake of Lecourt [49].
It throws the baby out with the bathwater. There is pro
letarian knowledge and mass knowledge which will fully
appear and will flourish unhindered when there will be mass
democratisation in the process of the creation of knowledge
with the deprofessionalisation of science, changing not only
the class composition of scientists but, most importantly, the
method and creation of knowledge, knowledge created not
by the few—the scientists—but by the many—the working
class and popular masses. As Gramsci once indicated, while
all human beings are capable of being intellectuals, only a
few are assigned that task. Similarly, while all human beings
are capable of creating knowledge, only a few are given that
task. Mass democratisation would imply a redefinition and
redirection of that process of the creation of knowledge. This
process would not mean, of course, the absence of a divi
sion of labour. But it would mean a change in the power
relations in the creation of knowledge with a dramatic ex
pansion of the capability of creation of knowledge, with the
working class and popular masses being the agents and not
the objects of that knowledge.
In other words, science is a social relation and, as such,
the key operational issue is not only for what class that
knowledge is being produced (the uses of science) but, most
28
importantly, by what class and its related question, with what
class (the class character of sciences) that knowledge is be
ing produced. The failure to understand the importance Of
these points explains the overabundance of references in
which authors continue to search for the perfect socialist
scientific method that would enable them to find the socialist
truth. That search is not only a theoretical but a practical
task as well. And it requires a political and professional com
mitment to the working class. In other words, it requires to
break with the role to which the scientist is assigned under
bourgeois order and to ally himsclf/herself with the working
class, not to lead that class but to assist it in its potential
for human liberation and creation of knowledge. Let me try
to be very specific and advance an example of the proposed
relationship with which I have experience, namely, two dif
ferent ways and approaches to find reality at the work place.
One would be the bourgeois or positivist approach to find
the nature of a specific health problem (e g, toxic exposures)
in a factory and a way of solving it. The ‘expert’ (epidemio
logist or any other social scientist) usually called by manage
ment would (1) establish a hypothesis de travaille based on
his previous knowledge of that problem. Needless to say, it
is part of the scientific ideology that he should be “objec
tive” and unemotional about the issue under study. His only
aim is to find the truth. As such, he would have a “healthy
skepticism” about any subjective statements or situations,
relying more comfortably on facts, and verymuch in parti
cular on quantifiable facts: (2) try to obtain as much infor
mation as possible from each individual worker in order to
ascertain the facts. Through questionnaires, interviews,
medical records, etc, he would try to obtain from each worker
as much ‘objective’ and quantifiable information as he could
get and find relevant. He would also try to locate the collec
tive dimensions of the problems by adding up the individual
problems; (3) last but not least, he would try to test the
hypothesis by statistical manipulation of quantifiable
(objective) information.
He would finally submit a report to management’s imple
mentation. In that modus operandi of research, workers
appear as passive subjects of research remaining in the
background and not in the forefront in the analysis and solu
tion of the problem. This method of inquiry and data gather
ing is the most frequent tool used in social science research.
The citizens, workers, blacks, women, etc, are studied indi
vidually, providing information through key instruments of
inquiry', questionnaires or interviews. In all these approaches,
three ideological positions—presented as scientific conditions
—are that (1) theory and fact are two separate entities of
which the former is supposed to be built upon the analysis
of the latter; (2) the expert, the holder of proper methods
of inquiry, is the active agent while the studied object the
worker or citizen is a passive one, i e, the mere provider of
information; and (3) collective information is the aggregate
of individual information. The process and findings of this
scientific inquiry are, of course, presented as objective and
value-free (universal and classless) [50].
It is not surprising that in the late sixties, when many anti
authoritarian movements appeared in the Western capitalist
world, many of those analysed passive objects—workers,
Radical Journal of Health
blacks, women—rebelled against that science and against
those scientists. At thaHime, alternative relations of produc
tion of knowledge were established. In many Italian and
Spanish factories, for example, workers committees and
assemblies were established which rebelled against the type
of science that was carried out in those factories. From then
on, they did not allow any scientists to come inside the fac
tory and ask them questions [51]. Instead, they developed
another approach in which the process of inquiry was carried
out under their direction. Consequently, a new production of
knowledge took place in which (1) all information regarding
the specific health problem was (and is) produced and discus
sed collectively with the correct understanding that a collective
problematic is far more than the mere aggregate of individual
problematics. Moreover, workers assemblies have a collective
memory and experience that puis their perspective. They know
what is going on and what has been going on in that factory
process and environment for a long time. And they have first
hand experience with what that problem has meant in their
collective and individual health and well-being. Out of their
collective discussion, they develop a hypothesis of what is
happening in the factory regarding the specific health pro
blem. In that process of generating and collecting data, sub
jective feelings, anxieties and uneasiness are the propelling
forces which guide all processes of gathering both objective
and subjective data; (2) the workers call in scientists of their
own choosing to assist them in the collection and analysis of
whatever data the workers feel needs study. In this process, the
workers keep a healthy skepticism about the meaning of
science, expertise, and objective information. They scrutinise
all objective data, and through the process of mutual valida
tion, they accept the value of the data depending on how it
fits within their own perception of reality. It is worth stres
sing here that many years of exposure to occupational
medicine has taught workers the lesson that science is not
value free knowledge but very value loaded knowledge, reflec
ting the values of institutions where science is created and
the values of scientists who create that science; (3) once
agreed collectively on the nature of the problem, the workers
demand to participate collectively in the solution of that
problem.
This collective production of knowledge based on collec
tive practice is an alternate form of production of knowledge
to the individual production of knowledge, characteristic of
the bourgeois model. Needless to say, it puts the scientist in
a different social relation with the subject of study. It puts
him/her in an assistant role with his/her information and
knowledge being just a part of a broader and more impor
tant knowledge which is created by the practice of the work
ing class. Needless to say, the majority of scientists would
oppose that diminution of their protagonism, since it would
diminish their power. Many arguments are likely to be used
against that change of power relations—ideological argu
ments presented as scientific arguments to defend specific
class interests. The bourgeoisie and the majority of profesionals will oppose that change by every means possible, in
cluding sabotage. Still, that the majority of professionals
would oppose change does not mean, of course, that a
minority within those professions cannot play a very impor
June-Sept 1987
tant role in taking sides with the forces for change. But in
that process of changing class alliances, they will have to
change, not only their roles (from leaders to assistants) but
also their methods of work and the social and political con
text in which they use them. And it will be in that new realm
of practice that new social relations and a new science will
be created.
Struggle for Democracy
I have shown in the three sections of this article how
bourgeois ideological dominance reproduces dominant/
dominated relations in the spheres of production, politics
and science, including medicine. Also, I have shown how the
working class rebels against this bourgeois domination in a
continuous process of class struggle, which leaves its mark
on all those spheres. The class struggle takes many different
forms, but aims at changing and/or breaking with those pat
terns of domination which oppress the working class and
popular masses. It follows, from what has been said, that
their liberation requires the breaking of that pattern of con
trol where the few and not the many decide on the nature
of our societies. And, by democratisation, I do not mean
the mere existence of a plurality of parties and existence of
civil rights. I mean far more than that, I mean a profound
change in the pattern of control of the spheres of produc
tion, consumption, representation, ideological discourse, and
scientific endeavour where the many and not just the few
control. Specifically, democracy cannot be seen as limited
to the passive and indirect realm of representative politics.
It has to be seen, as Marx and Engels said, as the massive,
active and direct involvement by the collectivity of workers
and citizens in the governance of social institutions where
they work, reside, study, enjoy themselves and are being taken
care of. As Hal Draper has indicated, the greatest contribu
tion which Marx and Engels gave to the history of humanity
was to reveal the clear symbiosis between socialism and
democracy. As he put it, “Marx’s socialism (communism)
as a political programme may be most quickly defined, from
the Marxist standpoint, as the complete democratisation of
society, not merely of political forms’’ [52]. The struggle for
democracy needs to combine struggles in the institutions of
representative democracy, where power is delegated to fulltime representatives—the “experts” in politics—with, most
importantly, struggles to achieve forms of direct and mass
democracy where power is retained by the users and workers
in all societal institutions. For example, in order to change
not only the priorities but also the nature of medical and
scientific institutions, there is a need to win control of those
institutions, not only indirectly through elected officials in
the realm of representative democracy, but most importantly,
through direct and assembly type of democracy' where
workers, employees, users and communities control those
institutions. In other words, a socialist transformation will
not occur without a massive and direct participation by the
majority of the population in that process of transformation.
To sum up, there is a need for the working class, through
its different instruments and forms of struggle, to aim at a
massive democratisation of our societies, understanding
democracy, not as an exercise in voting every so many years,
29
but, most importantly, as a direct form of participation on
a daily basis by the working class and popular masses in all
economic, political and social institutions (including the
medical and scientific institutions). It is only in this way that
the democratisation of our institutions will imply a massive
transformation of the majority of our working populations
from being passive subjects to active agents in the redefinition
of those societies, a transformation that takes place as part
and parcel of their becoming the agents and not the objects
of history.
Ginzberg E. The Limits of Health Reform: The Search for Realism,
p 3. Basic Books, New York, 1977.
16. Sec Greenberg E. The American Political System. .4 Radical
Approach. Winthrop, Cambridge, MA, 1977.
17. By means of production, 1 mean not only the means that the workers
use for their work but also the infrastructure of production and
distribution that enables the produced goods and services to be used
and consumed.
18. For an expansion of this position, see Navarro V. Dictatorship and
Democracy. Meanings and Implications for Class Struggle (mimeo),
Johns Hopkins University, Baltimore, MD, 1979.
19. Etzionc A. Risk at the work place. The Washington Post, Dec. 28,
1978.
20. Hart Poll. Common Sense, Vol 3, 1975. That lack of trust of
References
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1. The Trilateral Task Force on the Governability of Democracies. The
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Governability of Democracies. Trilateral Commission, New York, 21. Contrary to bourgeois ideology that postulates that the state
May 1975.
apparatuses are neutral and can be used undistinctively by any class
2. By ‘Capitalism’ I mean a mode of production in which a class, the
or group, I believe that the state’s apparatuses reflect the power rela
capialist class, extracts as much labour power from each worker as
tions of the whole of society and thus are under the dominant
possible; labour power that is needed to (1) put the means of pro
unfluence of the capitalist class. That dominance explains its com
duction (owned, controlled and possessed by the capitalist class)
position (the class position of the top echelons of the state personnel),
to work; and (2) produce value, including profit. Labour power is
its structure and its function (i e, to reproduce the capitalist relathe human energy and competence that the worker provides to enable
tionsY For a further expansion of this position, see Part Ill, “State
the means of production to work. It is usually referred to as work.
power and medicine’’ of Navarro V. Medicine Under Capitalism.
3. A most representative view of this position is Marcuse H. One
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Dimensional Man. Beacon Press, Boston, 1975.
22. Two examples of that perception arc Tudor Hart J. The point is to
4. Ehrenreich J, Introduction. In The Cultural Crisis of Modern
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the working class struggles around health and its consequences on
in the capitalist state J.T.H. reduces socialism to a juridical-political
the redefinition of medicine, the author added “coal miners struggle"
category, i e the nationalisation of the health sector. K F reduces
as a mere perfunctory note to that introduction of his volume without
socialism to the absence of market relations and to the mechanism
actually referring to it. As with many other US radicals. Ehrenreich
of societal allocations done by the state for the “benefit of society”.
ignores the dramatic and continuous struggles around health related
In that vision, socialism is defined by the relations of exchange, not
issues that are being carried out by the US working class.
by the relations of production. Socialism, however, is a social for
5. See Marshall D. The miners and the UMW: Crisis in the reform
mation in which the working class and its allies are the dominant
process. Social. Rev. 40/41, 65, 1978, for a detailed account of those
class. Thus, socialist control is working class control.
struggles.
23. Navarro V. Class Struggle, the State, and Medicine. Martin
6. The struggles against the nature of work under capitalism occur,
Roberston, Oxford, 1978.
not only because of the actual damage imposed on the worker at
24. Kirschten D. Risk assessment. How much is a life worth, Nat. J.
the work place, but also because of the harm created to the workers
7, 252, 1979. Also, for an excellent account of struggles in the US
and their dependants in all spheres of their lives.
to protect the workers against the risky environment, see Berman
7. See Braverman H. Labour and monopoly capital. In The Degrada
D. Death on the job. Monthly Review Press, New York, 1978.
tion of Work in the Twentieth Century. Monthly Review Press, New 25. Navarro V. The crisis of the Western system of medicine in contem
York, 1974. Also, for an analysis of how the process of class struggle
porary captalism. Int. J. Hlth Serv. 8, 205, 1978.
has shaped the form of bourgeois dominance in the process of work,
26. Representatives of this position are H. Marcuse and most of the
see Friedman A. L. Industry and Labour, Class Struggle at Work
theorists of the Frankfurt School A more recent example of this
and Monopoly Capitalism. Macmillan, New York, 1977.
single society ideology is Kellner D. Ideology. Marxism, and advan
8. Bosquet M. The prison factory. New Left Rev. 73, 23, 1972. Also,
ced capitalism. Social. RevAl, 37, 1978. It is worth mentioning that
see Linhart R. L’etabli, Minuit, Paris, 1978.
the first major works of Althusser (Pour Marx and Lire le capital)
9. Quoted from Doye R. J. Management Accounting, 1970.
also carried that position of a single society ideology. Since 1968,
10. Class dominance is a process of continuous endeavour on the part
however, Althusser has broken with that position. For an excellent
of the capitalist class or bourgeoisie to maintain, regain, strengthen
and detailed critique of Althusser’s position on this subject, see
and extend their interests in all economical, political, ideological
Sanchez Vazquez A. Ciencia Y Revolution. Alianza Editorial,
and cultural spheres of society over the ones of the dominated class
Mexico, 1978.
or working class. In this article, dominance and hegemony are used
27. Marx K. The eighteenth Brumaire of Louis Bonaparte. In Selected
interchangeably.
Works (Edited by Marx K, and Engels F.), pp 117-118. Lawrence
II. Class struggle is the conflict among classes that appears in all
& Wishart, London, 1968.
economic, political, ideological and cultural spheres of society and
28. Marx K. and Engels F. The German Ideology, p 64, Lawrence &
that takes place in the pursuit of the'ir interests. Under capitalism,
Wishart, London, 1974.
the main conflict is between the capitalist class and the working class.
29 Therborn, G. What Does the Ruling Class Do When it Rules. New
12. Gramsci A. Quaderni del Carcere, p 30. Einaudi, Turin, 1978. It
Left Books, London, 1978.
is worth stressing that the unions are, of course, very important
30. Quoted in “Interview con suvlovico Geymont, El mito del progreso
instruments of struggle by the working class. But the focus of those
y de la neutralidad de la ciencia". El Viejo Topo 24, 13, 1978.
struggles on economic issues transforms them into limited and
31. Bell D. The Post Industrial Society, 1977.
limiting instruments for revolutionary change, i e, change from one
32. See Stalin J. Dialectical and Historical Materialism. A good criti
to another mode of production.
que of the work appears in Lecourt D. Proletarian Science. The Case
13. Marx K. Grundisse. Penguin Books, London 1973.
of Lysenko, pp 110-111, New Left Books, London, 1976.
14. See Kotelchuck D. Asbestos research: Winning the battle but losing 33. Sweezy P M. and Bettelheim C. On the Transition to Socialism.
the war. Hlth PAC Bull. 61, 1-32, 1974. Also Epstein S. The Politics
Monthly Review Press, New York, 1971.
of Cancer, pp 86-87. Sierra Club Books, San Francisco, 1978.
34. Lecourt D, op tit.
30
15.
Radical Journal of Health
American Indians, he writes that “much of the spiritual misery of
Claudin-Urondo C. Lenin and the Cultural Revolution. Harvester
the remnants of non-Western culture in the US is due to this un
Press, Sussex, 1977.
informed intellectual fascism of most of our leading philosophers,
36. Navarro V. Social Security and Medicine in the USSR. A Marxist
scientists, philosophers of science..(p 207). The roots of the pro
Critique. Lexington Books, Lexington, MA, 1977.
blems, however, are much deeper than Feyerabend seems to realise.
37. J am not using the categories of Yes or No in an either/or type of
He does not touch for example, on the key issues of why those
relationship. Rather, I am using them in a dialectical way, i c, that
‘fascist’ ideas are the ruling or leading ideas.
the autonomy of science takes place within a set of class relations
45. Braverman H, op cit.
that both influence science and arc influenced by science.
38. The meaning of “ultimate instance” is that although conflicts may 46. Quoted in Breilh J. op cit.
appear between scientific developments and capitalist relations, those 47. Bridford K. et al, Estimates of the Fraction of Cancer in the United
Stales Related to Occupational Factors. Prepared by the National
capitalist relations tend to eventually impose themselves on those
Cancer Institute, National Institute of Environmental Health
developments.
Sciences and National Institute for Occupational Safety and Health,
39. Harnecker M, Los conceptos elementales de material'ismo historico.
Siglo med, XXI, 3, 1977.
Sept. 15, 1978.
40. Durkheim E. Las Reglas del Metodo Sociologicio, p 50. La Plcyade, 48. The fact that those assumed causes are only apparent but not the
real ones docs not make them irrelevant. They may allow for a
Buenos Aires, 1974.
description but not for an explanation of reality. The vast array of
41. McMohan B. Principles and Methods of Epidemiology (in Spanish:
empirical phenomena immed:ately observable in social life can only
La Prensa Medica MexicanaY p 2. 1975. For an excellent critique
be explained if one analyses the social reality behind those
of ideology within epidemiology, sec Breilh J. Critica de la Interappearances.
pretacion Ecologica Functionalista de la Epidemiologia. Universidad
Autonoma de Miexico, 1977 (mimeograph).
49. Lecourt, op cit.
42. Dorland Medical Dictionary, Saunders, Philadelphia, PA, 1968.
50. For a critique of similar positivist approaches used in social science,
43. Kuhn T. The Structure of Scientific Revolutions, Univ, of Chicago
see Scientific method in sociology. In Sociology. Traditional and
Press, Chicago, IL, 1962.
Radical Perspectives (Edited by Sherman H J. and Wood J L.),
44. For a critique of the concept of linearity in scientific knowledge,
do 275-324. Harper and Row. New York, 1979.
see Kuhn T. op cit. Also for an alive but not always rigorous discus
51. For an analysis of the political and economic forces that determined
sion on this subject, see Feyerabend P. Science in a Free Society.
the Italian experience and for a more detailed account of the pro
New Left Books, London, 1978. Neither Kuhn nor Feyerabend touch
cess outlined here, see Assennato G and Navarro V. Workers parti
on the socio-economic and political determinants of the scientific
cipation and control in Italy. The case of occupational medicine.
breakthroughs, a kev subject which leaves their positions wanting.
/nt. J. Hlth Serv. 10, 217, 1980.
A further fault of Feyerabend’s work is the key determinant role that
he considers scientists have in initiating or stopping changes. For
52. Draper H. Marx on democratic forms of government. The Social.
example, in examining the situation of blacks, chicanos and
Regist. 101, 1974.
35.
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31
The ‘Baby M’ Court Case in the US
cindy jaquith
Some months back a New Jersey court gave a ruling on a surrogacy' case which has sparked off intense debate in the
west on the entire issue of surrogate motherhood. In the Baby M case, the child was taken away from the surrogate
mother on the basis of a contract she had signed with the father of the child and his wife. .4 myriad ofprejudices against
women and working people—some falsely presented as feminist ideas—have been put forward, along with a generous
dose of pseudoscience and mysticism both in the court and outside it.
THE New Jersey court case of “Baby M” reveals a brazen
disregard for children. By taking the child away from her
mother, Mary Beth Whitehead, and by upholding a ‘sur
rogate mother* contract, Judge Harvey Sorkow has struck
a blow against rights the working class has fought for more
than a century and a half.
The case began when William and Elizabeth Stern went
to a surrogacy agency to hire a woman to bear them a child.
Agency head Noel Keane arranged a contract between
William Stern and Mary Beth Whiuhead. Whitehead sign
ed papers agreeing to be artificially inseminated with Stern’s
sperm, carry a pregnancy to term, and then deliver her baby
to the Sterns for S 10,000 plus medical expenses. But in the
course of pregnancy and the birth of the baby, in March 1986,
Whitehead decided she wanted to keep her child, whom she
named Sara. She informed the Serns and said they hould
keep their $ 10,000.
The Sterns filed a suit and immediately got Judge Sorkow
to order Whitehead to hand her daughter over to the Sterns.
The Sterns then went to Whitehead’s house with five cops
to seize five-week-old Sara. Whitehead escaped with the child
to Florida, but private detectives hired by the Sterns tracked
them down. The detectives took Sara away and turned her
over to the Sterns, who renamed her Melissa.
Whitehead’s Contract
Surrogate mother contracts are similar to involuntary ser
vitude contracts in many respects, and just as exploitative,
unjust, and invalid. The woman signs a contract guarantee
ing that she will carry a pregnancy for someone else for nine
months. According to Judge Sorkow’s ruling, she is legally
bound to this contract whether or not she changes her mind.
This is bad enough—but even worse given the nature of
the rights she gives up. Whitehead relinquished control of
her body for nine months with the contract she signed. She
had to agree to “assume all risks” of the pregnancy, “in
cluding the risk of death” She had to agree to “abortion on
demand of William Stern” if the fetus showed signs of
“physiological abnormalities,” determined by the doctor be
ing paid by Stern.
Whitehead herself could not choose to have an abortion
without “breaking” the contract. She also had to agree not
to smoke, drink liquor, or use medications not prescribed
by the Stern-paid doctor during her pregnancy. While these
conditions were imposed on Whitehead, the contract allow
ed Stern to terminate the agreement immediately if
Whitehead had a miscarriage in the first five months. And
he wouldn’t have to pay her a cent.
The other side of the contract that has no validity is that
Whitehead agreed nine months beforehand to surrender a
child she planned to bear. This is completely inhumane, both
to the child and mother. Under adoption law, a woman has
a period of time after her baby is born to decide if she wants
to put the child up for adoption, even if she concluded at
some point in her pregnancy that this is what she wanted
to do.
Women’s Right to Choose?
Gary Skoloff, the Sterns’ lawyer, made the fantastic argu
ment in court that surrogacy contracts are actually an ad
vance for women’s rights. “You prevent women from becom
ing surrogate mothers and deny them the freedom to
decide. . . it’s being unfairly paternalistic and its an insult
to the female population of this country?’ he claimed.
This argument was defended by Jan Sutton, spokesper
son of a group called National Association of Surrogate
Mothers. “Surrogate child-bearing is not exploitation of
women?’ she wrote in a letter to the New York Times. “It
is our individual right voluntarily to create a child for another
family. To deprive women of this right is clearly a threat to
feminist concerns?’
Surrogate contracts are not an extension of the fight for
women’s right to control their own bodies. That fight is to
secure the right of the woman to decide when and if to have
children, free from interference from the government, church
officials, doctors, husbands, lovers, boyfriends, or any other
individuals. This struggle has embodied the fight for birth
control; sex education; safe, legal abortion; and protection
from forced sterilisation. It is irfterconnected with the broader
struggle by women to be treated equally with men in all
aspects of society and not be disqualified because of
pregnancy, children, or lack of children.
Surrogacy contracts run completely counter to this strug
gle, what it has already achieved, and the future it points
to. Far from an expansion of women’s rights, these contracts
deny rights previously conquered by women and working
people as a whole.
A New York Times magazine reporter visited the offices
of Noel Keane. “His comfortable, two-story offices in Dear
born, Mich, were full of prospective surrogate mothers, often
with husbands and babies in tow, and infertile couples who
had come to check out the candidates for surrogacy?’ wrote
reporter Annie Taylor Fleming.
“The well-groomed couples.. . were each assigned a
private office, through which the surrogates were rotated,
to proffer their fertility and show off the living, gurgling pro
of thereof?’ For each women and eventual baby he successful
ly markets, Keane pulls down $ 10,000 for himself.
Male companions of the women also get into the business.
One man who accompanied his female friend to the office
told Fleming, “I’ll take care of her when she’s pregnant again,
but the baby means absolutely nothing. It’s like watching so
meone’s car for nine months. We’re in it for the money; it’s
a business.” Keane argues that he provides a public service,
Radical Journal of Health
that he is showing sensitivity to “the pain and cries’’ of the
“infertile.” Judge Sorkow upheld this notion of the ‘rights’
of the infertile. He ruled that state “refusal to enforce these
surrogate contracts. . . wold constitue an unconstitutional
interference with procreative liberty since it would prevent
childless couples from obtaining the means to have families?
‘Rights’ of ‘Infertile’
To believe Keane and Sorkow, a new class of oppressed
people—‘the infertile—has arisen. No one should deny them
their ‘right’ to ‘their own’ child, a ‘right’ supposedly
guaranteed by the US Constitution.
But Keane and Sorkow have things turned upside down.
The government has an obligation to guarantee that every
child has piotection and nurture—health care, education, and
decent living conditions. This obligation extends to other
dependent human beings as well, such as the aged and peo
ple who are incapacitated by physical or mental illness.
But the government has no obligation to guarantee every
adult the ‘right’ to ‘their own’ child. Judge Sorkow claims
the law should recognise surrogacy contracts in order to
satisfy an ‘Intense drive to procreate’. There is no instinc
tual drive to procreate, however. There is an instinct to have
sex—procreation is sometimes a consequence.
The attitude that people must have ‘their’ child with ‘their’
genes so they can continue ‘their bloodline’ or ‘family name’
is deeply rooted in class society. William Stern presented this
reactionary notion in the court case, explaining he had no
living relatives because many were killed by the Nazis. He
said he needed Whitehead’s baby to continue ‘his’ bloodline.
The Nazis, of course, are the most famous advocates of
continuing certain bloodlines. They also ended up trying to
exterminate other bloodlines they deemed socially unfit.
Under capitalism, the welfare of the child is not the prin
cipal concern nor are the rights of the woman who gives
birth. Defining the line of inheritance is. The working class,
which has no property to pass on to its offspring, is never
theless affected by ruling-class ideology about the family.
Fears, insecurities, and hopes of immortality, all bred by class
society, lead many working people to try to ‘continue the
family name’. This introduces enormous pressures, with the
children being $t!e greatest victims.
Surrogate mother contracts are simply the latest—and one
of the most degrading—manifestations of the way capitalism
treates children. If surrogacy served some socially useful pur
pose, it could be argued that society should promote its prac
tice. But it serves no progressive purpose. Humanity is not
on the brink of extinction. Many children are being born and
many more will be. There is not a social need to increase the
number of babies.
Surrogacy is not like adoption, which is socially necessary
today. Despite the fact that adoption is immersed in profit
making and that abuses against the children and parents in
volved do occur, there is a need for this institution to help
children without care.
And this is its starting point—not the ‘need’ of some adults
to have ‘their’ child. The concept of adoption is that society
must find a way to provide care to all children lacking it.
That’s progressive.
June-Sept 1987
The concept of surrogacy is that society owes all adults
the ‘right’ to ‘their’ child. There’s nothing progressive at all
about that—it is reactionary.
It opens the door to such things as the international baby
racket that has received so much publicity and condemna
tion. According to the New York Times, the number of
foreign-born babies adopted in the United States shot up
from 4,868 in 1981 to 9,945 in 1986. The real number is un
doubtedly much higher. Most come from Asia or Latin
America. Some are outright stolen from their mothers by
baby dealers; others are torn away under extreme duress by
these merchants.
This happens because there are fewer children in this coun
try available for adoption than there used to be, even though
racist prejudices still prevent the adoption of many US-born
children who are ‘not white*. Capitalist businessmen prey
ing on couples without children see a profit to be made,
because the baby ‘shortage* has driven the price of babies up.
But the fact that there are fewer homeless babies in the
United States is good. It marks human progress on several
fronts—in relation to society’s treatment of children and
other human beings, the advance of science and technology,
and the advance of women’s rights.
In many primitive societies, when it wasn’t possible to feed
everybody, it was the practice to kill some infants and other
dependents. Under feudalism and lasting beyond, the first
born son in the families of the landed nobility had special
rights over other children. This practice has also been wiped
out.
The brutal exploitation of child labour in textile mills, coal
mines, and agriculture has become illegal in this country. The
labour movement won this victory, as it won the right to free,
compulsory education through high school. A century ago,
many children were still losing their parents in shipwrecks,
epidemics, or other events. The number of human beings
perishing under such circumstances is greatly reduced today
in this country. And children without parents live under much
better conditions.
Social attitudes toward ‘orphans’ and ‘adopted children’
have also been changing in a progressive direction. These
children are less often seen as somehow abnormal and deser
ving different treatment than children who live with a
biological parent. Prejudices have also subsided with regard
to children born to unmarried women—so-called ‘bastards’
or illegitimate children.
Humanity as a whole has advanced and deepened its
solidarity for all members of society. This has been the pro
duct of struggle by workers and farmers. And it is linked
to advances in science and technology that have helped work
ing people shed various aspects of exploitation, inequality,
and prejudice.
Is Technology the Enemy?
It is important to recognise the progressive role science and
technology play—including under capitalism. This is
especially true in the light of arguments that surrogate births
show society is becoming the victim of technology and
predictions that science will turn most working-class women
into ‘breeders* of babies for the rich.
33
The trend is actually the opposite—women are having
fewer children today than ever before and they have taken
gaint steps away from their socially imposed role as
‘breeders’. This has happened because of women’s victories
in the fight for abortion rights and birth control, changing
attitudes toward women, changes in women’s own self
perception, and science.
Scientific discoveries mean that women today are better
informed about sex and health. Access to birth control and
abortion, while still restricted to some degree, allows them
far more decision-making power about when and if to have
children. Technology has also produced labour-saving devices
that have greatly reduced the hours women spend on
domestic labour, further freeing them to participate in the
labour force and society as a whole. Women have seized on
these advances to struggle for and win greater rights.
One result of this is a decline in the number of children
women have, now that they have more freedom to plan
pregnancy or decide not to have children at all. According
to the US Census Bureau, the average number of people per
household was 2.67 in 1986, down from 3.14 in 1970. There
is also greater social acceptance of couples who live together
and decide not to have children, and of adults who choose
to live alone, also a growing category, according to the Cen
sus Bureau.
One consequence is the ‘shortage’ of children to adopt.
A new phenomenon has arisen in relation to this, that of
couples frantically seeking ‘their own’ child, frequently after
not having had children earlier in life. Prior to this, many
children were adopted by relatives or neighbours who already
had children and took in others as an elementary act of social
responsibility.
Technolpgy has helped make possible the current situa
tion where there are fewer children to adopt. Technology has
benefitted women and all working people—increasing life
spans, lowering infant mortality, boosting food production,
and reducing labour time. And as such, it is being used by
the working class to lessen exploitation and reduce class, race,
and sex inequalities. It is not technology that is responsible
for abuses like surrogacy, it is capitalism, with its drive for
profit and its warping of human values.
Surrogacy is and will remain a marginal practice. Far from
being ‘the wave of the future’, it is actually a throwback to
the past.^Judge Sorkow’s ruling upholding surrogacy con
tracts has simply opened up the debate about this practice,
exposing its real nature to many working people for the first
time. On April 10, the New Jersey Supreme Court overturn
ed Sorkow’s ban on visitation rights for Whitehead. She now
has the right to see her daughter once a week for two hours.
Judge Harvey Sorkow, who presided over the New Jersey
trial, called it a “routine custody case’’. His portrayal of the
trial as a dispute between a “father” and a “mother” con
fused the issues and distracted attention from the exploitative
and unjust nature of surrogacy contracts. A custody case
usually arises when two people who have been jointly rais
ing children separate and cannot agree on who will get the
children. William Stem and Mary Beth Whitehead were never
jointly raising Whitehead’s newborn daughter and never in
tended to.
34
Stern’s sole ‘claim’ to the child was a scrap of paper call
ed a surrogacy contract. In upholding this ‘contract’, the
judge argued that Stern is the ‘biological father’ of
Whilehead’s child. According to the judge, this gives Stern
a ‘right’ to “his own biologically genetically related child”.
Whitehead was merely “the surrogate” hired by Stern to
“carry his child to term”.
Psychologist Lee Salk, a witness called by Stern’s lawyers,
went so far to propose that Whitehead be termed a “sur
rogate uterus” rather than a “surrogate mother”, to remove
any suggestion that she has a legitimate relationship to her
daughter. But it is precisely Whitehead’s biological, social,
and emotional relationship to the child that is key to the case.
Stern’s supposed ‘biological’ connection is irrelevant. Stern
is not the ‘father’ of Whitehead’s child. Richard Whilehead,
who is living with Mary Beth Whitehead and her other
children, is the ‘father’ in this case. Being a ‘father’ is not
determined biologically (leaving aside the fact that there is
no scientific way to prove it was Stern’s sperm that made
Whitehead pregnant).
Throughout human history, a ‘father’ has been the hus
band or companion of a woman who is raising children. It
is based on his relationship to the woman that a man
becomes ‘father’ to the children. Due to death, divorce, or
husbands who walk away, many women may then live with
someone else, who then becomes a ‘father’ to her children.
They remain ‘fathers’ as long as they are living with the
woman and sharing responsibility for the children. In a grow
ing number of cases, w omen are bringing up children without
‘fathers’ at all.
Being a sperm donor gives no man a right to raise the
resulting child, any more than being an egg donor gives a
woman that right. (In the practice called ‘surrogate gesta
tion’, a woman is implanted with the fertilised egg of another
woman. The ‘surrogate gestator’ carries the pregnancy and
gives birth, turning the baby over to the other women. The
practice is used in some cases by a couple of one race who
hire a woman of another race to bear a child who will also
“look like them”.)
Neither eggs nor sperm can be the basis for deciding who
is the ‘mother’ or ‘father’ of a child, or who has the right
to’ bring that child up. It is the woman who carries the
pregnancy, gives birth to the baby, and begins nurturing that
baby who has the right and responsibility to raise the child—
and the right to all the social benefits she needs to do so.
The only reason the state should intervene to take her child
away is if she is guilty of child abuse.
Nothing of the kind was proven in the case of Mary Beth
Whitehead. The Sterns brought into court an army of
psychologists and social workers who insisted Whitehead was
an ‘unfit mother’. Their evidene? Whitehead had a ‘nar
cissistic personality disorder’, in part because she dyed her
hair; she gave her children pandas, instead of pots and pans,
to play with; she had a shouting match with a nun who
teaches her son at a Catholic school; she once worked as a
dancer in a bar; and her husband was an alcoholic.
Lawyers also proudly pointed out that the Sterns make
more than S 90,000 a year, while Whitehead is dependent
on the $ 28.000 her husband makes as a sanitation worker.
Radical Journal of Health
the right to safe, legal abortion and birth control, as well
as sex education in the public schools. It means protection
of women from forced sterilisation.
Women’s physical ability to bear children should not be
used as a pretext to super-exploit them on the job paying
What are Society's Responsibilities?
them less than men, excluding them from certain jobs, or
In the struggle to end women’s oppression and guarantee denying them emoloyment if they are pregnant or already
children the best care possible, the working class needs a have children. The working class should demand equal pay
twofold approach. It needs to fight for women’s right to enter for equal work and affirmative action so women can achieve
the work force and all arenas of society without any restric full equality in employment and education.
tions or discriminatory treatment because of their child
Workers should demand full maternity benefits for
bearing capacities. It also needs to fight for the government women, including the right to return to the same job—
to carry out its responsibility to provide care for children and without loss of accrued seniority time—after the birth of a
all other dependent human beings, instead of allowing the child. Absence from work because of pregnancy should be
burden for this care to fall on individuals, especially on treated exactly like other contractual situations related to
women.
leaves from work.
The government should provide lowcost child care from
For women who have children, the working class should
infancy on up. It should guarantee an education, medical demand all the state aid they need to care for them. And
care, decent housing, and recreation for all the young, aim it should defend their right to have the courts compel men
ed at helping them develop into independent human beings. who walk away from shared responsibility for children to
All laws or practices that discriminate against children— pay child support.
The struggle for these demands is part of the fight for a
based on class, race, sex, handicaps, or ‘legitimacy—should
be eliminated.
different type of government, one that acts in the interests
The working class must also challenge any disqualifica of workers snd farmers, not a handful of capitalist families.
tion of women based on their having or not having children. By bringing such a government to power, working people
This being with championing the right of women them will lay the basis for further measures to provide care for
selves to freely decide when and if to bear children. It means children and to achieve equality for women
But none of this is relevant to whether Whitehead is ‘unfit’
to raise her child. What is relevant is that she gave birth to
the child and began raising that child.
(Continued from p 2)
puterised tomography nor nuclear imaging are tested in the
same way as drugs are required to.
Not only instruments but many medical and surgical pro
cedures are also introduced without adequate trails. For in
stance results of the systematic trial of amniocentesis were
published only last year after its extensive use for over a
decade. The chorion villi biopsy is already extensively used
without any scientific trial. Because of such a situation many
innovations like gastric freezing, high concentration oxygen
for neonates, the use of hyperbaric oxygen in intensive care,
insulin coma for the treatment of schizophreniae etc were
introduced without evaluation, used and subsequently aban
doned after they were proved ineffective or unsafe.
Amniocentesis and chorian villi biopsy remind us their
large scale misuse for female foeticide in India. In fact some
of the technological innovation appear explictly geared
towards use of sexist and racist cultural practices to gain fast
currency and early returns on the resultant technology.
Every country that is attemtping to meet the genuine needs
of people, has to take crucial decision about selecting
appropriate technologies as an alternative to the costly,
rendering services to few and profit oriented technologies.
In the field, activists are also required to select and develop
alternative technologies to provide immediate relief to people.
Therefore, in addition to the technology being a political
question, it is also a direct practical problem in political prac
tice. This has led many to experiment with various alternative
methods of medical care using simple but effective
technology and develop models to prove their feasibility. This
question is also linked with proliferation of the non-
June-Sept 1987
government organisations and needs detailed discussion.
Such experiments in alternative technologies are not
limited to using different physical tools but encompass the
way medical care is delivered and attempts to humanise it.
—Amar Jesani
(Continued from p 13)
Sattaur O, Cherfao J, and Mackenzie D, Nobel price for inventors of
monoclonals. New Scientist, 18th October 1984, p 3-4.
Schiller F, Neurology: The electrical root. In Historical Aspects of the
Neurosciences, Eds, Rose FC, Bynum W F, Raven Press, New York.
1982, p 4.
Skilling H H, Exploring Electricity, Ronald Press Co., New York, 1948.
Solomon P and Patch V, Handbook of Psychiatry, Lange Medical
Publications, Los Altos, Ca, p 465.
Spillane J D, The Doctrine of Nerves, Oxford, London. 1981.
Thylor D C, One hundred vears of epilepsy surgery: Sir Victor Horsley’s
contribution. Journal of Neurology, Neurosurgery and Psychiatry,
49: 485-488, 1986.
Veith I, Hysteria; The History of a Disease, University of Chicago Press,
Chicago, 1965, p 232.
Walter W G, The future of clinical neurophysiology. In Handbook of
Electroencephalography and Clinical Neurophysiology, Ed. Remond
A, Vol 1, Elsevier, Amsterdam, 1971, p 43.
Weinberg S, The First Three Minutes, Bantam, New York, 1977, p 145.
Williams D. The last word. In Epilepsy (Proceedings of the Hans Berger
Centenary Symposium), Eds. Harris P, Mawdsley C, Churchill Liv
ingstone, London, 1974, p 347.
Winter H J, Science, In A Cultural History of India, Ed. A L Basham,
Oxford, London, 1975, p 149.
Bindu T Desai
Division of Neurology Cook County Hospital
1835 W Harrison Street
Chicago
Ill 60612
USA
35
UPDATE
News and Notes
Strengthening the Cuckoo’s Nest?
A Comment on Mental Health Bill
FREUD and subsequent psychoanalysis,
psychotherapy and psychiatry have radically chang
ed the world view with regard to mental health and
illness. Western capitalist countries and socialist
countries have largely accepted these changes and
have evolved structures and legal provisions that pro
vide a relatively better deal to the mentally ill.
However, in all these countries the changes have
been within the overall framework of social control,
which was anyway the purpose of feudal notions of
‘lunacy’.
In India, as in most backward countries, the tradi
tional ‘lunacy’ worldview is still dominant even
within the modern legal framework. Mental health
and illness in India was till last year governed by
the Indian Lunacy Act of 1912 formulated under
British imperialism.
The Indian Lunacy Act (ILA) incorporated only
a one line definition of a ‘lunatic’—-“a lunatic is an
idiot or a person of unsound mind’—but had as
many as 46 sections dealing with how the property
of a lunatic should be administered. Between the
period of the enactment of the ILA and the new
Mental Health Bill (MHB), passed by parliament
in 1966, there have been significant global ad
vancements in explaining, understanding and
treating mental illness. But the new MHB in India
provides only a cosmetic change over its predecessor.
It condemns all mentally ill persons, excluding those
mentally retarded, as criminals. The new definition
of a mentally ill person is “a person who is in need
of treatment by reason of any mental disorder other
than mental retardation”. Thus, apart from ex
cluding the mentally deficient, the MHB is no dif
ferent in its basic form from the archaic ILA.
Advances in psychotherapy, psychoanalysis and
community mental health care, among other alter
natives, are not even mentioned in the MHB. The
wide range of mental illnesses is ignored. The
monopoly of treating the mentally ill is given to
psychiatrists who know very little about alternative
36
therapies. For the psychiatrist chemotherapy and
electric shocks or even psychosurgery are the only
means for dealing with mental illness. Psychiatrists
trained in India do not have any significant exposure
to even psychotherapy (with the exception of
perhaps those trained in NIMHANS), let alone
psychoanalysis and other non-invasive alternatives.
This sole reliance on psychiatrists in the MHB will
only further medicalise a problem that has largely
social origins. Historically, it has been well establish
ed in psychological and sociological research that.
menial pathology stems largely from society itself.
Poverty, exploitation, insecurity, alienation and
above all class society itself are harbingers of men
tal illness.
In spite of this knowledge the MHB is no more
than a provision for locking up and managing the
property of the mentally ill. It is interesting to note
that “property” forms the cornerstone of the MHB
as in the case of the earlier ILA. For the imperialist
powers the ILA was an important means of con
trolling and manipulating the power structure by
dispossessing many uncompromising landed
aristocrats and local power brokers of their proper
ty by invoking the provisions of the ILA through
which any magistrate could declare a person men
tally unsound (without any aid of a medical pro
fessional). What the MHB has done is to shift the
onus of establishing mental “unsoundness” from the
judiciary to the psychiatrist. Thus the enactment of
the MHB is consistent with the dangerous trend of
the general medicalisation process of human
health—it is more a police bill than a health bill.
Though on the whole psychiatrists have been
critical of the MHB and have demanded amend
ments, the Indian Psychiatric Society (IPS) has
welcomed the medicalisation and the provision in
the bill for admission of mentally ill patients to
privately run psychiatric nursing homes, besides
government owned psychiatric hospitals, which
alone were authorised earlier to admit such patients.
Radical Journal of Health
In fact the main interest of the psychiatrists in
pushing this bill was to gain this provision. This pro
vision too is consistent with the general trend of
privatisation. However, in the same breath the IPS
has strongly condemned the provisions for licens
ing and inspection of private psychiatric practice by
a state authority—the IPS plans to approach the
supreme court to rid the MHB of this latter provi
sion (but it will not challenge the MHB itself)!
Mcdicalisation and privatisation of mental health
care will only worsen the situation for the mentally
ill. Further, as regards rights of the mentally ill per
son there is only passing reference with regard to
protecting the patient from ‘cruelty’ of a practi
tioner. But this toothless protection is overridden by
the fact that the family, state and the medical pro
fession have full control over the patient physically,
mentally and socially. The decision-making about
diagnosis, therapy, admission, treatment and
discharge are vested in the patient’s family and doc
tor. The patient has no say whatsoever in the mat
ter. Therefore a patient suffering from a simple
neurotic condition may easily face confinement if
the family (for instance in a family property feud)
or the state (for instance in case of an ideological
adversary or a political prisoner) sanction so on
behalf of the patient who supposedly is incompe
tent to make a decision about his/her well-being.
Thus on the human rights front the new MHB
fails completely. If at all, it strengthens control over
mentally ill persons clearly abrogating their fun
damental rights and implicating them as stigmatis
ed and unlawful citizens.
Hence the MHB needs to be challenged not only
by psycho-professionals of all variety but also by
civil rights groups, lawyers and social scientists. The
MHB’s basic form needs to be changed from a social
control perspective to a human rights perspective
Mental illness and health conditions need to be
defined in detail and the independence of the men
tally ill person needs to be protected. The protec
tion should have a social basis, and under present
conditions can be best ensured with the assistance
of civil rights groups and the judiciary. All concern
ed, therefore must strive to make the MHB biased
in favour of the mentally ill and not against them.
Ravi Duggal
June-Sept 1987
Indian Workplace:
‘Safe’, "Clean' and "Healthy'?
A BILL amending the Factories Act has been pass
ed by the Lok Sabha some months ago. While the
Bill for the first time accords to workers some rights
which had hitherto never been recognised, it needs
to be dissected thoroughly. For the present it is in
teresting to note that even those rules regula
tions and norms which have been in force for
decades continue to be ignored or openly flouted.
Take the case of reporting of accidents and occupa
tional diseases. Anyone looking at the data
presented year after year in the Indian Labour Jour
nal, the official publication brought out by the
Ministry of Labour, would marvel at the safe, clean
and healthy environment in Indian industry*
Take a look at the accident figures for three
years—1981, 1982 and 1984 (the latest). In 1981 there
were a total of 3,41,423 injuries of which 740 were
fatal. In 1982, 3,02,268 injuries of which 599 were
fatal and in 1984 there were only 1,15,442 injuries
of which only 381 were fatal. Data was not available
for 4 states in 1981, for 5 states in 1982 and for 9
states in 1984. While the figures are not strictly com
parable because of inadequate reporting, it is in
teresting that the proportion of fatal accidents is less
than 0.5 per cent in all the years. The accident rate,
as everyone but the very naive knows, is extraor
dinarily low and is in no way related to the real situa
tion. Injuries are reported only when a worker is incapacited by them and thus a large number escape
being recorded.
The case of the non-recording of occupational
diseases is even more interesting. In 1981 there were
13 reported case of ODs, all of them being chrome
ulceration. In 1982, there was a sharp jump in OD
with 101 cases—with apparently an epidemic of
silicosis (87 cases), all from Madhya Pradesh! In
1984 there was a sharp drop to 27 cases and all of
them chrome ulceration again. Even more in
terestingly, the only state being troubled by OD was
Maharashtra for no cases of OD were reported from
anywhere else in the country! That the case repor
ting either of accidents or of ODs is atrocious has
been highlighted in these pages some years back
(SHR, Vol 1:3). The article on ‘Illness and Accident
Reporting in Industry’ had pointed out that the
reporting has consistently declined since 1960. But
is this very surprising civen the fact that the number
31
of medical inspectors of factories had been 11 in
1981, went up to 42 in 1982 and down again to 10
in 1984? Given this kind of situation, what role do
amendments ostensibly strengthening the Factories
Act play—especially given the fact that workers’
health has not been a prime concern in the labour
movement in India so far9
PP
Eyesight Problems
Among Workers
THE electronics industry is the largest employer in
the production sector in Malaysia. Upto October
1986, there were some 70,000 workers, most of
whom are women.
Eyesight problems are reported to be occurring
frequently and at an alarming rate among workers
in electronics factories. Those affected come from
the semiconductor assembly section. The work here
requires the workers to use microscope daily to tie
wires to pieces of semiconductors which are almost
invisible to the naked eye.
According to a survey published in the book,
Health Hazards in Electronics by Thomas H
Gassert, 44 per cent of the workers in Americanowned electronics factories in Malaysia complain of
eyesight problems while 42 per cent complain of
headaches.
The survey revealed that the eyesight problems are
due to the use of microscopes and TV monitors as
well as exposure to chemical vapours, smoke and
dust on a long-term basis.
Eye diseases such as conjunctivitis are caused by
chemical vapours and can spread from one worker
to another because the same microscope is used by
several workers. This problem is made worse by the
long hours of work. Salaries and bonuses are paid
based on a quota system and the quality of work
done. Hence, many workers may be driven to work
hard, without sufficient time or rest.
The survey also found that many companies do
not teach the staff the proper use of the equipment.
Microscopes and TV monitors which are defective
are also not repaired.
Noisy machines can also harm the electronics fac
tory workers as the noises can lead to hearing loss
38
and can cause tension which will lead to other health
problems.
In electronics factories, some machines such as
the metal stamping machines and the packaging
machine are very noisy. The use of ultrasound to
tie and test components also emits noise at a high
level.
The safe level of noise, according to Health
Hazards in Electronics, should not be more than 60
decibels and 16 kilohertz for an eight-hour work
ing period.
The book says that loss of hearing among elec
tronics factory workers is due to prolonged exposure
to a noise level above 80 decibels.
This exposure can also cause tension which will
eventually lead to other problems such as hyperten
sion, increased heart-beat, vein disorder, irritabili
ty and a lack of concentration. All these in turn may
lead to accidents at work, cause muscular tension,
nausea and headaches.
Utusan Konsumer, March 1987
Campaign to Ban
Hazardous Drugs
THE Drug Action Forum, West Bengal has initiated
an interesting campaign for a ban on the manufac
ture and sale of unscientific and harmful fixed-dose
combination of chloramphenicol-streptomycin.
They have been circulating a letter to manufacturers
requesting that they stop manufacturing these pro
ducts. The letter is signed by 270 practitioners of
West Bengal and sets out the reasons why they feel
a ban is necessary.
The letter points out (1) that the combination has
not been recommended against diarrhoea in any
standard textbook of medicine and there is no scien
tific basis for such use; (2) that chloramphenicol is
a valuable drug, the drug of choice for typhoid and
its indiscriminate use may cause the development
of resistance to typhoid bacilli; (3) that streptomycin
is not absorbed through the gastrointestinal tract
and is besides a first line drug in the treatment of
tuberculosis and is in perpetual short supply; and
(4) that there are many effective alternative
‘.reatments for diarrhoea when needed.
For more information contact WBDAF, P 254, Block B, Lake
Town, Calcutta 700 089.
Radical Journal of Health
Women’s Health Care in Brazil
carmen Barroso
In 1982, the ministry of health in Brazil decided to present a comprehensive programme of women's health. The programme
was drafted by four doctors, two of whom were feminists and clearly reflected the politics and the philosophy of the
women’s movement as it had been evolving in the previous decade. The author who was closely associated with early
efforts in this direction writes about the problems encountered in evolving the plan and in implementing it.
BACK in 1982, I was helping the electoral campaign of a ban services, were now presenting a new demand. Can you
candidate for governor in the state of Sao Paulo, and together guess what? Sex education! The rationale presented was that
with a handful of other volunteers, 1 was in charge of draf they needed information in order to guide their children. But
ting the items on women’s health to be included in his cam as soon as the question period was open after a given lec
paign agenda. It was not easy, I can tell you!
ture, the issues that used to come up were those of frigidity
To begin with, the very legitimacy of having a special pro and power relations between the couple.
gramme for women was questioned. Again and again we had
Why did these problems begin to emerge in public? In
to argue that yes, all human beings are entitled to good health tensive migration and the growth qf megalopolis had resulted
care, but women do have special health needs, both because in the severing of traditional family ties and neighbourhood
of their biological reproductive functions and because of the groups. That, together with increasing work alienation, had
sexual division of labour prevalent in our society. Other helped to raise the expectation towards couple relationships
arguments had to do with priorities and there we were as a major channel of personal fulfilment. Besides, women’s
repeating that: Yes, we knew that infant mortality rates were access to the mass media—especially to TV romantic novels,
unaceptably high, but did they know what maternal mor which were reaching 75 per cent of urban homes in 1980—all
tality rates were? Or: yes, we agreed that work-related ac acted together to question the use made by many men of
cidents and illnesses that reached both men and women women’s bodies. The word use does not reflect my intention
should be greatly diminished, but wouldn’t they also agree to shock you: it is the common euphemism used by rural
that women did have a right not to have to resort to women to mean sexual relationship (and that certainly tells
clandestine abortion?
us something about the quality of this relationship!). To cut
When feminism, after decades of demobilisation, reemerg a long story short: the fact was that tensions were mounting
ed in the Brazilian political scene in the mid-seventies, the in the bedroom, and these were showing up in group discus
overall national priority was the struggle for democracy and sions whenever poor women had an opportunity to speak.
the prevailing idea was that a focus on women’s specific issues
The year 1982, as you know, was when the debt crisis came
was divisive and self-defeating. Even where women’s subor to the forefront and the country had to resort to the IMF
dination was acknowledged, it was dismissed as an unim structural adjustment policies. As always happens in crisis
portant political question, a mere byproduct of class exploita situations, the old neo-malthusian ideology came out of the
tion or a cultural tradition that would naturally disappear closet again as an apparently easy solution to the difficult
as a consequence of the development process. Forgive me economic problems. In 1983, sectors of the military, together
the oversimplification but, as I said, I am referring to the with private family planning organisations drafted a plan to
prevailing ideas, those that set the climate where a project curb population growth. This raised the same fears prompted
can grow or fade away. And feminism managed to flourish by similar attempts made in the sixties and seventies. The
quite well thanks to a strategy of downplaying women’s major fears were: diversion of government efforts from the
specific issues and to restricting them to those in the sphere root causes of poverty, foreign intervention on national
of production. It thus managed not to alienate Important priorities and open doors for coercion of poor people to have
partners in the struggle for democracy: the left and the fewer children.
But at that point those arguments were no longer strong
catholic church.
enough
to resist the creation of government programmes. On
But, by the end of the seventies, it was not possible to con
the
one
hand, the advantages of fast population growth, an
tinue ignoring women’s daily struggle to control their
reproduction. The fertility rate was going down quite rapid argument which was popular in the sixties, had long been
ly. And that in all regions of the country, in all social classes, discredited. On the other hand, contraceptives were widely
and even in the rural areas. The demographic figures only available to those who could buy them, and it was difficult
became available several years later, but whoever had any to deny that, in the absence of government support, poor
contact with the poor soon became aware that pills, tubal women were going through tremenduous sacrifices in order
ligation and clandestine abortion—no matter their high to regulate their fertility.
What happened then was that, instead of just opposing
costs—were more and more widespread. And what was more
surprising was that Mothers Clubs and other grassroots the population control plan, the ministry of health decided
organisations—most of which had been created in the six to present an alternative: a comprehensive programme of
ties under the umbrella of the catholic church—having evolv women’s health. Drafted by a committee of four doctors, two
ed from their traditional handicrafts and religious activities of them feminists, the programme embodied a set of prin
to the active mobilisation to press local governments for ur ciples the women’s movement had been formulating through
June-Sept 1987
39
its practice in the previous years.
It started with a thorough diagnostic of the causes of mor
tality and morbidity among women over 10 years of age,
which numbered around 45 million in 1980. Free health ser
vices provided through the public system or through the
social security system had been mostly limited to pre-natal
and natal care, and grossly inadequate both in terms of
coverage and quality. The new programme was based on the
idea of comphrchensiveness. Services should not be restricted
to reproductive functions, they should include cancer preven
tion and the control of sexually transmitted diseases, and
be integrated with general clinical care. Married women of
fertile age were not to be the sole clients. Older women and
adolescents were also to receive adequate care. And public
services should include both the provision of information
and all means of contraception and infertility treatment.
An important element of the preventive aspect was the
educational component. In order to enable women to take
control of their own health, they should have access to needed
information. But much more than that, they should have the
opportunity to develop the attitudes conducive to the effec
tive use of this information. That is, instead of the prevail
ing authoritarian doctor-client relationships, health services
should contribute to the enhancement of self-esteem and selfrespect, so that women could have pleasure in taking care
of their own bodies.
All this was very beautiful and very nice on paper. But
a small and inexperienced staff at the ministry of health had
to spend an enormous amount of time in political negotia
tions to make the programme viable. Opposition came from
two main sources: at first, from the democratic sectors who
did not trust the military government and suspected the pro
gramme to be just another disguised population control in
itiative. This mistrust vanished gradually with increased
transparency of the decision-making processes and the elec
tion of Tancredo Neves in 1985.
The other sector was the catholic church, whose teachings
have little impact upon the practices of the members of its
congregations, but whose hierarchy is very vocal. The
ministry diligently courted the.church and apparently manag
ed for a while to get its agreement to look the other way
But the church became very active again last year, when the
social security system jointed the programme. The church
efforts are now aimed at restricting the'availability of what
they consider unethical methods of contraception, that is,
barriers, pills, IUDs and all others not based on periodic
abstinence.
But, in spite of this resistance, some important
achievements have occurred. What has been most remarkable
has been the adoption by the health system of educational
practices developed by the women’s movement. It is now
quite well-established that doctors, nurses and semi
literate health assistants, all need refresher training, and
many in-service programmes throughout the country have
aimed both at technical updating and at clarification of at
40
titudes and values.
Educational materials originally developed for
consciousness-raising groups have been widely used in smallgroup discussions where health workers of all ranks have,
for the first time, a chance to analyse critically their prac
tices and assumptions about women as clients. The techni
ques used put an emphasis on respect for differences of opi
nion among group members, and are quite revolutionary in
the sense that they cut across hierarchies in the workplace.
Another important innovation is that sex education is now
a key element of the training programmes. Reproductive
health issues cannot be separated from sexuality. Just to give
an obvious example: if a woman cannot use a diaphragm
because she cannot bring herself to put a finger inside her
vagina, nothing will be accomplished by technical instruc
tion. So sex education starts by re-examining the educational
practices of our society that taught us to have shame and
fear of our own bodies. And this, of course, is related to
women’s role in society. Therefore, a little history of Brazilian
women is introduced in some of these training programmes.
As most health workers are themselves women, their
evaluations of the educational programmes often point to
self-awareness as an important by-product. But the ultimate
aims of those programmes are two-fold: first, to influence
the overall attitude of the worker towards the clients, who
should be respected as autonomous human beings in charge
of their own health and reproductive decisions; and second,
to prepare the workers to conduct similar training sessions
with the clients. This has begun to happen in many units,
but it still depends largely on the initiative of interested
workers.
An evaluation carried out in late 1986 pointed out as the
major achievements of the programme, the development and
printing of educational materials and norms of clinical pro
cedures. These norms refer to sexually transmitted diseases,
pre-natal care, breast and cervical cancer prevention. Family
planning norms have been developed put are not printed yet.
Norms for childbirth are still in the drafting. The programme
has also supported the development of national technology
in the areas of spermicides and diaphrams. However, the units
where the programme has been effectively implemented still
are not more than a hundred, distributed among a few states.
What lies ahead for the future? I think it will depend on
three widely different factors. First, the success of the pro
gramme requires an administrative reform to give it efficiency
it now lacks. As it stands now, the decision-making is highly
centralised and the decision-process quite bureaucratised.
And this, of course, has greately delayed its launching at the
local level.
Secondly, the future of the programme is tied to the future
of the women’s movement in at least two ways. Women will
have to remain active as a pressure group at the central levels
of government so that the the church hierarchy does not suc
ceed in curtailing the scope of the programme. On the other
Radical Journal of Health
hand, at the local level, clients increasingly aware of their
rights will have to keep a constant eye on the quality of the
services to avoid abuses and a tragic gap between intent and
consequences.
Thirdly, resources for the programme depend on the solu
tion to the debt crises. At the moment the programme is
mostly supported by a five-year grant from UNFPA. But even
so, the programme relies basically on the smooth running
of the public health services. And, as you probably know,
Brazil has been exporting capital to the industrialised coun
tries in the last few vears. A large proportion of the GNP
is going to service the debt, the balance of payments is go
ing down due to increasingly unfavourable terms of exchange,
government revenues are being sharply cut. In this scenario,
institutional stability is threatened. At the level of the health
services, a most likely outcome is a sharp drop in the already
low salaries of health workers. They become demoralised and
spend a large proportion of their time fighting against salary
cuts.
If common sense prevails, and new economic agreements
allow the economies of the third world to resume growth,
the Brazilian health programme will be strengthened, its dif
ficulties corrected. Since it corresponds to such great needs,
and it has been drafted with such audacity and care, it
deserves this chance.
STATEMENT about ownership and other particulars about newspaper
RADICAL JOURNAL OF HEALTH to be published in the first
issue every year after the last day of February.
FORM IV (See Rule 8)
Bombay
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Quarterly
publication:
Amar Jesani
3 Printer’s nameWhether citizen of
Yes
India?:
C/o C 6 Balaka,
Address:
Swastik Park, Chcmbur,
Bombay - 400 071
Amar Jesani
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India?:
As above
Address:
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5 Editor’s name:
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India:
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Address:
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Bandra, Bombay 400 050
6 Name and address of individuals
Socialist Health Review
who own the newspaper and partners
Trust, Refinery View,
or shareholders holding more than
Chcmbur, Bombay.
one per cent of the total capital:
I, Amar Jesani. hereby declare that the particulars given above are
true to the best of my knowledge and belief.
(Amar Jesani)
Dated March 1, 1987
of
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Signature
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41
Book Reviews
Explosion of Alternative Information on Drugs
CAP Reports on Drugs and the Third World. Chloroform—Sale and Hazards: a Malaysian Study; no 9.- Pizotifen—
Double Standards in Marketing, no 11; Cyproheptadine—Risks and Unethical Marketing in Malaysia, no 12;
Stanozolol—Toxicity and Unethical Marketing in Malaysia and the Third World. Consumers’ Association Penang,
Malaysia, 1986.
Consolidated List of Products Whose Consumption and/or Sale have been banned, withdrawn or severely restricted
or not approved by governments, II Issue, UN, 1987.
IN the last couple of years, with the emergence of a vocal
and visible consumer movement all over the world, has come
about something of an explosion of alternative information
in these areas. Until very recently, information about con
sumer products, etc, was the monopoly of the industry. Even
the governments of most third world countries did not have
access to data such as the hazardous nature of a drug, its
side-effects if any, whether the drug was banned in other
countries of the world, etc. This had a direct impact on the
drug consumer movement in that the arguments of the drug
companies were difficult to counter in the absence of rele
vant alternative information.
Thus breaking the information monopoly has become one
of the prime objectives of the consumer movement, especially
the drug consumer movement. Most groups all over the world
have been producing volumes of literature which is very
useful in showing up the drug industry for its unethical prac
tices. All the publications under review fall into this category
and are themselves a reflection of the growing strength of
the movement.
The Consumer Association of Penang (CAP) brought out
a series of reports in 1986 aimed at providing the public with
the results of some of the important areas of CAP’S activities.
The first of the series is on chloroform. The study finds
that in Malaysia “despite all the documented evidence of its
dangers, chloroform is present in many products’’. Strengths
below 10 per cent are exempt from the Malaysian Poison Or
dinance 1952 and the Poisons List 1983. Chloroform is a
commonly used ingredient in cough preparations. Interesting
ly, the Drug Index for Malaysia and Singapore lists only three
preparations under chloroform containing products. And yet
the study has found numerous others in the market. It has
also drawn attention to the inadequate information available
especially with reference to the hazardous nature of the pro
duct, particularly when consumed by children. A review of
the advertising of these products in the lay press has also
been undertaken. Of the other three booklets, two are on
antihistamines and one on an anabolic steriod. All the three
were presented to the ministry of health, Malaysia in July
1986. In October the government announced that these three
drugs had been banned. Manufacturers and distributors were
given three months to withdraw all products containing these
drugs.
Although pizotifen, an antihistamine, is classified as a
Group C poison, the study group found that it could be easily
bought over the counter. The drug used in the treatment of
migraine in developed countries is heavily promoted as an
appetite stimulant in Malaysia. No contraindications are ever
42
mentioned. Similar is the case with cyproheptadine, another
antihistamine drug. In the US only one preparation of the
drug, Periactin is marketed and is indicated for use in allergy
conditions and as a supporting drug in anaphylactic reac
tions. The study finds that the company, Merck, Sharp and
Dohme is practising double standards in its marketing of the
product in developing countries.
The Consolidated List is in a sense a triumph of the drug
consumer movement all over the world. In 1982, because of
pressure from these groups, the UN General Assembly “aware
of the damages to health and the environment that the con
tinued production and export of products that have been
banned and/or permanently withdrawn on grounds of
human health and safety... is causing in the importing coun
tries’’ and because many of these countries lack adequate
information suggested to the secretary-general that a Con
solidated List be prepared of products whose consumption
and/or sale have been banned, withdrawn or severely
restricted or not approved by governments. The list was to
be easily readable, and was to contain both the generic as
well as brand names. Needless to say, this sent shock waves
through the multinational drug industry. The pressure that
was put on the group entrusted with the task to leave out
the brand names, is a telling illustration, if one were need
ed, of the enormous political influence that the industry
wields on governments in the developed countries as well as
in the third world.
The first issue of the List came out in December 1983 and
again was the target of much flak from the industry and
vested interests. The Coordinating Committee had to make
a sustained campaign to scuttle the industry’s move to do
a hatchet job on the List, and all such future publications.
The current List is a 655 page volume listing 600 products
(100 more than the last one). It is basically in three parts—
pharmaceuticals, agrichemicals and industrial chemicals. It
records the status of each of these products in all countries
(or at least as many as have provided the information). At
the end of the volume is a list of brand names of these pro
ducts.
It must be stressed that this is the first time such infor
mation is available in a consolidated manner in one volume.
Every effort must be made to keep the initiative from being
killed. For one thing, governments either because of the usual
bureaucratic problems or because they are under pressure
from vested interests, are not very prompt in providing in
formation about changes in legislation regarding particular
products. It is here that voluntary groups could play a role.
PP
Radical Journal of Health
Workers’ Health and Labour Militancy
gerald markowitz
The Struggle for Workers' Health: A Study of Six Industrialised Countries by Ray H Eiling, Baywood Publishing
Co, 1986, 500 pages, $ 37.50.
US workers face a multitude of dangers on the job and (he
Reagan administration has been largely successful in hob
bling the Federal Occupational Safety and Health Ad
ministration (OSHA) and state regulatory efforts. This book
puts the problem in an international perspective, with very
disturbing results. Eiling shows that even at its best, OSHA
compares very poorly with other capitalist countries’ occupa
tional safety and health systems.
Swedish policy seeks to insure that employment is fitted
to the health requirements of workers. Sweden’s concept of
health is also unusually broad, taking into consideration not
only physical conditions but also the use of “piece work, shift
work, incentive systems, and psychosocial factors related to
physical and mental illness.” For instance, Swedish research
has shown that the degree of control workers have over their
work affects their rate of coronary disease.
•Eiling uses a Marxist framework to analyse occupational
safely and health (OSH) problems: “Most if not all OSH
problems stem from the inequitous exploitation of relatively
powerless workers engaged in producing value which is ex
propriated for the private use of a ruling elite,” he states. Eil
ing surveys the history and political economy of the coun
tries he studies, and details the OSH system in each. The
countries studied are the US, Britain, the German
Democratic Republic (DGR), the Federal Republic of
Germany, Finland and Sweden.
At the core of the Swedish system are 1,11,000 safety
delegates elected through their unions. There must be a
delegate in every plant with at least five employes. These
delegates are empowered to interrupt work that poses an im
mediate or even long-range danger to workers. Every
workplace with over 50 employees must have a joint labour
management safety committee in which workers are in the
majority. The committee helps hire plant physicians and
safety engineers. Sweden’s system cannot even be compared
to the US’s non-system. Here, only workers who are
represented by health and safety conscious unions like the
Oil, Chemical and Atomic Workers can expect protection.
Even so, Eiling notes that Swedish workers are subject to
some of the same pressures as those in the US. Even in
Sweden, workers can be cowed by management threats to
move or shut down in the event of costly health and safety
demands.
Eiling suggests that only a revived and militant labour
movement can improve the US’s abysmal health and safety
system. But by describing what workers have won in other
capitalist countries, Eiling shows that the fruits of struggle
can be crucial to workers’ well-being.
Eiling compares six elements in the countries’ OSH
systems: policy, sponsorship and control, education,
organisation, information and financing. He concludes that
Sweden and the GDR have developed the most comprehen
sive systems for protecting workers’ health; Finland’s system
is somewhat less strong. Britain and the Federal Republic
of Germany rank much lower, and the US offers workers the
least protection, he concludes. While acknowledging that his
conclusions are tentative, Eiling’s analysis is extremely useful
for both activists and researchers.
Eiling maintains the single biggest factor determining the
quality of a country’s OSH system is the strength of its
workers’ movement. In Sweden, for instance, 95-98 per cent
of blue-collar workers are organised and 70-75 per cent of
other workers are unionised. As a result, Sweden has
developed a system that is light-years ahead of the US (where
only 18 per cent of workers are unionised).
Gerald Markowitz is coeditor of “Dying for Work”
(Indiana University Press) and “Slaves of the Depression:
Workers’ Letters About Life On the Job” (Cornell University
Press). Bay wood Publishing Company is at Box D, 120
Marine St Farmingdale, NY 11735. Reprinted from The
Guardian (US), August 8, 1987.
Systems Approach to Problem-Solving
Agencies Working Together: A Guide to Coordination and Planning by Robert Ross, Kevin Gilmartin and Charles Dayton,
Sage Publications, 1982. Price S 7.95, pp 119.
THIS publication is part of the Sage Human Services Guides
Series (Vol 28). It is an attempt at delineating various ap
proaches to inter-agency coordination based on an actual
study of such coordination in the state of California. With
a spate of NGOs working in the field of ‘human services’
the need for effective communication and coordination bet
ween various agencies, so that they can help each other, also
increases. In essence this book is a guide written for all sorts
June-Sept 198/
of welfare and social service agencies. It discusses various
methodologies and approaches ‘tried out successfully* that
can help build up effective inter-linkages between agencies
in order to provide better services to their clientele.
The book is useful for those who feel that a systems ap
proach solves most problems in management.
RD
43
Dialogue
Medicine in USSR
Analysis Lacks Rigour
anant r s
BOB DEACON’S ‘Medical Care and Health under State
Socialism’ (RJH Vol 1.1) starts on a very sound note. In the
first part, it separates six main aspects of socialist health care
and shows that there is much more in real socialist health
care than what the traditional left thinks it to be—widely
available and almost free medical care. An analysis of
medical care in any post-revolutionary society would be in
adequate, unless it systematically goes into the aspects dealt
with by Deacon. I would add two more aspects to a really
socialist communist health care: (i) rational use of drugs and
other medical facilities (investigations, hospital-beds, etc),
(ii) a clear break from a medicalised attitude towards
healthproblems (an attitude which believes that ‘there is a
pill for every ill’, and still worse looks upon all deviations
from the upper class white male model as abnormal or even
all physiological phenomenon as health problems to be
solved by medical therapy).
In analysing the Soviet medical policy, however, Deacon
is not careful, or rigorous enough. The empirical basis of
his conclusions is, therefore, quite problematic.
For example, he makes the usual mistake of comparing
Soviet Union with advanced capitalist countries—the Euro
pean Economic Community. This is an ahistorical com
parison. These EEC countries were far ahead of Russia at
the time of Revolution in 1917, and hence we should com
pare Russia of today with say Portugal or Italy which were
also like Russia, quite backward, at that time. The USSR is
even today backward in some respects as compared to the
United States or some imperialist European powers. This in
itself does not mean at all that Russia is not socialist or
socialism is worse than capitalism.
In assessing whether or not USSR is spending ‘more’
money on health care, Deacon makes a second added mistake
of taking the medical care expenditure of capitalist coun
tries as ‘standard’. It is well known that advanced capitalist
countries were overusing drugs and other medical facilities,
that the medical-industrial complex is a big racket. Hence
if a country is spending less on medical care than these stupid
civilisations, that by itself cannot be taken as a bad thing.
An appropriate indicator would be to find out what percen
tage of medical needs are being met and in what manner.
Admittedly this is a difficult indicator to quantify and we
may not get proper, comparable data about this. But some
rough estimation can be made. A rough estimation in a pro
per direction is better than a precise estimation in a wrong
direction: If medical expense as an indicator of better care
is to be taken, then the comparison has to be made with the
pre-revolutionary situation. Finally, we must remember that
the ultimate aim of a socialist society would be reduce the
necessity of medical care and hence the relative proportion
of medical expenses as well.
Deacon has properly drawn attention to the both ‘relative
and absolute rise’ in USSR in the so-called ‘disease of moder
44
nisation’ like cardiovascular diseases and cancer. But more
information is needed to draw valid conclusions. As infec
tious diseases decline, even in a really socialist society, more
people are likely to die of degenerative disorders. In the im
perialistic countries a very large number of people die
prematurely (in their forties or fifties) of these degenerative
disorders because of the unhealthy ‘American way of life’.
One must know whether such a premature morbidity and
mortality in the USSR exists or ndt, is rising or not and
whether (like in western capitalist countries) it can be trac
ed to wrong kinds of food, work environment, social environ
ment and so on. The rise in the USSR in “the age-adjusted
death rate by 18 per cent over last decade” as quoted by
Deacon is an indicator. But we need more information before
drawing valid conclusions.
Deacon’s article contains hardly any information about
whether or not the domination of doctors as experts, over
paramedics and the patients, the philosophy of ‘the-doctorknows-all-and-hence-will-decide-all’ has decreased in the
USSR or not. The lowering of the status of doctors in terms
of their pay-scales and privileges is different from changing
the role of expertise. In the absence of proper specific infor
mation on these aspects (point numbers nine to twelve in his
table no III), his conclusions on these points cannot be taken
as valid.
If all these and such points are rigorously taken into ac
count to find out the trend (and" not merely a static picture
in a particular year), one has a hunch that one would come
to the same or even more critical conclusion than Deacon’s.
USSR is a stale socialist society which has gone far ahead
of many comparable capitalist societies but cannot be call
ed a socialist society in the sense in which Marx understood
this concept. But one must be aware that Deacon’s conclu
sions in this article are not based on solid evidence.
Lastly, a word about the sexual division of labour in
medical care in the USSR. As pointed out by Deacon, 90
per cent of primary health care physicians in the USSR are
women. This is quite in contrast to capitalist countries
wherein males overwhelmingly predominate in this position.
But in the USSR, in the thirties and forties, (he status and
pay-scales of engineers and scientists were kept much higher
as compared to doctors since the planners gave higher priori
ty to these skills. This tradition still persists, though it now
appears to be changing. Men predominated in these more
prestigious, more paying fields and women went to less
prestigious, less paying positions of doctors. This shows that
though USSR has got over the typical sexual division of
labour as found in capitalist medicine, a different mode of
sexual division of labour has taken its place; and has
stabilised—something one does not expect in a truly socialist
society. Deacon has missed this point in his discussions of
medicine in the USSR.
Radical Journal of Health
Politics of MCH
pad ma prakash
MANISHA GUPTE’s article (RJH, I: 2) provides a broad
framework for analysing health policy vis a vis women.
The needs of capitalist accumulation mediate through
patriarchal structures and relations suppressing women’s
rights to health and reproduction. This mediation takes
different forms in different societies. In a country like
India, it is intcresing to look at the process by which the
needs of capitalist development have simultaneously
strengthened and altered patriarchal structures. It is
especially necessary to take cognisance of the manner in
which the Indian state has coopted and adapted the
demands of a ‘democratic’ polity for its own purpose. The
history of maternal and child services in India provide
an illustrative example of this. In the evolution of policies
and programmes directed at the welfare of mothers and
children especially in recent years, it is possible to discern
the way in which the state has, responded to the growing
influence of the women’s movement and has accomodated
the demands of the increasingly vocal and influential con
sumers of health care. ‘Programming reproduction’ is just
one aspect of MCH services. Further, there is also the
question of how progressive movements must view such
policies and programmes.
As early as the mid-nineteenth century concern for
maternal health motivated a series of efforts. This con
cern was, of course, somewhat spurious. Introducing
‘modern’ methods of maternal and child care had served
multiple objectives. Firstly, it was seen as a means of
approaching women so as to “educate them. . . show them
the beauties of Christianity, for only then would the
regeneration of India be a reality and the conversion of
its people an accomplished fact”.
Secondly, the MCH movement in India even in its
limited spread, enlarged the base of operation of ‘scien
tific’ medicine which in England was becoming highly
organised and sex and class biased. The MCH rhetoric
of the time saw indigenous maternity practices as the main
cause of the high maternal mortality and held modern
practices, especially in hospitals not only as being pro
gressive but safer and more hygcnic. It was to staff these
new lying-in hospitals that Indian women were encouraged
to take up medicine. This is especially ironic since at about
the same time women in Britain were fighting bitter battles
to be allowed to train for and practise medicine. Clearly
the move in India had little to do with encouraging women
to enlarge their sphere of activity in society, but more with
the needs of the colonial government.
Thirdly, the promoting of modern maternity practices
through the MCH movement fitted well with the philo
sophy of the reform movement advocating women’s
education in India—so that as mothers they would be
capable of giving birth to and bringing up a new genera
tion of progressive Indians. The MCH movement became
a vehicle for bringing about this ‘regeneration’ of India
for both the British and the Indian liberals although it
meant different things to the two. Its outreach however,
was confined to the upper classes in the urban areas in
the presidencies. Needless to say it hardly had any impact
June-Sept 1987
on the maternal mortality or child mortality in the
country.
MCH continued to be a priority area in the health
policies of independent India. The Bhore committee con
tinued to view these services as not only a measure for
reducing maternal mortality but as a necessity in order
that women could adequately perform the function of
motherhood. Facilities for the protection of women’s
health in the ‘productive’ sphere were mainly meant to
ensure her ‘reproductive’ adequacy. But at the same time
the maternity and child welfare centre “with its combined
attack on the health and social problems of the Indian
home” was expected to play a vital role in the programme
of ‘national reconstruction’.
Increasingly however, investments in the reproductive
health of the woman became far more important than her
•health in the factory or the field. “The protection of the
health of the expectant mother and her child” (irrespec
tive of whether she occupied a place in the sphere of
production) became of paramount importance “for
building a sound and healthy nation”. The mother became
officially recongised in policy as the channel for
‘educating’ the entire family. After this although MCH
continued to be a national programme its focus became
increasingly narrow and its implementation poor. Quite
apart from the fact that MCH programmes did not
recognise the real causes of maternal mortality their
impact on the section of the population which accounted
for a large proportion of maternal deaths was minimal.
Interest in MCH also began to decline. (For example, there
were hardly any ICMR research projects in the area after
the mid-sixties. This disinterest in the health of the mother
is manifest even in those areas outside MCH which had
some import for maternal health. For instance, research
in anemia—increasingly the focus* became narrow and
oriented towards developing quantification methods
which all but ignored the real problems in the area.)
Recent years have seen a revival of interest in MCH
which has to be seen in the context of other developments
such as the status and location of women, the current
priorities of the state as well as the pulse of popular/mass
movements.
In the last decade a great deal of attention became
focussed on women’s status and issues affecting their
status. This decade, the UN Women’s decade ironically
enough, also saw a deterioration in the economic situa
tion of women. Much work has been done on how the
development processes have in fact been the cause of
women losing their jobs and the means of livelihood—as
for instance happens when the introduction of new
technologies in agriculture results in women having to give
up their traditional occupations, or when modernisation
of processes handled by women in industry results in the
loss of jobs.
At another level, the only sector which has recorded
a growth in employment, the service sector, has also
registered a significant rise in women’s employment. In
other words it would not be wrong to infer that while the
45
economic and social status of women of the labouring
classes is rapidly declining, women who have access to
formal education, generally from the better-off layers of
the urban working class and the middle class, arc finding
jobs in the expanding service sector. This in turn con
tributes to the growing purchasing power the middle class
which provides a market for the products of the expand
ing consumer industry. This factor has to be kept in mind
when assessing the purported objectives and the real
impact of any programme such as the MCH.
Secondly, there is the undoubted impact of the women’s
movement not only on national policies but international
ly as well. The movement has had the result of highlighting
the low social, economic and health status of women.
Indices such as maternal mortality suddenly became
major issues which needed to be tackled or at least should
appears to have been dealt with.
Thirdly, the health status, health care structure and the
priorities bf health care have undergone a change. One
could well hazard a guess that the class differential in
health status has become sharper than ever before (See
for instance NIN’s nutrition surveys which actually shows
a decline in consumption levels—although of course, the
NIN has grossly tried to cover it up). Inevitably the sex
differential in health status would also have sharpened.
As a consequence the class biases in health care delivery
have become clearer. In addition, the trend towards in
creasing privatisation as well as the more widespread use
of the fee-for-service principle even in state health services
will aggravate the disparities in people’s relative access to
service. Inevitably of course, the priorities of health pro
grammes have also changed.
AU this has to be taken into-a ccount in understanding
the real nature of MCH programme. Because the state
needs to sustain the growth of the purchasing power of
the expanding middle class, women’s employment in
certain sprreres’ is a desirable goal. Thus health care-for
women so that they are able to handle the two spheres
of activity becomes a necessary service which the state
accepts responsibility for. Promoting the small family
norm is again desirable—both so that resources can be
optimised as well as because the process of socialising
children to fit into patriarchal society can take place
efficiently.
Thus for instance, quite clearly, the nutritional supple
ment component of these programmes is irrelevant to the
section of the population who cannot obtain two full
meals. Pumping an expectant mother with vitamins when
she has abominably low calorie intake is an absurd
exercise—and the state is well aware of it. The compo
nent is really meant for a different class—the small
farmer/lower middle class, where there is just about suf
ficient food but not enough to take care of the extra needs
of pregnancy. On the other hand, the anganwadi program
mes may well be used by all sections, including the poorest
women who may then be ‘released’ to work the fields
without encumberances or alternatively at the EGS sites
thus increasing the numbers on state dole (which accrues
to the image of a welfare state).
46
But most importantly these programmes are redifining
and restructuring the role of women in patriarchal class
society at. the present juncture. Beginning with the
breastfeeding campaign, the immunisation programme
and the anganwadis, the woman’s role in the upbringing
of the child is being redefined. The concept of the family
with its hierarchies as the primary socialising institution
in capitalist patriarchal society is being reemphasised.
Investments of all kinds in the family and in children are
rising. In order to ensure the continued existence of the
family, the ruling class has to reetch the female stereotype
which will accomodate the new feature of an employed
mother and wife. The setting up of a department for
women and children cannot be regarded merely as a
response to the pressures of the women’s movement. It
has a necessary role to play in drawing up a new image
of Indian womanhood. It is in this context that we have
to assess any programme, whether in health or otherwise,
directed at women.
How then do we regard these programmes? Should we
reject them entirely? Or can elements of these be used to
advantage to weaken the very structures which the state
is trying to strengthen?
While this needs to be tackled in a more elaborate
manner, here are some pointers . For one thing, any
critique of state services—especially in MCH—must
ensure that the trends which emerge as a result do not
reject state services by opting for more expensive and
perhaps less efficient private care. This will only mean that
the tendency of the state towards ridding itself of its
welfare obligation will get an added boost. On the other
hand, by highlighting the inadequacies of the service, there
is an opportunity to initially pressurise for better service
but in the long run also to show up the non-viability and
insincerity of the welfare goals.
At the same time the sexist and class bias of these
services also need to be brought out in the open. The fact
that these programmes project a model of Indian woman
hood which reinforces existing norms which themselves
need to be challenged is a task that the health groups and
the women’s movement must take seriously. And this is
a difficult challenge—it comprises not merely in confron
ting the real objectives of state services, but in tackling
the inherent sexist and class ideology of the medical
establishment.
IN SEARCH OF OUR BODIES
Feminist View of Health and Reproduction in India
Papers presented at the workshop on “Women, Health and
Reproduction in December 1986 organised by Shakti. Plus
the invigorating discussions which threw up myriad
questions—more questions perhaps, than answers. And that
is the best way to begin the search for our bodies, by peeling
away the layers of myth and mystique which have distorted
our understanding of ourselves as women.
Available from Mira Savara,-Shakti, B-10, Sun and Sea Apts,
J P Road, Versova, Andheri (W), Bombay 400 058.
Radical Journal of Health
Radical Journal of Health
Index to Volume I
(1986-87)
Anatomy of Nuclear War by Achin Vanaik
113
A Bird’s Eyeview of Psychology by Poornima Rao (Book Review)
39
Bombay’s Health Priorities by PP (Update)
130
Community Participation in Integrated Child Development Programmes by V Raman Kutty
133
Contradictions Where There are None by Thomas George (Dialogue)
40
Condition of the Working Class in England by Frederick Engels (Quote)
Cover 3
Don’t Just Reduce Risk, Transform It! by Dave Rosenthal
119
Double Standards: Some Improvements (Update)
131
Multinationals and WHO (Update)
31
The Earth is a Satellite of the Moon by Lionel Rugama (Poem)
Cover 1
ECT and Drug Therapy: Is there an Alternative? by A R (Dialogue)
76
Exploding Myths by Anant Phadke (Book Review)
37
Female Patients versus Male Doctors’ Universe by Jytte Willadsen
69
Fifth International Women and Health Conference (Update)
68
Health Care in Mozambique by Padma Prakash
25
Health Hazards of Nuclear Cycle by Manan Ganguli
116
Health in Nicaragua by Amar Jesani
3
Health in Seventh Plan: Boost to Private Sector by Ravi Duggal (Update)
29
Homeopathy by B K Sinha
32
Holistic Alternative to Scientific Medicine by Howard Berliner and Warren Salmon
59
Hunger and Myth of Plenty by Bernard D’Mello (Book Review)
138
Immunisation as Populism: A Report by Asha Vohuman
52
Ills of Public Hospitals by PP (Update)
68
(The) Irreversible Welfare State: Its Recent Maturation, Its Encounter with the Economic
91
Crisis and Future Prospects by Goran Therborn and Joop Roebroek
Isolate Apartheid Health Care (Update)
100
Issues in ‘Post Revolutionary’ Health Care (Editorial Perspective)
1
Legislation on Abortion in Yugoslavia (Update)
67
Light on ‘Blind Spots’ by U N Jajoo
74
Local Traditions and Primary Health Care (Update)
30
Medical Care and Health Policy under State Socialism by Bob Deacon
11
Medical Officers: The ‘New Middle Class’? (Dialogue)
107
Medical Response to Nuclear Threat
112
Milk Monitors by Pauline Jackson (Book Review)
136
Miracles and Profits in Sickness by Virginia Scott (Update)
101
My Sin. . . Analgin by Anil Pilgaokar (Poem)
Cover 2
Myth of Alternative Medicine by Thomas George (Dialogue)
140
Nightmare of a Dream by Padma Prakash (Editorial Perspective)
109
(The) Numbers Game by V T Padmanabhan
129
Physician’s Oath and Statement of Medical Ethics
Cover 4
Political Economy of State Health Financing by Ravi Duggal
79
Politics of Primary Health Care by Imrana Quadeer (Editorial Perspective)
41
Population Policy and Situation in China by Malini Karkal
22
Privatisation of Medicare: Help from GIC by K R (Update)
66
Programming Reproduction? Maternal Health Services by Manisha Gupte
55
Ruins and War by ACJ (Update)
130
Sex Determination Tests: A Survey by Sanjeev Kulkarni (Update)
99
Social Dialectics of Primary Health by Guy Poitevin
43
State in Health Care by Smarajit Jana (Editorial Perspective)
77
State in Medical Care by Sujit Das
86
Towards a Left Critique of New.Drug Policy by Anant R S
102
Towards Rational Therapy-LOCOST (Update)
100
Vaccine Production in Private Sector by R S Dahiya and Peeyush Sharma (Dialogue)
140
June-Sept 1987
47
Author Index
ACJ: Ruins of War (Update)
131
Anant R S: Towards a Left Critique of a New Drug Policy
102
A R: ECT and Drug Therapy—Is there an Alternative?
76
A R S: Medical Officers—the ‘New Middle Class’?
107
Berliner. Howard and J Wanen Salmon: The Holistic Alternative to Scientific
59
Medicine—History and Analysis
Dahiya. R S and Peeyush Sharma: Vaccine Production in Private Sector
140
Das, Sujit: Organising Doctors: A Difference in Approach
73
Das, Sujit: State in Medical Care
86
Deacon, Bob: Medical Care and Health Policy under State Socialism
11
Duggal, Ravi: Health in Seventh Plan—Boost.to Private Sector
29
Duggal, Ravi: Political Economy of State Health Financing
79
Ganguli, Manan: Health Hazards of Nuclear Cycle
116
George, Thomas: Contradictions Where There are None
40
George, Thomas: Myth of Alternative Medicine
139
Gupte, Manisha: Programming Reproduction?
55
HAI News: Double Standards—Some Improvements
131
Jackson, Pauline: Milk Monitors
135
Jajoo, U N: Light on ‘Blind Spots’
73
Jana, Smarajit: State in Health Care
77
Jesani, Amar: Health in Nicaragua—Epidemiology of Aggression
3
Karkal, Malini: Population Policy and Situation in China
22
K R: Privatisation of Medicare—Help from GIC
66
Kulkarni, Sanjeev: Sex Determination Techniques—A Survey
99
Kulty, Raman V: Community Participation in Integrated Child-Development Programmes
133
LOCOST: Towards Rational Therapy
100
Mankad, Dhruv: Issues in ‘Post Revolutionary’ Health Care
1
Padmanabhan, V T: The Numbers Game
124
Phadke, Anant: Exploding Myths
37
Pilgaokar, Anil: My Sin. . . Analgin
Cover 2
Poitevin, Guy: Social Dialectics of Primary Health
43
Prakash, Padma: Health Care in Mozambique
5
Prakash, Padma: Nightmare of a Dream
109
PP: Bombay’s Health Priorities
130
Quadeer, Imrana: Politics of Primary Health Care
41
Rao, Poornima: A Bird’s Eyeview of Psychology
39
Roebroek, Joop and Goran Therborn: The Irreversible Welfare State
91
Rosenthal, Dave: Don’t Just Reduce Risk, Transform It!
119
Rugama, Lionel: The Earth is a Satellite of the Moon
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Salmon, Warren J and Howard Berliner: Holistic Alternative to Scientific Medicine
59
Sharma, Peeyush and R S Dahiya: Vaccine Production in Private Sector
140
Sinha, B K: Homeopathy
32
Therborn, Goran and Joop Roebroek: The Irreversible Welfare State
31
Vanaik, Achin: Anatomy of Nuclear War
113
Vohuman, Asha: Immunisation as Populism
52
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On Headaches
It’s beautiful to be a communist
even though it gives you lots of headaches.
And the thing is that the communist’s headaches
are supposed to be historical, that is to say
they don’t go away with aspirins
but only with the realization of Paradise on Earth.
That’s how it is.
Under capitalism our heads ache
and they decapitate us.
In the struggle for the revolution the head is a time-bomb.
In the construction of socialism
we plan headaches
which doesn’t make them any less frequent, just the other way arour.
Communism will be, among other things,
an aspirin the size of the sun.
roque dalton (El Salvador)
Position: 3736 (2 views)