Merchants of Health:
Medicine and Consumer Culture in the United States, 1900–1940

Nancy Tomes

Over the last one hundred years, Americans have lived longer, received better medical care, and pursued health more single-mindedly than ever before. American medicine has risen from a position of relative mediocrity to world dominance in research and a privileged place in modern culture. As a consequence, some scholars have argued, the "American century" might well be termed the "health century." Yet within the last three decades, unsettling change has swept through the American health care system. Due to growing concerns about patients' rights and health care costs, physicians and hospitals now deliver their services under fiscal and regulatory constraints unimaginable even a decade ago. Policy makers, politicians, and voters are engaged in an often rancorous debate about what has gone wrong with American health care. As the new century begins, the health care crisis looms large in the national psyche.1	1
These recent developments leave historians of medicine with a great deal to explain. Much as the falling of the Berlin Wall forced diplomatic historians to rewrite the history of the Cold War, the health care crisis of the 1990s forces us to reconsider medicine's place in twentieth-century American history. Long treated as an exemplar of the modern profession, medicine seemed exempt from external regulation by virtue of its practitioners' technical expertise and unique relationship with patients. The startling fall of this "sovereign profession," as the sociologist Paul Starr termed it in 1982, from a powerful lobby and an icon of progress to an object of national angst thus invites new historical interpretations.2 In providing those interpretations, historians of medicine have an unprecedented opportunity not only to address contemporary concerns but also to reflect on the changing meanings of scientific expertise, social welfare, and personal choice in twentieth-century American society.	2
In recent years, senior scholars, chief among them Kenneth M. Ludmerer, David J. Rothman, Paul Starr, and Rosemary Stevens, have stepped up to the challenge of offering historical insight into the current health care crisis. Through the history of the hospital, the medical school, and the medical profession, they have charted the rise and fall of medicine's professional autonomy and cultural authority during the last century. Their work illuminates what Ludmerer calls medicine's "first revolution," that is, the convergence of major scientific discoveries, institutional innovations, strong leadership, and pressing social needs that brought American medicine unprecedented professional authority and prestige by the 1950s; they also explore the subsequent developments, such as internal loss of cohesion, external challenges to expert authority, and changing views of public spending, that paved the way for a second, so-called managed care revolution. 3	3
The "two revolutions" narrative, most clearly summed up in Starr's The Social Transformation of American Medicine, has much to recommend it as a synthesis. But to date, it has been a narrative focused primarily on elite actors, such as the American Medical Association (AMA), medical educators, hospital administrators, corporate executives, and federal policy makers. In contrast, the categories of "patient" and "public" remain sketchy. Scholars assume that widespread popular esteem for science undergirded medicine's growing cultural authority in the first two-thirds of the twentieth century and that the weakening of this popular confidence has been central to its loss of autonomy in the last third. Yet the process by which that popular esteem was developed, exercised, and eroded remains largely outside recent histories of modern American medicine.4	. . .