5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h .docx

5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h C a r e
S o l o t n o n , H . A . 1 9 8 4 . T h e E x a r c i s e M y t D .
N e w Y o r k :
H a r c o u r t B r a c e J o v a n o v i c h .
S p i l m a n , M . A . , A . C i o e t z , J . S c h u l t z , R .
B e l l i n g h a m ,
a n d D . J o h n s o n . 1 9 8 6 . E f f e c t s o f a H e a l t h
P r o m o -
t i o n P r c r g r a n t . J o u r n a l o f O c c u p a t i o n a l
M e d i c i n e
2 8 : 2 8 . 5 - 8 9 .
S t e i n , . f . 1 9 8 5 . I n d u s t r y ' s N e w B o t t o m L i
n e o n H e a l t h
Ciare Costs: Is Less Better? Hastings Center Report
l - 5 ( . 5 ) : l 4 * 1 8 .
S t e r l i r r g , J . D . , a r . r c l f . . f . W e i n k a m . 1 9
8 6 . E x t e n t , P e r -
s i s t e n c c a n c l C l o n s t a n c y o f t h e l { c a l t h y
W o r k e r o r
H c r l t l . r y P e r s o n F . f f e c t b v A l l a n d S e l e c
t e d C l a u s e s o f
Death. Journal of Occupational Medicine 28:348-
5 3 .
S y m e , L . S . , a n d L . F . B e r k m a n . 1 9 7 6 . S o c
i a l C l a s s ,
Susceptibility and Illness. American Jonrnal of Epr

demiologl' I 04: l-8. ,
U.S. Department of Health, E,ducation, and !ilelfare.
1,979. Healthy People: The Surgeon General's Re-
port on Health Promotion and Disease Preuention.'Washingtorr.
'Walsl.r, D.C. 1984. Corporate Smoking Policies: A
Revrew and an Analysis. Journal of Ocarpational
M e d i c i n e 2 6 : 1 7 - 2 2 .
A Cesn FoR RrpocussrNc Upsrnndtvt: THE Pouucet
EcoruouY oF lrrlurss
. l o h n B . M c K i n l a y
M y f r i c n c l , I r v i n g Z o l a , r e l a t e s t l - r e s t o
r y o f a
p h y s i c i : r r r t r y i n g t o e x p l a i n t h e d i l c m r n
a s o f t h e
r n o c l e r n p r a c t i c e < l f r r e d i c i n e :
" Y o u k n o r , " ' , " l r c s a i c l , " s o r l e t i r n e s i t f
e e l s l i k e t l - r i s .
T h e r c I a m s f a n c l i n g b y t l r e s h o r e o f a s w
i f t l y f l o w -
i n g r i v c r a n t l I h e e r t h c c r y o f l c l r o w n i n
g m a n . S o I
j r r n r p i n t o t l i c r i v c r , p u t n 1 y r r r n s a r o u n
c l h i m , p u l l
h i r n t o s h o r e a n c l a p p l y a r t i l i c i a l r c s p i r
a t i o n . . f u s t
w l r c n h c b c g i n s t o b r c a t h c , t h e r c i s r r t o t
h e r c r y f o r
h c l p . S o I j u m p i r r t o t l r c r i v e r , r c : r c h h i
m , p u l l h i n r
t o s h o l c , a p p l v a r t i f i c i e l r c s p i r a t i o n , a r

- r d t h e n j u s t
a s h e b c g i r r s t o b r e a t h e , r l n o t h e r c r y f o r
h e l p . S o
b a c l < i n t l r c r i v e r r r g r r i n , r c r r c h i n g , p u l
l i n g , a p p l y i n g ,
b r c a t h i n g a l i c l t h c n r u r o t h c r v e l l . A g a i n
a n c l a g a i n ,
w i t h o u t e u c l , g o e s t h c s c q u e n c e . Y o u k n o
w , I a n r s o
b u s y j L r r r - r p i n g i n , p r - r l l i n g t h e m t o s h
o r e , a p p l y i n g
a r t i 6 c i r l r c s p i r a t i o n , f h r r t I h a v e n o t i m
e t o s e e w h o
t h c ' h e l l i s u p s t r c r r n . r p u s h i n g t h e n r a l l i
n . " r
I b e l i e v e t h i s s i r l r p l e s t o r y i l l u s t r a t e s t
w o i m -
p o r t r r r l t p o i n t s . F l r s r , i t h i g h l i g h t s t h e
f a c t t h i r t a
c l e a r r n a j o r i t y o f o r " r r r e s o u r c e s a n c l i r
c t i v i t i e s r n
t h e h c a l t h f i e l d a r e c l e v o r e d t o w h a r I r e r
m
" c l o w n s t r e a n r e n c l e : r v o r s " i n t l - r e f o n n
c l f s u o e r f i -
c i a l , c a t c g o r i c a l t i n k e r i n g i n r e s p r l n s e t
. , a f m o s t
p e r e r . r n i a l s h i f t s f r r t r . n o r . r c I ' r e a l t h i
s s u e t o t h e
n e x t , w i t h o r - r t r c a l l y s o l v i n g a n y t h i n g .
I a n t , o f
c()urse, not suggesting that sucl.r effclrts are en-
t i r e l y f u t i l e , o r t h i t t a c o n s i d e r a b l e a m o
u n t o f

short-te n'n good is not being accomplished.
Clearly, people iurd groups have important im-
rnediate rreeds which must be recognized and at-
t e n d e d t o . N e v e r t h e l e s s , o n e u r u s t b e w a r
y o f
tlte shryt-tertn nLtture
^nd
ultinxate futility of
s u c h c l o w n s t r e a r n e n d e a v o r s .
Sec.ond, the story indicates that we should
sor.nchow ceasc oLlr preoccupirtion with this
short-tern-r, problem-specific tinkering and begin
focussing ()ur attelltion upstrearrr, where the real
problen.rs lie. Such a reorientation would mini-
mally involve irn anirlysis of the nreans by which
vrrricrrrs inclividr.rals, interest groups, and large-
scale, profit-oriented corporations are "pushing
preople it.r," arid h<tw they subsequently erectr at
sorne point downstreanl, a health care structure
t,, ,.rui.. the Ireeds wlrich they have had a hand
in creirting, ancl for which rnoral responsibility
o u g h t t o b c a s s u m e d .
in this paper two related themes will be devel-
oped. First,'l wish ,o highligh, the activities of
tlie "manufa*urers of ilinesi"-those individu'
als, interest groups, and organizations which, in
addition t., iroiuiittg maieriat goods and ser--
vices, also produce, ai an inevitable by-product'
wides
of thi
focusr

vidua
be re
range
nomi(
The
to rev
tofs lr
a t - r i s k
r e q u e s
n-rake
irnd sc
h i n d t
polnt.
term "
l e a s t t
c o u l d ,
the fan
how tl:
levels <
v i c e s . 2
p a r t i c u
t u t i o n s
stfuctu
p a t h o l <
c o u l d r
spectru
forces r
d i s e a s e ,
. . , I
that th,
vention
the inirr
s o c i a l c
decidinl

evet ls
newly e
of healt
little at;
ness.a It
develop
Inls parl
A p o
suggests
the t
,adequat
s r t
t l e
2 8 3 4 8 -
r l C l a s s ,
I o f E p i -
W e l f a r e .
ryal's Re-
e u e n t i o n .
r l i c i c s : A
'tpational
widespread morbidity and mortality. Arising our
of this, and second, I will develop rr case for re-
focussing our attention away frorn those indi-
viduals and groups who are mistakenly held to
be responsible for their condition, roward a

range of broader upstrean-l political and eco-
nomlc Iorces.
The task assigned to nre for this conference was
to review some of the br<tad social structural fac-
tors influencing the onset ()f heart diseirse rrnd/or
at-risk behavior. Since the issues coverecl by rhis
request are so varied, I have, of necessity, had t<r
rnake sorne decisions concerning lroth c.m;rhasis
and scope. These decisions and the rcasoning be-
hind them should perl"raps be expl:rinecl at this
point. With regard to what can be cclvered by the
t e r m " s o c i a l s t r u c t u r e , " i t i s p o s s i b l e t o
i s o l a t e a t
l e a s t t l . r r e e s e p a r a t e l e v e l s t , f a b s t r a c t i
o n . O n e
could, for example, focus on such subsystenrs irs
the family, irnd its associated social networks, and
how tl.rese rnay be inrportantly linkecl to clifferent
levels of health status :lnd the utilizatior.r <lf ser-
vices.2 Or-r a second level, clne cor.rld consicler lrorv
p a r t i c u l a r o r g a n i z a t i < l n s a n d b r o a d e r s o
c i a l i n s t i -
t u t i < x r s , s u c h a s n e i g h b r l r h o o d r r r r c l c r
: r n r n r u n i t y
s t n r c f u r e s , r l l s o a f f e c t t h c s < l c i a l c l i s t r
i b u t i c l n o f
p a t h o l o g y : r n c l : r t - r i s k b e h a v i o r . t ' f h i r
c l , r t t t e n t i o n
c o u l d c e n t e r o n t h e l r r o a d e r p o l i t i c i r l - c
c o n o m r c
spectnlnr, and how thesc irclurittedly ntorc rcntote
forces uray be etiologically involvecl in the onset of
o l s e a s e . . . .
. . . l l n t h i s p a p e r l I w i l l a r g u e , f o r e x a r r p

l c ,
t h a t t h e f r e q t r e n t f a i l u r e o f r n : r n y h c a l t
h i n t e r -
vention prograrl.ls can bc Iargely' ilttributcrd t()
t h e i n a c l e c l u a t e r e c o g r " l i t i o r r w c { i v c t
o r r s l ' r e c t s o f
s o c i i r l c o n t e x t . . . . T h e m o s t i r n L r o r t a n t
f a c t o r r n
d e c i c l i n g o n t h e s u b j c c t r r e i r ( ) f r h i s p . 1
P s L h e , , -
ever, is tl-re fact that, r.vhile there aprpreirrs t() be;r
n e w l y e m e r g i l t g i n t e r e s t i n t h e r p o l i t i c r
r l e c o n o l n y
o f h e a l t h c r r r e , s o c i a l s c i e n t i s t s h a v e , a
s y e t , p a i c l
little atterrtiorr to thc- ltolitical "r,rrr,rrriy
,rf ill-
a e s s . a I t i s n r f i n t e n t i o n i n t h i s p a p e r t o
b e g i n t o
d e v e l o p a c i r s c f t r l t h e s e r i o u s c o n s i c l e r
a t i o n o f
this paiticular :1rell.
A C a s e f o r R e f o c u s s i n g U p s r r e a m : T h e P o
l i t i c a l E c o n o m y o f l l l n e s s 5 1 7
long time, criticism of U.S. health care focussed
on the activities of the An-rerican Medical Asso-
ciation ancl the fee for service system of physi-
cian peryment.t'. Lately, however, attention ap-
pears to be refocussing on the relationship
between irealth care arrangements and the struc-
tr"rre of big business.T Ir hes, for: ex:rnrple. been
suggested that:

. .
"vith
the ncw rrncl apparently pcnnancnt in-
volventent of n'rajor corpor:ttions in health, it is be-
coming ir.rcrcasinglv inrprobablc tliat tlic Unitcd
Statcs cirn redircct its he:tlth priorities withour, ar
the same time, changing thc ways in which Anreri-
crn industry is orgarrized and thc wrys in whicl-r
m o n o p o l y c a p i t a l i s r n w o r k s . s
I t i s m y i m p r c s s i o n t h a t n r a n y o f t h e p o l i
t i c a l -
economic .rrgllments concerning developlnents
i n t h e o r g a n i z a t i o n o f l r e a l t h c a r e a l s o h
a v e c o n -
s i c l e r a b l e r e l e v a n c e f o r a h o l i s t i c u n c l e
r s t a n c l i n s
of thc etiology ancl distribution of nror:lriclity,
r n o r t a l i t y , a r r d a t - r i s k b e h a v i o r . I n t h c :
f o l l o w i n g
s e c t i o n s I w i l l p r e s e n t s ( ) n r c i r t r p o 1 1 1 1
1 1 J s p c c t s ( ) f
these arsunlents in thc hope clf contributing to r.r
b e t t c r u n d e r s t a n c l i n g o f a s p e c t s o f t h e p
r > l i t i c a l
e c ( ) u o n l y o f i l l n e s s .
AN UNEQUAL BATTLE
Tlre downstreanr efforts of hcalrh reseirrchers
ancl practiticlncrs agrrinst thc upstreanr c'fforts of
the nrirnr-rf:rcturers of illness havc fhc irp;lcarirncc
of art rrncqual w:rr, uitb a resounding uicttny as-
sured for those on the sicle of illness ancl the cre-
a t i o n o f d i s c a s e - i n c l u c i n s [ ) c h a v i o r s . T l

r e b . . r t t l c -
betwecn heirlth '"l,orl<ers ancl thc n'rrrnufacturcrs
of illncss is Lrneclu:rl on rlt lc:rsr nvo grclunds. In
the first place, we alw.l),s seenr t() rrn'ive rxr the
scene irnd begin to worl< rrfter tl'rc rerrl danrage
h a s a l r e a d y b e e n d o n e . B 1 ' t h e t i r r e h e r r
l t h w o r k -
e r s i n t c r v e n e , p e < l p l e h i r v e a l r c . a c l i , f i
l l e d t h e r r r r i -
fici:rl needs created fitr tltent bv the rn;lnufirctur-
e r s o f i l l n e s s : r n c l r r r e h r r b i t u : t t c c l t o v
a r i o u s
a t - r i s k b e h a v i o r s . l n t h e a r e a o f s n r o k i n g
b e h a v -
i o r - , f o r e x i l m p l e , w e h r r v e e n i l l u s t r r r t
i o u n o t
only of tl.re lateness of health rvorkers' arrival on
t h e s c e n e , a n d t h e e n o r m i t y o f t h c t a s k c o
n -
fronting them, but i,rlsci, jLrclgine by recent evi-
c l e n c e , o f t h e r c s o u n d i n g d e f e a t b c i n g s t
r s t a i n e d
; are en-
rount of
rplished.
tant lm-
I and at-
wary of
,tility of
should
ith this
rd begin
the real
ld mini-

y which
d large'
pushing
?rect, at
tructure
a hand
nsibiliry
e devel-
,ities of
rdividu'
hich, in
nd ser-
roductt
ii
, l
I
it
l l
ri
il
I
A p o l i t i c a l - e c t > r r o r r i c a n a l y s i s < l f h e i r
l t h c a r e
suggests that the entire structure of institutions
ur the United Stares is such irs to preclr-rdc the
a d e q u a t e p r o v i s i u r r o f s e r v i c e s . ' I n . . r e a
s i n g l y , i t
qeems, the provision of care is being tied to rl-rc
r i t i e s o f p r o l i t - r n a k i n g i n s t i t u t i o n s . F o r

a
518 fbw ard Altcrnatives in I'{e rith Clare
in this area." To push tlte river analogy even fur-
ther, the tzrsk becornes one of furiously swim-
ming against the florv and {inally being swept
away when exhausted by the effort <lr through
c l i s i l l u s i o n m e n t w i t h a l a c k o f p r o g r e s s .
S o l o n g
:rs we continue to fight the battle clowllstream,
a'rncl ir-r suclr rrn incffective maltrter, we are
cloomed to fnlstration, r'cgreatcd failr"rre, ilnd per-
h a p s u l t i n r a t c l v t o a s i c k e r s o c i e t y .
S e c o n d , t h c p r o n r o t e r s o f d i s e i r s e - i n c l t r
c i n g b e -
h a v i o r a r c n r a n i f e s t l y m o r e c f f e c t i v e i n t
h c i r u s e
of lreh:rviorirl scier.rce knou'lec]ge than rrre thoser
of r.rs whil arc collcernccl with the eraclication of
s u c h b e h a v i < l r . I n d c e c l , i t i s s o r l r e w h r r
t p a r r r d o x i -
crrl tl-rat wc shor-rld be rnceting here to consicler
how bchavioral scic'ncc l<r.rowleclgc arld tech-
niques can bc' effectively cr.r.tployecl to reclrtce or
prcvent irt-risk bchavior, rvhen that sarnc body
<rf knowleclge has alrcadlt been usecl to creatc
t h e a t - r : i s k b e h a v i o r u ' c s c c l < t o c l i r n i n
a r e . H o u ,
c r n b i r r r a s s i n g l y i n c f f c c t i v c i r r e o u r t r . t
; . t s s I t r e t ] i r r
c f f o r t s i n t h c h c r r l t h f i c l c l ( c . g . , a l c o h o
l i s n r , o b e -

s i t , v , d r t r g a b u s e , s a f c c l r i v i n g , p o l l u t i
o n , e t c . )
i.vhen cornparccl r,vitl-r nrrrny of tl-rc trtx c-xempt
p r o n r o t i ( ) n a l c i f o r t s o n b c h a l f < l f t h c i l
l r t e s s g c n -
c r r r t i n g r l c t i v i t i c s o f l a r g c - s c r r l c c o r p o
r r r t i o t r s . l ( r I f
i s a f a c t t l r e t w c r t r e c l c l t t o n s t l a b l y t t r o
r e c f f e c t i v c
i r r p c r s u r r r . l i n g ; r e o p l c t o 1 . r 1 1 1 c h 1 1 s g
i t c n r s t h c v
n c v e r c l r c i r n r f t h c y r v o u l c l r r c c c l , o r t (
) p u r s u e i r t -
r i s l < c o u r s c s o f r r c t i o n , t h l r n w e r r r c i t t
p l c v c t t t i t r g
r i r h a l t i n g s u c h b e l . r a v i o r . M i r n y r r c l v c
r t i s e n r c t r t s
r l r e s ( ) i n g e r r i o L r s i r r t l r c i l a p p e a l t l r a
t t h c y l ' r i r v c
c u t e r t a i n n r c n t v a l u e i n t h c i r ' o r ' v n r i g h r
r r r t c l b e -
c < l r r r c c n r b o c l i c c l i n o u r r t r t t i r > t l t l f o l
l i h t r n r o r . I l v
r v a y ' o f c ( ) n t r i l s t , r - n r r t t v h e l r l t h i r c l v
c r r i s e n r e r r t s
l a c [ < r r n y c < l t n p a r a [ r l c r ' r , i c l c s p r e a c l
a p p c : r l , o f t e r t
r l p p c : l r [ > o l i n g , a v u r t c r r l a r ; i r n c l l a r g c
l , v n r i s c l i -
r c c t e o .
I w o u l c l a r s u e t h a t o r t c n r r r i o r p r o b l e n r
l i e s r r r
t h c f a c t t h i l t w c r r r c O v c r l y c o n c c r n c c l w
i t h t h c
r,r'er: itself, ancl witlr holv we crln urorc efiective ly

p e r t i c i p i l t c i n i t . I n t h c h c a l t l t f i e l c l w c
h r r v e u t t -
q L l e s t i ( ) l i i n g l y e c c c p t c c l t l . r c i t s s u l l l
p t i ( ) n s p r c ' -
scntecl bi, the r.urrnufrlcturcrs of illncss rtncl, els a
c o n s e q u c r l c c , h i r v e c o n f i n c c l o u r e f f o r t
s t ( ) o n l , v
c l < l r v n s t r e r r r n o f f e n s i v c s . A l i t t l e r e f l
c c t i o n w o r - r l c l .
I b e l i e v e , c o n v i n c e a n y o n e t l ' r a t t h o s c o
n t h e s i c l c
o f l . r e a l t l . r r r r c ' i n f a c t l r > s i n e . . B u t t ' r
r t h e r t l " r a n
nrerely tryirrg to u'in thc war, we Ireccl to stc1.r
back and question the prcmises, legitittracy and
r r t i l i t y o f r h e w . r r i t s e l f .
THE BINDING OF AT-RISKNESS
TO CULTURE
I t s e e m s r h i r t t h e ; r p p e a l s t o a t - r i s k b c ' h
a v i o r t h a t
rrrc engincerecl by the nratrr-tfacturers of illness
a r e p a r t i c u l i r r l , v s u c c e s s f t r l l t c c a u s e t h
c v a r e c o n -
strllctecl in sr,rch a way as to bc incxtr:icably
b o u n c l w i t h c s s c n t i r r l c l c n r c n t s c l f o u r e
x i s t i n g
c l o n r i n a r r t c u l t u r e . T h i s i s a c c o m p l i s h e
d i n i
n u r n b c r o f r v a y s : ( a ) E , x h o r t a t i o r - l s t o a
t - r i s k b e -
h a v i o r a r e o f t e n p i g g y b a c k e c l o n t h o s e l e
g i t -
inrizecl values, beliefs, rrncl nort.ns wl-rich are

widcly recogniz.ecl rrncl arlhered to in tl.re dorni-
r r r u r t c u l t u r c . T h c i c l e a h c r e i s t h a t r f a
p e r s o n
rttould onll do X, tl.re n thcy
"voulcl
also be doing
Y and Z. (b) Apperrls rrrc rtlso aclvrtrtcecl which
c l a i r r r o r i n r p l y t h a t c c r t i r i n c o u r s c s o f
a t - r i s k a c -
tion arc sulrscribed to or cnclorsecl Lly r.r.rost of
t l r c c u l t u r c h c r o c s i n s o c i c t l ' ( e . g . , p e o p
l e i n t h e
c r r t e r t a i n n . r c n t i n c l u s t r ) ' ) , o r b y t h o s e
w i t h t e c h n i -
c r r l c o m p c t e n c c i n t h a t p a r t i c u l i r r f i e l c l
( e . g . ,
" c l o c t o r s " r c c o n i r l e n c l i t ) . T h e i c l c a l . r
c r e i s t h a t
if ir persorr rt.,ould onl1, i11 X, then he/she would
bc rloing plctf' nruch thc srrnre as is clone or rec-
o r n n r e n d c c l l r y s u c h p r c s t i l i i o u s p e o p l e
a s A a n d
ll. (c) ir'tificial necds rtre ttrrurufacttrrecl, the ful-
f i l l i n g o f i v h i c h l r e c o n r c s r r b s o l t t t c l y e
s s e n t i a l i f
o r r c i s t o b c r t I n c r r n i n u f r r l a n c l u s e f u l
m e m b e r o f
socictr'.-I'hc itlea l.rcrc is th.rt if e pL-rsoll does not
d o X , o r t t ' i l l r r o t r / r . , X , t h c l t t h c y a r c e
i t h e r d e f i -
c i c n t i n s o t . t t c i n r p o t ' r i l r t t r t : s p e c t , o r
t h e y a r e
s o r n e r l < i n c l o f l i a b i l i t y f o r t l r c s o c i a l
s y s t e n l '

Varirrtiorts ()n thcsc rtttcl ttther kinds of appeal
strrrtegies hrrvc', of cotlrscr, been employed for a
1,,,.,g ii,.t't. ttorv b1' thc pr()lroters of at-risk be-
h,rvior. Thc rtrarruf:rcttrrcrs of illness are, for ex-
a n r p l e , i o s t c r i n g t h e b c l i c f t h a t i f y o u w
a n t t o b e
rul attractivc, rltasculirlc llli-tllr of a "coolr" "nat'
itrrll"'uvot.tlr,i,, 1'or.t rvill sn.rokc cigareftes;.that
y o l l c a n o n l l ' l t e : r " g , r o . l p a r e n t " . i f y o u
h a b t t u -
rrte votrr chilclren tc, .:aniy' cookiei, etc:, And
,r,",''it,,"'";;';';';iy i,;;;i; *i1., voi' will feed
v,,ur, l-ri'.lr.t.,cl foocis in", ,tihigh in cholesterol
All of tl.rese appeals hlve isolated some baslc
goals to which'nrost people subscribe (e'g'' peo'
ple w,
ents,
imply,
throul
r:egula
h a v i o r
b e h a v r
twlnec
h a p s e
d i s p l a l
b e r s h i l
S u c l
at-risk
en.rplcll
hauirtr.
concep
p h y s i o l
sented

rnerrnin
terrr. Tr
we are
w o r t h l c
m o u t h v
k i l l e r s ,
a n d s u c
t h a t n t i r
ity is a
tencc. (
good nii
b y t a k i r
p h a r r n a r
t a s k o f r
q u a s i - h e
p e n d e n c .
edly four
h a r m f u l .
There
being or
and the 1
appear fr
never-en(
be linkec
have alre
sumer. B
quasi-hea
ments of
even crei
O I
request al

and ple want to be masculine or feminine, good par-
ents, loving spouses, etc.) and rnake clairn, or
imply, that their realization is only possible
through the exclusive use of their product or the
regular display of a specific type of at-risk be-
havior. Indeed, one can argue that certain at-risk
behaviors have become so inextricably inter-
twined with our dorninant cultural systen.r (per-
haps even symbolic of it) that the routine public
display of such behrrvior ahnost signifies menr-
bership in this society.
Such tactics for the habituation of people to
a t - r i s k b e h a v i o r : r r e , p e r h a p s p a r a d o x i c
a l l y , a l s o
employed to elicit what I ternl "quasi-health he-
hauior." Here again, an artificially c()nstructed
conception of a person in sorne fanciful starc of
physiological and emotional equilibriunr is pre-
sented as the ideal state to strive fclr, if one is to
meaningfully participate in the wider social sys-
tem. To assist in the attainment of strch a state,
we are advised to c()nsulre a range of cluite
worthless vitar.nin pills, rrrineral supple rneuts,
n-routhwashes, htrir shar.npoos, laxatives, pain
killers, etc. Cle:rrly, one cannot exucle radiance
a n d s u c c e s s i f o n e i s n o t t a k i r r g t l r i s v i t
a n r i r r , o r
t h a t m i n e r r r l . T h e a c h i e v e l n e n t o f c l a i l y
r e g u l i r r -
ity is a prerequisite for: an effective socirrl exrs-
t e n c e . O n e c a n o n l y c o m p c t e a n d w i r . r a f t
e r a
good night's sleep, and this can only bc ensurccl
by taking such ar.rd such. Arr entre;rreneurial
pharrnaceutical indusrry appears clevotecl to thc

task of rnaking people overly conscious of tl.rcsc
quasi-health concerns, ancl to engeuclering a cle-
pendency or.r products which have been rcpeat-
e d l y f o u n d t o b e i r r e f f e c t i v e , r r n c l c v c n
p o t e n t i a l l y
h a r r n f u l . r r
T h e r e a r e n o c l e r r r s i g n s t h a t s u c h a c t i v i
t y i s
being or will be regulatcd in any effcctive way,
a n d t h e p r o u r o t e r s o f t l - r i s q u a s i - h e a l t h
b e h a v i o r
appear free to rallge ()ver the entire bocly in thi:ir
never-ending search f<tr new arcas ancl issues to
b e l i n k e d t i r t h e f a n c i f u l e q u i l i b r i u n - r t
h a t t h c y
have already engineered ir.r thc mirrcl of tl-re con-
sumer. By binding the display of at-risk and
q u a s i - h e a l t h b e h a v i o r s o i n e x t r i c a b l y t o
e l e -
m e n t s o f o u r d o m i n a n t c t - r l t u r e , : r s i t u a t
i o n i s
even created whereby t() request people to
change or alter these behavi,r., i, ,.r.,or. or less to
request abandonment of dominar.rt culrure.
A C l a s e f o r R e f o c u s s i n g U p s t r e a m : T h e P
o l i t i c a l E c o n o r n y o f I l l n e s s 5 1 9
The term "culture" is ernployed here to de-
note that integrated system of values, norms, be-
liefs and pattems of behavior which, for groups
and social categories in specific situations, facili-
tate the solution of social structllral oroblems.L2
This de{rnition lays stress on two features com-
n-ronly associated with the concept of culture.

The first is the inter:relirtedness ancl interdepen-
clence of the various elements (vaitres, ltorrns,
b e l i e f s , o v e r t l i f e - s t y l e s ) t h a t a p p i l r e n t
l y c o m -
prise culture. The settnd is the vierv that a
culturirl systr:lll is, in sor-ne llart, a response to
social structural problems, rrncl thirt it can be re-
g i r r d e d a s s o m e k i n d o f r e s o l u t i o n o f t h e
r n . O f
c o u r s e , t h e s e s o c i a l s t r u c t u r a l p r o b l e m s
, i n p z r r -
tial rcsponse to whicli a cultural patte rn
errlerges, may themselves havc been engineerecl
ir-r the interests of creating certail-r bcliefs, nornls,
life styles, etc. lf one rrssullres that culture c:rn bc
regr.rrclecl as s()u1c kincl of rcrlcti()r1 fonnatiorr,
tlren onc must l)e nrinclfr-rl of tlre unrlnticiDiltcc{
s o c i l l c o n s e q u e n c e s o f i r r v i t i r r g s o n t e r
t l t c i ; r r i o n
in lrehirvior which is ir Dart <>f a clonrinrrnt clll-
t t r r a l p a t t e n r . T h e r e c l u e s t f r o n r h c r r l t l
r w o r k c r s
f r l r a l t e r a t i o n s i r r c c r t a i r r a t - r i s k l r e h a
v i o r s n r a y
r c s r r l t i n e i t h e r i r r v k w a r c l c l i s l o c a t i o r r
s o f t l r c i r . r -
t c r r e l a t e c l e l e r n e n t s o f t h c c u l t u r a l p r r
t t e r n , o r t h e
c l e s f r u c t i o n o f a s y s t e r u o f v a l u e s r r n c l
n o r m s ,
e t c . , w h i c h h a v e e n r e r g e c l o v c r t i n r e i n r
e s p ( ) u s e
t o s i t u a t i o n a l p r o b l e n r s . F r o n r t h i s p e r s
p e c t i v e ,
a n c l w i t h r e g a r c l t o t h e u t i l i z a t i o n < l f n r
c c l i c i r l

c r r r c , I I . r a v e i r l r e a c l l , r r r g r r e d e l s e w h e
r c t h a t , f o r
c c r : t r r i r . r g r o u p s o f t h e p o p u l a t i o n , u n d
e r u t i l i z - a -
t i o n m i r y b e " h e a l t h y " b c h r r v i o r , : r n r l t h
c r r c l v o -
c a c y o f i n c r e r r s c d u t i l i z a t i o n a n " u u h c i r
l t l . r y "
r e o u e s t f o r t h c t r b a r r c l o r r n r e r r t o f e s s c n
t i a l f e a -
t u i e s o f c u l t u l e . r r
THE CASE OF FOOD
P e r h a p s i t w o r " r l d b c u s e f u l a t t h i s 1 ' r o i
n t t o i l l u s -
t r : r t c i r r s ( ) r ) ) r ' ! l e t a i l . f l o r n , r r r c P e r t
i l r c n t : l r t J , t l r e
stylc and nragnitucle of operation engagecl ir-r by
t h e r n r u r u f i r c t u r e r : s o f i l l n e s s . I l l u s t r a
t i o n s , r r e , o f
c o u r s e , r c a c l i l y a v a i l a b l e f r o n r r r v a r i e t
y o f d i f f e r -
e n t t l r e a s , s u c h a s : t h c r e q u i r c n r e n t s o f e
x i s t i n g
o c c u p a t i o n a l s t r u c t u r e , e n r e r g i n g l e i s u r
e p a t -
t e r n s , s n r o k i n g a n c l d r i n k i n g b e h a v i o r , a
n d a u t c l -
that
lness
con-
:ably
sting
i n a

k be-
l e o i t -
I a r e
lomi-
erson
Coing
vhich
rk ac-
rst of
n the
chni-
( e . g ' '
that
'ould
and
: ful-
al if
:r of
i not
defi-
are
peal
o r a
be-
ex-
r b e
nat-
fiat
'itu-
and'eed

rol.
lsic
'eo-
52O Toward Alternatives in Health Care
mobile usage.14 Because of current interest, I
have decided to consider only one area which is
irnportantly related to a range of large chronic
diseases-namely, the 161 billion dollar industry
involved in the production and distribution of
food and beverages.l5 The present situation,
with regard to food, was recently described as
follows:
The sard history of or,rr foocl supply resembles the
energy crisis, and not just because food nourishes
our bodies while petrolcum fuels the society. 'We
long ago surrendcred control of food, a vital re-
source, to privatc corp()fations, just as we surren-
dcrecl control of encrgy. The food corporations
havc shaped thc kinds of foocl we eat for their
grcater profits, just rrs tl-re er-rergy companies have
dictatcd the kincls of fuel we use.r6
From all tl.re indeper.rdent evidence available,
and despite clain.rs to the contrary by the food
ir-iclustry, a wiclespread decline has occurred clur-
ing the past three decades in American dietary
s t a n d a r d s . S o r r r e f o r t y p e r c e n t o f U . S . a
d u l t s a r e
overweigl.rt or clowrrright fat.t7 The prevalence
of excess weight in tl.re Anrerican population as
a whole is high-so high, in fact, that in some

s e g m e n t s i t h a s r e a c l - r e d e p i d e m i c p r o p o
r t i o l l s . l s
There is evidencer that the foocl industry is rna-
n i p u l a t i n g o u r i m a g e o f " f o o d " a w a y f r o m
b a s i c
staples toward synthetic and highly processed
iterr.rs. It l.rirs been estillated that we eat between
21 and 2-5 pe rcerrt fcwer dairy products, vegeta-
bles, and fruits than we did twenty years ago,
rurcl frorr 70 to u0 percent lnore sugary snacks
a n c l s o f t c l r i n k s . A p p a r e n t l y , m o s t p e o p
l e n o w
eat more pr<lcessed encl synthetic foods than the
real thing. There arc eveu suggestions that a fed-
e r a l , n i r t i o n w i d c s u r v e y w o u l d h a v e r e v e
a l e d
how serious our clietary situation really is, if the
Nixon Adrninistration h:rd rrot cancelled it after
reviewing some enrbarrassing preliminary re-
sults.r" The surve y :rpparently cor.rfirmed the
trend towarcl deterioratins diets first detected in
an earlier household f.rod consullption survey
i n t h e y e a r s I 9 5 - 5 - l 9 6 . 5 , u n d e r t a k e n b y t
h e D e -
partrrcrnt of Agriculture.20
Of course, for the foocl industry, this trend to-
ward deficient synthetics and highly processed
iterr.rs makes good economic sense. Generally
speaking, it is much chezrper to make things
look and taste like the real thing, than to actu-
ally provide the real thing. But the kind of foods
that result from the predominance of economrc
interests clearly do not contain adequate nutri-
tion. It is common knowledge that food manu-

facturers destroy important nutrients which
foods naturally contain, when they transform
them into "convenience" high profit items. To
give one simple example: a wheat grain's outer
layers are apparently very nutritious, but they
are also an obstacle to making tasteless,
bleached, white flour. Consequently, baking cor-
porations "refine" fourteen nutrients out of the
natural flour and then, when it is financially
convenient, replace some of them with a syn-
thetic substitute. ln the jargon of the food indus-
try, this flour is now "enriched." Clearly, the
food industry employs this term in rnuch the
same way that coal corporations ravage moun-
tainsides illto mud flats, replant them with some
soil and seedlings, and then proclaim their
rnoral accomplishment in "rehabilitating" the
land. While certain types of food processing
may make goocl economic sense, it rnay also re-
sult ir-r a deficient end product, and perhaps even
prolnote certirin cliseases. The bleaching and re-
fining of wheat proclucts, for example, largely
eliminates fiber or rougha€te from our diets, and
sorne authorities have suggestecl that fiber-poor
diets can be blarnecl for some of our lnaior in-
t e s t i n a l d i s e a s e s . l t
A vast chernic:rl additive technology has en-
abled rnanufacturers to acquire enormous control
over the food ar.rcl treverage tlarket and to foster
phenorrenal prolitability. It is estimated that drug
-ornpanies
akrrre rnake sonlething like $500 mil-
lior.r a year through chenrical additives for food. I

have aiready suggested that what is done to food,
in the way of processing and artificial additives'
rnay actually be iniurioui to health. Yet, it isclear
thai, despite such well-known risks, profitability
makes such activity well worthwhile' For exam-
ple, additives, likc preservatives, enable food that
might perisl', in
"
.h.rn period of time to endure
trnlhong.d for months ,,. .u.. years. Food man-
ufacturers and distributors can saturate super-
ln,rrket she lves across the country with their protl-
ucts because there is little chance that they wtu
spoil. Moreover, manufacturers can-purchase vast
quantities of raw ingre dients when they arecbeap'
pro
ther
lonl
prlc
T
i t i s
finer
dietr
b o r r
brr
s u g a
1 2 6
o f c <
try i
e a c h
p e a r l
- ^ : ^l r l J r L

t i o n '
b l a d r
deger
peop
w h i c
g e t . I
S e n a (
were
tive, I
leacl t
I n
food
sourc
ceptlc
hood
m a n l l
them
as lnu
nitudt
to the
pany,
I i n 1 9
sugar-
enorm
Unitec
advice
Breai
gove
use c
flavo
: . c o n t :
3mPl. becor

ctu-
)ods
)mic
utri-
anu-
,hich
form
;. To
)uter
they
eless,
I cor-
rf the
cially
syn-
ndus-
y, the
,h the
noun-
. some
their
;" the
essing
so re-
s even
nd re-
rrgely
;, and
,poor
rr in-

ls en-
,ntrol
[oster
drug
) m i l -
r o d . I
food,
tives,
clear
bilitY
Kam-
that
dure
nan:
to€r-
ioa'
vtill
vast
€4P:r' ''
produce and stockpile the proccssed result, and
then withhold the oroduct from the market for
long periods, hoping for the inevitable rise in
prices and the consequent windfall.
The most widely used food additive (although
it is seldom described as an aclditive) is "re-
fined" sugar. Food manufircturers s:lturate our
diets witl-r the substance fr<lm tlre cla1, we are
b o r n u n t i l t h e d a y w e d i e . C l h i l d r e n i r r e
f e d
b r e a k f a s t c e r e a l s w h i c h c o n s i s t o f - 5 0 p e
r c e n t
sugar.22 fhe averagc Arle'rican aclult cor.rsurnes
1 2 6 p o u n d s o f s u g a r e a c h y c a r - a n d c h i l d r

e n ,
of c<>urse, eat nruch nrore. For the candf ir-rclus-
t r y a r l o n e , t l r i s a n r o u n t s t o a r o u l l c l $ 3 b
i l l i c l n
each year. The Arnerican sull:1r rnanirr, which ap-
p e a r s t o h a v e b e e n c l e l i b e r e t e l y e n g i n e e
r e d , i s a
m a j o r c o n t r - i b l r t o r t o s u c h " d i s e r r s e s o f
c i v i l i z a -
t i o n " a s d i a b c t e s , c o r o n a r y h e a r t d i s c a s e
, g a l l
b l a d d e r i l l n e s s , a n d c a n c e r - a l l t h e i n s i d i
o u s ,
degenerative conditions which urost often afflict
people in aclv:rncecl cairitalist societics, br.rt
which "underdcvel<>pcc1," nor.rsLrgar e rrtcrrs never
g e t . ( ) n e w i t r r c s s a t a r e c e n t n r c e t i n g o f
a U . S .
Senate C'orln.rittc-e, srricl thirt if thc foocl irrciustry
were proposing sugrrr toclay as :r nc'"v foocl rr.lcli-
t i v e , i t s " n r e t i r b o l i c b e h a v i o r l v o u l t l u n
r i o u l r t e d l v
l e a d t o i t s b e i n g b r r n r r c c l . " 2 i
In sur.r-r, f[re rcfore, it see'r'r-rs that the Antcrrcirrr
f o o d i n d u s t r y i s n r o b i l i z i n g p h e n o n r c n r r
l r e -
sources tr> aclvrrnce r-rrrd bincl r-rs to its ()vn c()n-
ception of food. We irrc lroml'rrrrclccl fronr chilcl-
h o o d w i t h $ Z b i l l i o n r v o r t h o f d c l i b e r a t c
l y
m a n i p u l a t i v e i r c l v e r t i s e n r c n r s c a c h y e r r
r , u r o s t ( ) f
t h e m u r g i n g L l s t o c ( ) l l s u n r e , l l l n o n g o t l
r c r t l r i n g s ,
a s n t u c l ' r s u g a r a s p o s s i b l e . T o h i e h l i s h t

t h c n r l g -
n i t u d e o f t h e r c s o u r c c s i n v o l v e d . o l l c c :
1 n D o r n r
t o t h e a c t i v i t y o f o r r e w c l l - k r r o w n l . e v c
l r q e c o n . r ^
p a n y , O o c r l - ( i r l r r , r v h i c h , r l o n c s p c n t $
7 1 n r i l l i r l n
t n 1 9 7 I t o a c l v c r t i s e i t s a r t i f i c i a l l l ' f l i t
v o r e c l ,
sugar-srrturrrtecl ;rrocluct. lir:lly rccognizitrg thc
enonnity of the problenr rcgarcling foocl in thc
United Stete s, Zvr,e rdling ,iif.r. ilc- followirrg
, advice:
A Casc for Refocussing Upstrean'r: The Political Iiconorny of
Illness 521
THE ASCRIPTION OF
RESPONSIBILITY AND
MORAL ENTREPRENEURSHIP
So far, I l-rave considered, in some detail, tl-re
ways in whicl-r industr;', through its manufacture
irncl distribution of a variety of products, gener-
ates at-risk behavior and disease. Let us now fo-
cus on the activities of health workers further
down tlre river irnd considcr their efforts in a so-
cial context, which has rrlreacly been large[y
s h a p e d b y t h e n r r t n u f a c t u r e r s u p s t r e a m .
Not only shoulcl wc be mindful of the cultur-
ally clisruptive and largely unanticipated conse-
quences of health inter:vcntion efforts mentioned
earlier, but rllso of tl-re underlying ideology on
which so rnuch of this activity rcsts. Such inter-
vention appears basec{ <ln an assunlption of the

culpability of indiuiduals or groups who ei-
t h e r r n : r n i f e s t i l l n e s s , o r c l i s p l i r y v a r i o
u s a t - r i s k
b e h a v i o r s .
Fron.r thc ilssrurption that indiviclua[s ancl
g r ( ) u p s w i t h c e r t i l i n i l l n c s s e s o r d i s p l a y
i n g r , r t -
r i s k b e h : r v i o r e r e r e s p o n s i [ r l e f o r t h e i r
s t r r t e , i t i s
e relafively e asy stcp to irdvocating solne
clrirnges in behrrvior on the prrrt ()f tl.rose in-
v o l v e c l . I l y a s c r i b i n g c u l p a b i l i t y t o s o m
e g r o u p
o r s o c i a l c a t e g o r y ( u s u a l l l ' c t l . r r - r i c r -
n i n o r i t i e s a r r d
f h o s e i n l o w e r s < l c i < l - e c o l . r o n r i c c a t e g
o r i e s ) a n d
h a v i r r g t h i s a s c r i p t i o n l e g i t i n . r a t e d b y h
e a l t h p r o -
fessionals irncl acceptecl by otlrcr segments of so-
cicty, it is 1-rossible to rlobilize res()Lrrces to
char.rgc' rhe offencling behirvior. Certain perople
r r r e r e s p o n s i b l c f o r u o t i r p p r o x i n r a t i r . r
e , t h r o u g h
t h c i r a c t i v i t r e s , s o l r e c o n c e p t i o n o f w h a
t o u g b t
t o b c a p p r o p r i a t e l r e h a v i < l r o n t h e i r p a r t
. i l / h e n
n.rcrrsurecl agirinst thc artiflcial concepti<ln of
w l u t c l u g h t t o [ r e , c e r t a i n i n d i v i c l u a l s i
r n d
groups are founci to bc' deficicrrt in several im-
porfant respects. Tl-rey arc aither doing sonre-
t h i n g t h a t r h c i r o u g h t n o t t o b c c l o i n g , o r
t h e y

r l r e n o r d o i n g s o n r e t h i n g t h a t t h e y o u g h t
t o b e
c l o i n g . I f o n l y t l r e y r ' v o u l c l r e c o g n i z e t
h e i r i n d i -
v i c l u a l c u l p a b i l i t y a n d a l t e r t h e i r b e h a v
i o r i n
sonre :rppropriate frrshion, they rvould irnprove
t l r e i r h c : r l t h s t . r t u s o r t h e l i k e l i h o o d o f
n o t c l e v e l -
o p i n g c e r t a i n p a t h o l o g i e s . O n t h e b a s i s o
f t h i s
lir-rc of rcasoning, res()ulces are being rnobilized
to bring those whcl clepart fnrn.r the desired con-
ccption into conformit,v lvith what is thought t<r
B r e a k i n g t h r o u g h t h c f o o c l i n t l u s t r y r v i l
l r e q r - i i r c
S o v e n r n r c n t a c t i o u - b a n r r i n g o r s l r a r p l y
l i n r i t i n g
u s e o f d a n g e r o s s r c l . l i t i v c s l i k c i i r t i f i c i
a l c o l o r s e n c l
f l a v o r s ,
" ' , . 1
, ' . , g . , r . r r r r t l r c r l r r i r i n g w h c l r t p r ( ) c l u
c t s t o
c o n t a i n f i b e r - r i c h w h e i l t l l c n l l , t o g i v c j
u s t t w o c x -a m p l e s . F o o t l , i f i t i s t o l r c c o r
n c s : r f c , w i l l h r l v c t o
D e c o m e p r r t ( ) f D , , l i r i . s . l +
522 Toward Alternatives in Health Care

be appropriate behavior. To use the upstream-
downstream analogy, one could argue that peo-
ple are blamed (and, in a sense, even punished)
for not being able to swim after they, perhaps
even against their own volition, have been
pushed into the river by the manufacturers of
illness.
Clearly, this ascription of culpability is not
limited only to the area of health. According to
popular conception, people in poverty are
largely to blame for their social situation, al-
though recent evidence suggests that a social
welfare system which prevents thern fron-r avoicl-
ing this state is at least partly responsible.25
Again, in the field of education, we often hold
"dropouts" responsible for their behavior, when
evidence suggesrs that the school system itself is
rigged for failure.25 Similar examples are readily
available frorn the fields of penology, psychiatry,
and race relations.2T
Perhaps it would be usefr,rl to bricfl1' outline,
at tl-ris point, what I regirrd as a bizarre relation-
ship between the activities of the manufacturers
of illness, the ascription of culpability, ancl
health intervention encleavors. .Firsl, imporrant
segments of our social systent llp[)car to ire con-
trolled and operatec'l in such a way that peciple
must inevitably fail. The fact is tl.r:rt there is of-
ten no choice over whether one can find employ-
m e n t , w h e t h e r o r n o t t o d r o p o u t o f c o l l e g
e , i n -
volve oneself in unt<lward behavior, or beconre
sick. Second, cven though inclividuals ancl
g r o u p s l a c k s u c h c h o i c e , t h e y a t e s t i l l l r l

a m e c l
f o r n o t a p p r o x i m a t i n g t h e a r t i f i c i a l l y c o
n t r i v e c l
n o r r n a n d a r e t r e a t e d a s i f r e s o o n s i b i l i t v
f o r
t h e i r s t a t e l : r y e n t i r c l y w i r h t h e r n . F o r c
x e i n p l c ,
son-re ilLress conditions r.nay be the rcsult of par-
ticular: behavior and/or involver-nent in ccrtarr.r
occup:rtional r:olc relationships over which those
affected have little or no contrc>1.28 Third, after
r e c o g n i z i n g t h a t c e r t a i n i n d r v i d u a l s a n c
l g r o u p s
h a v e " f a i l e d , " w e e s t a b l i s h , a t : r p o i n r c l
o w l . r -
stream, a substructure of services which are re-
garded as evidence of progressive beneficence cln
the part of the systern. Yet, it is tl-ris very systctr
which had a primary role in manufacturing rhe
problems and need for these services in the first
prace.
It is around certain asDects of life stvle thirt
m o s t h e a l t h i n t e r v e n t i o n e n d e , r v o r s a p p
c i t r t o
revolve and this probably results from the
observability of most at-risk behavior. The mod-
ification of at-risk behavior can take several dif-
ferent forms, and the intervention appeals that
are employed probably vary as a function of
which type of change is desired. People can ei-
tber be encouraged to stop doing what they are
doing which appears to be endangering their
survival (e.g., smoking, drinking, eating certain
types of food, working in particular ways); or

they can be encouraged to adopt certain new
patterns of behavior which seer-ningly enhance
their health status (e.g., diet, exercise, rest, ear
certain foods, etc.). I have already discussed
how the presence or absence of certain life sryles
nr some groups may be a part of some wider
cultural pattent which ernerges as a response to
social structural problems. I have also noted the
p()tentially disruptive consequences to these cul-
tural patterns of intervention programs. Under-
lying all these aspects is the issue of behavior
control and the attempt to enforce a particular
tvpe of bel-ravioral conformity. It is more than
coincidental that the at-risk life styles, which we
irre all admonished to avoid, are frequently the
rype of behaviors which depart from and, in a
scnse, jeopardize the prevailing puritanical, mid-
dle-class ethic of what ought to be. According to
this ethic, activities as pleasurable as drinking,
snroking, ()vereating, and sexual intercourse
nrust be harrnful and oueht to be eradicated.
The implortant poilrt lrere is which segments
of society ancl whclse interests are health work-
els serving, and what are the ideological conse-
quences of their acticlns.2e Are we advocating
tl.re nrodification of behavior for the exclusiue
purpose of ir.nproving health status, or are we
r-rsing tlre cluc.stion of health as a means of
<rbt:rining sorre kind of moral uniformity
through the abolition of disapproved behaviors?
-fo wlrat extent, if at all, are health workers ac-
tively ir-rvolved in some wider pattern of social
r c g u l r r t i o r t ? r 0-Such questions also arise in relation
to the
burgconing literature that links more covert per'

,,rnility ciraracteristics to certain illnesses and
at-risk lrehaviors. Capturing a great deal of at'
tention in this ..g"id are" th; recent srudies
which associate hleart disease with what ls .
terr.ued a Type A personality. The Type A p-e1 ,
i
,4
'i
S O
n r
sir
tin
se(
ofr
otl
tin
h i t
o f
i n s
l
b a r
nor
pe(
car
i n i
ing
the
tho
tex'
strr
duc
tise
eml

m a l
ther
N.
disr
i n l
pers
age
behr
war
conl
faih"
ii trait
how
and
itive
TI
som'
tionr
deal
ideo
Paft
festa
: Seca
pro{
tem
A Case for Refocussing Upstream: The political Econornv of
Illness 523
from the

The mod-
;everal dif-
>peals that
unction of
ple can ei'
at they are
ering their
ing certain
ways); o/
:rtain new
ly enhance
e, rest, eat
discussed
n life styles
on-re wider
'esponse to
r noted the
r these cul-
ns. Under-
'f behavior
particular
more than
, which we
luently the
r and, in a
nical, mid-
:cording to
s drinking'
rntercourse
icated.
1 segments
alth work-

,ical conse-
advocating
: exclusiue
or are we
means of
uniformitY
behaviors?
rorkers ac-
ir of social
ion to the
sovert per'
lesses and
deal of lr:
nt snrdies
r what .is
,pe A fili
sonality consisrs of a complex of traits which
produces: excessive competitive drive, aggres-
slveness, impatience, and a harrying sense of
time urgency. Individuals displaying this pattern
seem to be engaged in a chronic, ceaseless and
often fruitless struggle with themselves, with
others, with circumstances, with tirne. some-
times with life itself. They also frequently ex-
hibit a free-floating, but well-rationalized form
of hostility, and almost rrlways er cleeD-seated
insecurity.3l
. Efforts to change Type A traits appear to be
based on some ideai conception of a relaxed,
non-competitive, phlegmatic individual to which
people are encouraged to conform.32 Again, one
can questiol-l how realistic such a conception ls
in a system which daily rewards behavior result-

ing frorn Type A traits. One can clearly quesrion
the ascription of near exclusive culpaliility to
those displaying Type A behavior when rhe con-
text within which such behavior is n'ranifest is
structured in such a way as ro guarantee irs pro-
duction. From a cursory reading of job adver-
tisements in any newspaper, we can sc.e tlrat
e m p l o y e r s a c t i v e l y s e e k t o r c c r u i r i n d i v i
d u a l s
manifesting Type A characteristics, extolling
thenr as positive virtues.sl
. My earlier point concerning tlre potentially
disruptive consequences of requiring ilterations
i n l i f e s t y l e a p p l i e s e q t r a l l y w e l l i n t h i s
a r e a o f
personality irnd dise:rse. If health workers nrarr-
fge to effect sorne changes away from Type A
behavior in a system which requircs o'id ,.-
wards it, ther.r we must he aware irf rhe possible
consecluences of sucl-r chauge in tern.rs ui fu,ur.
f a i l u r e . E v e n t h o u g h t h e e v i d e n c e l i n k i n
g T y p e A
traits to heart disease appears cluite crnclui,uc,
how can health workeis- ever liope t<l combat
and alter it when such charircterisrics are so p()s-
itive.ly and regularly reinforced in this society?
The various points raisecl in this section irave
s o m e i m p o r r r n t n r o r a l a l t c l p r a c t i c a l i r t
r p l i c l -
ttons for those involved in health relateil en-
deavors. First, I have argued that our prevailing
ldeo]og.f involves the asJription of culpability to' ' p a r t i c u l
a r i n d i v i c l u a l s a n d ^ g r o u p s f o r ^ r h e m a n r

-
ior and have access to a body of knowledge and
resources which the.y can "legitimately" deploy
for its removal or alteration. (A detailed discus_
sion of the means by which this mandate has
b.gen.ac,9r1i1ed is expanded in a separare paper.)
Tli1d, [it] is possible ro argue thai a gr."t i.oi
of health intervention is, perh:rps unwittingly,
part of a wide pattem of social regulation. Ve
rnust be clear both as to whose intirests we are
s e r v i n g , a n d t h e w i d c r i m p l i c a t i o n s a n c l
c o n s .
quences of the activities we sllpport through the
appfication of our expertise. Finally, it is evident
from arguments I have presented that n-ruch of
our health interventiorr fails tct take adecuare ac-
count of dre social corlrexrs wl-rich fostei rnd re-
inforce the behaviors we seek to alrer. Tl-re liter:l-
ture of prever-rtive medicine is rcplete with
illustrations of the failurr of contexrless health
lntervention programs.
THE NOTION OF A
NEED HIERARCHY
A t t h i s p o i n t i n t h e c l i s c u s s i o n I s h a l l d r
s r e s s
sliglitly to consider thc relatior.rshirr lretrveen rhc
u t i l i z a t i c l n o f p r e v e n t i v e h e . r l r h s e r v i c
e s a n c { t h e
c()ncept of neecl as r.nturifc'st in this society. We
k n o w f r o n r : r v a i l a b l c t , v i t l c r r c c t h e t u p
p c r i o c i o -
e c o n o m r c g r o u p s : r r e g e n c r a l l y n r o r e r e s
p o n s i v c

to health intervention activitic's thrrn :rre fhose of
Iower soci<l-ec<tnonric stntLls. To trartirrllv ac-
c o u n t f o r t h i s p h e n o r . n c n o n , I h e v e f o u n c
l i i u s e -
ful to introducc the noti()n <>f a rteetl hicrarcby.
Ily this I refer to tlre fact rhar sonte neecls (c.g.,
f o o c l , c l o t i . r i r r g , s h e l t e r ) a r e p r o b a b l y
u n i v e r s , r l l y
recognizcd as relartecl to slreer survivill rrncl t:rke
p r e c e d e n c e , w h i l e o t h e r n e c c l s . f o r D i r r t
i c u l a r s o -
c i : r l g r o u p s , m a y b c p c r c e i v c e l a s l e s s i r
n m e d i -
ately intl'rortant (e.g., clental care, exercise, bal-
arrced cliet). ln other worcls, I conceive of a
hierarchy of necds, r:ruging frorr what cor-rlcl be
termed "prirnary neecls" (which relate nrore or
less to tl.re universally recognized imnrediate
n e e d s f o r s u r v i v a l ) t l r r o u g h t ( ) " s e c o n d a
r y
n e e d s " ( w h i c h a r e n o t a l w a y s r e c c l g n i z e d
a s m r -
portant and which n'ray be artificially cngineered
b y t h e n r a n u f a c t u r e r s o f i l l n e s s ) . S o m e w
t e r e b e -
tween the high priority, prirnary neecls and the
less importanr, sec()ndary needs are likely to fall
tton of either disease cr. it-risk behavior.
, it can be argued that so-callecl ,.health
ionals" have acquired a mandate to de-
ine the morality of different rypes of behav-
:
.i

ii
ifl
!::
*a,
:i!,.
ii.jl
i;,
Fifi,,)ll
l: ul.
., fr
524 Toward Altematives in Health Care
the kinds of need invoked by preventive health
workers. 'Where one is located at any point in
time on the need hierarchy (i.e., which particu-
lar needs are engaging one's attention and re-
sources) is largely a function of the shape of the
existing social structure and aspects of socio-
economrc status.
This notion of a hierarchy of needs enables us
to distineuish between the health and illness be-
havior of the affluent and the poor. Much of the
social life of the wealthy clearly concerns sec-
ondary needs, which are generally perceived as
lower than most health related rreeds on the
need hierarchy. If some patliology presents itseif,
or some at-risk behavior is recognized, then they
n a t u r a l l y a s s u m e a p r i o r i t y p o s i t i o n , w h i
c h
eclipses most other needs for action. In contrast,

rnuch of the social life of the poor centers on
needs which are understandably regarded as be-
ing of greater priority than r.nost health concerns
o n t h e n e e c l h i e r a r c h y ( e . g . , h o m e l e s s n e
s s , u n e n l -
ployrnent). Should sorr.re illness event preserlt it-
self, or should health workers alert people and
groups in poverty to possible further healti-r
rteeds, then these needs inevitably assume a posi-
t i o n o f r e l a t i v e l o w p r i o r i t y a n d a r e e c l i
p s e d ,
perhaps indefinitely, by more pressing prinr:rry
needs for sheer existence.
Frot.n such a perspectivc, I think it is possible
to understand why so much of our health inter-
ventiol.r fails in tl.rose very groups, at highest risk
to r-norbiclity, whorn we l.rope to reach ancl influ-
ence. The appeals that we rlake in alerting tl-rcm
t o p o s s i b l e f u t u r e n e e d s s i r n p l y n r i s s t h c
m a r k b y
giving inadequate recognition to those primirry
neecls which claily preoccupy their attention.
Nclt only does the notion of a need hierarchy
emphasize the clifliculty of contextless interven-
t i o n p r o g r a m s , b r " r t i t a l s o e n a b l e s u s t o
v i e w t h e
rejection as :1 n()n-conrpliance with health pro-
!1Alns, as, in a sensc, rational bel-ravior.
HOW PREVENTIVE IS PREVENTION?
'With regirrd to sorrre of the argurnents I have
presented, concerning the ultimate futility of
d o w n s t r e a m e n d e a v o r s , o n e m a y r e s p o n d
t h a t
effective preventive n-redicine does, in fact, take

accout.rt <lf this pr<lblem. Indeed, ltlany preven-
tive health workers are openly skeptical of a
predominantly curative perspective in health
care, I have argued, however, that even our best
preventive endeavors are misplaced in their al-
most total ascription of responsibility for illness
to the afflicted individuals and groups, and
through the types of programs which result.
While useful in a limited way, the preventive ori-
entation is itself largely a downstream endeavor
through its preoccupation with the avoidance of
at-risk behavior in the individual and with its
general neglect of the activities of the manufac-
turers of illness which foster such behavior.
Figure 49-l is a crude diagrar.nmatic represen-
tation of an overall process starting with (1) the
activities of the rnanufacturers of illness, wliich (2)
foster and habituate people to certain at-risk be-
haviors, which (-l) ultimately result in the onset of
certair.r types of morbidity and rnortality.sa The
predominant cur:rtive orientation in rnodern med-
icine deals alr.nost exclusively with the observable
patterns of nrorbidity and rnortalitn which are the
end-points in the process. The much heralded pre-
ventive orientation focuses on those behaviors
which are known to be associated with particular
illnesses arrd which can be viewed as the midpoint
in the overall pr<>cess. Still left largely untouched
arc thc entrepre neur-ial activities of the manufac-
turers of illness, who, tl.rrough largely unregulated
activities, foster the at-risk behavior we aim to
prevent. This bcginning pctint in the process re-
mains unaffccted by rl1osf preventive ertdeavors,
even though it is at this point that the greatest po-

tential for change, and perhaps even ultimate vic-
t o r y , l l e s .
I t i s c l c r t r t h : r t t l r i s p r r p c r r r t i s e s n l r l l
y q u e s t i o n s
and issues at a seneral level-more in fact than it
F i g u r c 4 9 - 1 .
1
T h e a c t i v i t i e s
of the -'>
manufacturers
o f i l l n e s s
t
Interventaon
w i t h a p o l i t i c a l
e c o n o m i c f o c u s
I
V a r i o u s
at-risk -_'
b e h a v i o r s
I
I
lntervention
w i t h a
preventive
focus
3

Observable
morbiditY
and mortalitY
A
I
lntervention
with a curativB
focus
1 S p O S l
has br
with l:
suing
enoug
Hopel
u l a t e r
tions I
directi
p l o y e <
t h e o r
strair.r i
profiti
c o n c l r
three r
REC(
a. Leg
I t i s p
healtlr
health
tive ef
long 1

w a r w
w i l l r t
i l l n e s s
d i v i d u
ties fo
we ou.
tion w
!7ides
latecl t
ratioltl
then s
would
as thir
tising
empt
educat
able rr
verely
activit
true t
their e
of the
ing wt
A s :
,,tion o
rtical of a
in health
:n our best
in their al-
, for illness
:oups, and

rich result.
ventive ori-
n endeavor
voidance of
nd with its
,e tnanufac-
ravlor.
:ic represen-
w i t h ( 1 ) t h e
s s , w h i c h ( 2 )
n at-risk be-
L the onset of
'tality.3a The
nodern med-
e observable
vhich are the
reralded pre-
re behaviors
th particular
he midPoint
y untouched
i1e manutac-
unregulated
r we aim to
' process re-
: endeavors'
greatest po-
-rltimate vtc-
ry questlons
r fact than tt
Observable
morbiditY
and mortality

A
I
lntervention
with a curative
iocus
is possible to resolve. Since most of the discussion
has been at such an abstract level and concerned
with broad political and economic forces, any en-
suing recommendations for change must be broad
enough to cover the various topics discussed.
Hopefulln the preceding argument will also stirn-
ulate discussion toward additional recommenda-
tions and possible solutions. Given the scope and
direction of this paper and the analogy I have ern-
ployecl to convey its content, the rask becomes of
the order of constructing fences upstream and re-
straining th<lse who, in the interest of corpclrate
profitability, continue to push people in. In rhis
concluding section I will confine rny renrarks to
three selected areas of recommendations.
RECOMMENDED ACTION
a . L e g i s l a t i v e I n t c r v e n t i o n
It is probably true thirt one stroke of cffective
h e a l t h l e g i s l a t i o n i s e q u i r l t o n l a r l y s r : p
a r a t e
health interventior.r endeavors and the currulrr-
r i v e e f f o r t s o f i n n u m e r a b l e h e a l t h w o r k e
r s o v e r
l o n g p e r i o d s o f t i r n e . I r r t e r m s o f w i n r r i
n g t h e
war which rvas describecl earlicr, grczrter changes
will result fron-r the coutinuecl r-roliticizatior.r of

illness than from the nroclification of specific in-
d i v i d u a l b e h : r v i o r s . T h e r e a r e r n a n y o p p
o r t u n i -
ties for a lcgislirtive reduction of at-riskncss, ar-rcl
we ought to scizc theur. Let rr.re give one sugges-
t i o n w h i c h r e l a t e s r o e a r l i e r p o i n t s i n t l r
i s p a p e r .
Widcspreilcl pr-r bl ic advcrtisi n g is i n.r portirr-rtl1' rc-
l a t e d t o t h c g r < l w t h a n d s u r v i v a l o f l a r g e
c o r p o -
r a t i o n s . I f i t w c r c l t o t s o c l c m o n s t r a b l y
e f f e c t i v c ,
then strch vilst sunls <lf nrot'rcy ancl resoLrrces
woulcl not be clevotecl to this activity. Mclrcover,
a s t h i n g s s t a n d a t p r e s e n t , a g r e a t d e a l o f
a c l v e r -
t i s i n g i s e n c o u r a g e d t h r o u g h g r a n t i n g i t
t a x e x -
empt st:1tlts olt solne vague grourrds 0f public
education.3s Til irlace r-n<tre stringent, enforcc-
able restricti()ns on advertisine would be to se-
v e r e l y c u r t a i l t h e m o r a l l y a b h o r r e n t p u s
h i r r g r n
activities of the rnanufactnrers of illness. lt is
t r u e t h a t l a r g e c o r p o r a t i o n s r r r c i n g e n i t -
r u s r r r
their efforts to :tvttid the consequences of rnttsr
o f t h e c u r r e n r l c e i s l a t i v c r e s t r i c t i o n s o l
r a d v c r t i s -
ing which only prohibir cerrain kinds of appe:rls.
. As a p<lssible solution to this anci in recogni-
t t o n o f t h e m o r a l c u l p a b i l i t y o f t h o s e w h
o a r c
A Case for Ref<>cussing Llpstrearn: The Political Economy of

Illness 525
actively manufacturing disease, I conceive of a
ratio of advertising to health tax or a rario of
risk to benefit tax (RRBT). The idea here is to,
in some way, match advertising expenditures to
health expenditures. The precise weighting of
the ratio could be determined by independently
ascertaining the severity of the health effects
produced by the manufacture and distribution
of the product by the corporation. For example,
it is clear that smoking is injurious to health and
has no redeeming benefit. Therefore, fclr this
product, the ratio could be determined as say, 3
to 1, where, for example, a company which
spends a non-tax deductible $ I rnillion to adver-
tise its cigarettes would be required to devote a
non-tax deductible $3 niillion to the area of
health. In the area of quasi-health activities,
where the product, although largely useless, may
n o t b e s o i n j u r i o u s ( e . g . , n a s a l s p r a y s , p
a i n
killers, miner:al supplerrents, etc.), the ratio
could be on, say, a 1 to I basis.
Of course, the manufacturers of illness, at the
present time, do "donate" large sums of nroney
for the purpose of research, with an obvious un-
derstanding that thcir gift should be recipro-
c a t e d . I n a r e c e n t a r t i c l e , N u e h r i n g a n d
M a r k l e
touch on the nature of this reciprocity:
One of the rnitst ironic pro-cigarcttc force s has
becn thc American Medical Association. This now-
e rful hclltl.r organization took a position in I yOS

clearly favor:rble to the tobacco intercsts. . . . In acl-
c l i t i o n , t h e A . M . A . w a s , u n t i l 1 9 7 i , c o n s
p i c r - r o u s l y
abscnt from the nrcnrbcrship of the N:rtir>nal Inter-
ilgcncy Council on Surokingl en.l Hcrrlth, ;r co.rlitior-r
of govcrnment agencies and virtually all thc na-
t i o r r a l h c a l t h o r g a n i z a t i o r - r s , f o r m c d i n
1 9 6 4 . T h e
A.M.A.'s largely pro-tobacco bchavior has been
linked with the acceptirnce of largc research su[rsi-
clies from the tobacco industry-anrounting, ac-
corcling to thc industry, to sonrc 18 million dol-
lrr rs.3t'
Cliven such rcciprocity, it would be necessary for
dris health money from the RRBT to be han-
clled by a supposedly independetrt government
agency, like tlie FDA or the FTC, for distribu-
tion to regular research instittrtions as well as to
consumer organizations in the lrealth field,
which are currently so unequally pitted against
the upstream manufacturers of illness. Such leg-
islation would, I believe, severely curtail corpo-
rate "pushing in" activity and publicly demon-
strate our commitment to effectively regulating
the source of many health problems.
b. The Question of Lobbying
Unfortunately, due to present arrangements, it is
difficult to discern the nature and scooe of
health lobbying activities. If only *. ..,uld 1.,-

c a t e ( a ) w h o i s l o b b y i n g f o r w h a t , ( b ) w h
o t h e y
are lobbying with, (c) what tactics are being en.r-
ployecl, and (d) rvith what consequences for
health legislation. Because these activities are
likely to jeopardize the myths that have been so
carefully engineered and fed to a gullible public
by both the manufacturers of illness and varrous
health organizations, they are clothed in
secrecy.3T Judging from recent newspaper re-
ports, concerning multimillion dollar gift-giving
by the pharmaceutical industry to physicians,
the occasional revelation of lo[rbying and politi-
cal exchange remains largely unknown ancl
Iiighly newsworthy. It is frequendy argued that
lobbying on behalf of specific legislation rs an
essential avenue for public input in the process
<.lf erracting laws. Nevertheless, the evidence sug-
gests that it is often, by being closely linked to
the distribution of wealth, a very one-sidccl
proccss. As it presently occurs, many legitinrate
interests on a ranse of health rel:rtcd issues cl<l
u o t h a v e l o b b y i n g i n p u t i n p r o p o r t i o n t o
t l . r e i r
uumerical strellgth and may actu:llly bc struc-
t u r a l l y p r c c l u d e d f r o m e f f e c t i v e p a r t i c i
p a t i o n .
W h i l e r e c o g n i z i n g t h e i m p o r t : r n c e o f l o b
b y i n g
activity and yet feeling tl.rat for certrrin interests
i t s s c o p e o u g h t t o b e s e v e r e l y c u r t a i l e d (
p c r h a p s
in tl-re saure way as the proposed resulation arncl
g l u b l i c a t i o n o f p o l i t i c a l c a r n p : r i g n c r l r
r t r i b u t i o n s ) ,
I a m , t o b e h r l n e s t , a t a l o s s a s t o w h a t s h

o u l c l
be specifically rccomr-nended. . . . 'l-he questi()r'l
i s : q u i t e a p a r t f r o m t h e s p e c i f i c i s s r - r e o
f c h a n g i n g
individual behavior, in what ways tt.ntld Luc pos-
sibly regwlate thc disproportionatcly influentittl
htbbying actiuitit's of tcrtain intert'st grottps irr
the health field?
c. Public Education
In the past, it has been colluron to advocate the
education of the public as a rneans of achieving irr.r
alteration in the behavior of groups at risk to ill-
ness. Such downstream educational efforts rest on
"blaming the victim" assumptions and seek to ei-
ther stop people doing what we feel they "ought
not" to be doing, or encourage them to do things
they "ought" to be doing, but are not. Seldom do
w e e d u c a t e p e o p l e ( e s p e c i a l l y s c h o o l c h i l
d r e n )
about the activities of the rnanufacturers of illness
and about how they are involved in many activi-
ties nnrelated to their professed area of concern.
How rnany of us know, for example, that for any
"average" Thanksgiving dinner; the turkey may
be producecl by the Greyhouncl Corporation, the
Smithfield Han-r by ITI the lettuce by Dow Chern-
ical, the potatoes by Boeing, the fruits and vegeta-
bles by Tenneco or the Bank of America?38 I
would reiterate that I arn not opposed to the edu-
catiorl of people who are at risk to illness, with a
view to altering their behavior to enhance life
c h a n c e s ( i f t h i s c a n b e d o n e s u c c e s s f u l l y
) . H o w -

ever, I would add the proviso that if we remain
comnrittecl to the education of peclple, we must
ensure that they are being told the whole story.
And, in rny view, imrnediate priority ought to be
given to the sensitization of vast nur.nbers of peo-
ple to thc upstrear.n irctivities of the uranufactur-
e r s o f i l l n e s s , s o r r e o f w h i c h h a v e b e e n o
u t l i n e d i n
this paper. Sucl.r a progranl, actively supported by
the fe cleral government (pe rhaps tirrough revenue
d e r i v e d f r o m t h e R R B T ) , r l l a y f o s t e r a
grorrndswell of consLrr.ner interest which, in turn,
rnay go solne way toward checking the dispro-
por:tionately influential lobbying of the large cor-
p o r r r t i ( ) n s a n c l i n t e r e s t g r o u p s .
NOTES AND REFF]RE,NCES
l. l.K. Zola, "I"lelping-l)()es It M:lttcr: The Prob-
le rns rnd l)rospccts of Mutr.ral Aid Groups."
Aclclrcsscd to thc Ur-rited Ostonry Associationt
lL)70.
?. See, for cxanrple, M.W. Susser and W. Watson,
Sociology in Metlicine, New York: Oxford Uni-
ver:sit1' Prcss, l97l . Eclith chcn, ct al.' "Family
Structure in Relation to Health and Disease'"
lournal of Ohronic Disctses, Vol. l2 (19601, p'
.5-54--567; and R. Keelncr, Fantily IIt Health: An
Inuestigatirnt in Cleneril Praciice, Charles C'
-l'l-ronrrr-s, 19(r3. There is, of course, voluminous
literaturc which rel:rtcs familv structure to mental
illness. Fcr.r, studies m()ve to th" leuel of consider' '
ing thc bro,rclcr social forces wl-rich promote the t'

< to ill-
rest on
kto ei-
"ought
r things
iom do
r i l d r e n )
f illness
/ activi-
oncern.
for any
:ey may
:ion, the
v Chem-
I vegeta-
r i c a ? 3 8 I
the edu-
s, with a
rnce life
). How-
: remain
ile must
le story.
ht to be
of peo-
ufactur-
:lined in
>rted by
revenue
,stef A
in turn,
dispro-
:ge cor-

family structures which are conducive to the on-
set of particular illnesses. !7ith regard to utiliza-
t i o n b e h a v i o r , s e e J . B . M c K i n l a y , " s o c i a
l N e t -
works, L^y Consultation and Help-Seeking
B e h a v i o r , " S o c i a l F o r c e s , V o l . 5 1 , N o . 3
( M a r c h ,
1 9 7 3 ) , p p . 2 7 5 - 2 9 2 .
3. A rich source for a variety of materials included in
t h i s s e c o n d l e v e l i s H . E . F r e e m a n , S . L e v
i n e , a n d
L.G. Reeder (Eds.l, Handbook of Medical Soctol-
crgy, New fersey: Prentice-Hall, 1972. I wotrld
a l s o i n c l u d e h e r e s t u d i e s o f t h e l r e a l t h i
m o l i c a t r o n s
o f d i f f e r e n t l r o u s i n g p a t t e n l s . R e c e n r c v
i d c n c c s u g -
g e s t s t h a t h o u s i n g - e v e n w h e n h i g h l y d e n
s e -
m a y n o t b e d i r e c t l y r e l a t e d t o i l l n e s s .
4 . T h e r e h a v e , o f c o u r s e , b e e n m a n y s t u d i
e s , m a i n l y
b y e p i d e m i o l o g i s t s , r e l a t i n g d i s e a s e p a r
r e r n s r o
c e r t a i n o c c u p a t i o n s a n d i n d u s t r i e s . S e l d
o r n , h o w -
e v e r , h a v e s o c i a l s c i e n t i s t s p u r s u e d t h e c
o n s e -
quences of these findings in terms of a broader
p o l i t i c a l e c o n o n l y o f i l l n e s s . O n e e x c e p t
i o n t c r
t h i s s t a t e m e n t c a n b e f o u n d i n s t u d i e s a n
d w r r t -

i n g s o n t h e s o c i a l c a u s e s a n d c o n s e q u e n c
e s o f e n -
v i r o n m e n t a l p o l l u t i o n . F o r a r e c e n t e l e m
e n t a r y
t r e a t m e n t o f s o m e i r n p o r t a n t i s s u e s i n t h
i s g e n c r a l
area, see H. Waitzkin and B. Waterntan, The Ex-
ploitation ctf' Illness in Capitalist Socicty, New
Y o r k : B o b b s - M e r r i l l C o . , 1 9 7 4 .
. 5 . S o m e u s e f u l i n t r o d u c t o r y r e i l d i n g s a
p p e a r r n
D.M. Gcrrdor.r (Ed., Problerns in Political Et'tnr
omy: An Urban Perspectiue, Lcxtngton: D.C.
H e a t h & C o . , 1 9 7 1 , a n d R . C , . l l d w a r d s ,
M . R c -
i c h a n d T . E . T e i s s k o p f ( E d s . ) , T h e C a p i
t a l i s t
S y s t e m , N e w . f e r s e y : P r c n t i c e - H a l l , 1 9 7
2 . A l s o , T .
C h r i s t o f f e l , D . F i n k c l h o r a n d D . G i l b a r g
( E d s . ) ,
U1t Against the American Myrb, New York: Holt,
R i n e h a r t a n d W i n s t o n , 1 9 7 0 . M . M a n k o f f
( E d . ) ,
The Pouerty of Progress: The Politicttl Economy
of American Social Prohleizrs, Ncw York: Flolt,
R i n e h a r t a n c l W i n s t o n , 1 9 7 2 . F o r n r o r e s
o p h i s t i -
c a t e d t r e a t m e n t s e c t h e c o l l c c t i o n e d i t e d
b y D .
Mernrelstein, I'.conomics: Mahrstreant Readings
a n d R a d i c a l C r i t i q u e s , N e w Y o r k : R r n d o
m
H o u s e , 1 9 7 0 . A d d i t i o r . r a l l y u s c f u l p a p e r
s : l p p e a r

i n J . B . M c K i n l a y ( E d . l , P o l i t i c s a n d L a t
u i t t
Health Cttre Pol/,:y. Ncw York: Proclist, 1973,
a n d J . B . M c K i n l a y ( E d . ) , E c o n o m i c A s p e
c t s o f
H e a l t h C a r e , N c w Y o r k : P r o d i s t , 1 9 7 3 . F
< > r a
h i g h l y r e a d a b l e a n c l i n f l u e n t i a l t r e a t m e
n t o f w h a t
i s t e r m e d " t h e n - r e d i c a l i n d u s t r i a l c o m o l
e x . " s c e
B . a n d J . E h r e n r c i c h , T h c A t n c r i t a n H ' e a l
t l t E m -
pire: Power, Prctfits and Politics, New York: Vin-
t a g e B o o k s , 1 9 7 1 . A l s o r e l e v a n r a r e T . R .
M a r -
yror, The Politics of Medicare, Chicago: Aldine
P u b l i s h i n g C o . , 1 9 7 3 , a n d R . A l f o r c l , , , t
h e p o l i t i -
c a l E c o n o m y o f H e a l t h C a r e : D y n a n r i c s '
W i t h o u t
A Case for Refocussing Upstream: The Political Economy of
Illness 527
Change," Politics and Society, 2 (1972), pp.
1 . 2 7 - 1 " 6 4 .
6. E. Cray, In Failing Health: Tbe Medical Crisis
and the AMA, Indianapolis: Bobbs-Merrill, 1970.
J.S. Burrow, AMA-Voice of American Medicine,
B a l t i m o r e : J o h n s H o p k i n s P r e s s , 1 9 6 3 . R
. H a r n s ,
A Sacred Trzst, New York: New American Li-
b r a r y , 1 9 6 6 . R . C a r t c r , T h e D o c t o r B u s i n
e s s ,

G a r d e n C i t y , N e w Y o r k : D o l p h i n B o o k s , 1
9 6 1 .
" T h e A m e r i c a n M e d i c a l A s s o c i a t i o n : P o w
e r , P u r -
p o s e a n d P o l i t i c s i n O r g a n i z e d M e d i c i n e ,
" Y a l e
L a w J o u r n a l , V o l . 6 3 , N o . 7 ( M a y , 1 9 5 4 ) ,
p p .
9 3 8 - 1 0 2 1 .
7 . S e e r e f e r e n c e s u n d e r f o o t n o t e 5 , c s p e c
i a l l y B . a n d
J. Ehrenreich's The Anrcrictrn Health limpire,
C h a p t e r V I I , p p . 9 5 - 1 2 3 .
8 . D . M . G o r d o n ( E d . ) , P r o b l e m s i n P o l i t i
c a l E c o n -
omy: An Urban Iterspectiue, Lexington: D.C.
H e a t h & C o . , 1 9 7 l , p . 3 1 8 .
9 . S e e , f o r e x a r n p l e , D . A . B c r n s t e i n , " T
h e M o d i f i -
c a t i o n o f S r n o k i n g B e h a v i o r : A n L , v a l u l t
i v e l l e -
view." Psych<tlogical Bulletin, Yol. 71 (June,
1 9 6 9 ) , p p . 4 1 8 4 4 0 ; S . F ' o r d a n d F . E d e r e r
,
" B r e a k i r r g t l . r c C i g a r e t t c H a b i t , " J o t r r n
t t l o f ' A m e r -
i c a n M e d i c a l A s s o c i a t i c t t t , 1 9 4 ( ( ) c t o b c
r , 1 9 6 5 ) ,
1 ' t y ' t . 1 3 9 - 1 4 2 ; C . S . K e u t z e r , e t a l . , " M
o d i f i c a t i o n
< r f S n r o k i n g B c h a v i o r : A R c v i e w , " P s y c h
o l o g i c a l
I l u l l e t i n , V o l . 7 0 ( D e c c r n b c r , 1 9 6 8 ) , p p .

. 5 2 0 - - t 3 3 .
M e t t l i n c o n s i c l e r s e v i c l c n c c c o u c c n r i n g
r h e f o l l o w -
i n g t c c h n i c l u e s f o r n r o d i f y i n g s r n , r k i n g
b e h , r v r o r :
( 1 ) l r e h a v i o r a l c o n c l i t i o n i n g , ( 2 ) g r o u p
c l i s c u s s i o n ,
( . 3 ) c o u n s e l l i n g , ( 4 ) h y p n o s i s , ( . 5 ) i n t e r
p e r s o r . r a l
c o m r n u n i c a t i o n , ( 6 ) s e l f - a n a l y s i s . F { e c
o n c l u d e s
t h a t :
l l a c h o f t h e s e l p p r o : r c h e s s u l l l l c s t s t h a t
s n r o k i n g b e -
h a v i o r i s t h e r e s r r l t o f s o n r e f i n i t c s e t o f
s o c i a l i r n c l
p s y c h o l o g i c a l v a r i a b l e s , y e t n o n e h a s e i t
h c r d e n r o n -
s t r t r t c d l l n ) , s i g n i f i c a t r t p o r v e r s i n p r e d
r c t r n g t h e s n r o k -
i n g b c h a v i o r s o f a n i n d i v i c l u a l o r l e d t o t
e c h n i q u e s o f
s m o k i n g c o n t r o l t h ; r t c o l r s i d c r c c l ; r k r r r
c , h a v c s i g n i f i -
c a n t l o r r g - t c r n r e f f c c t r .
I n C . M c t t l i n , " S n . r o k i u g i r s B c h a v i o r : A
p p l y r r g a
S o c i a l P s y c h o l o g i c a l T h e o r y , " . l o t t r n a l
o f H e a h h
a n d S o c i a l B e h a u i o r , l 4 ( J u n e , 1 9 7 3 ) , p .
1 4 4 .
I 0 . l t a p p e a r s t h a t a c o n s i d e r a l r l e p r o g r
o r t i o n o f a d v e r ,

t i s i n g b y l a r g c c < ; r p o r a t i o n s i s t a x e x e m
p t t h r o u g h
b e i r . r g g r a n t e d t h e s t a t u s o f " p u b l i c e d u
c a t i o n . " L . r
p a r t i c u l a r ; t h e e n o r m o u s r n e c l i : r c a n r p a
i g n , w h i c h
w t s r e c c n t l y w a g e c i b v m r r j o r o i l c < t r l p a
n i e s i n a n
:rttempt to preservc the pr"rblic myths they had so
c a r e f u l l y c o n s t r u c t e d c o n c e r n i n g t h e i r a
c t i v i t i e s ,
w a s a l r n o s t e n t i r e l y n o n - t a x a b l e .
I l . R c p o r t s o f t h e h i r r n r f u l n c s s a n d i n c f
f c c t i v c n e s s o f
c L - r t t i n p r t t d r t c t c a p p e e r a l t - u 9 s t w e e k l
y i 1 t l - r e
e Prob-
rouPs."
ciado['
Vatson,
:d Uni-
FamilY
sease.'
6AL P...
t t h : 4 4 ,
'les Qj
ninous
rne4tal
nsidgr':
|teidig

l l
tl:;
ji
lii
1i
i,i
press. As I have been writing this paper, I have
c o n 1 e a c r o s s r e p o r t s o f t h e l o w q u a l i t y o
f m i l k ,
t h e u s e l e s s n e s s o f c o l d r e m e d i e s , t h e h e a
l t h d a n -
gers in frankfurters, the linking of the use of the
aerosol propellant, vinyl chloride, to liver cancer.
T h a t t h e F o o d a n d D r u g A d m i n i s t r a t i o n (
F . D . A . )
is unable to effectively regulate the manufacturers
o f i l l n e s s i s e v i d e n t a n d i l l u s t r a t e d i n t h
e i r i n e p t
h a n d l i n g o f t h e w i t h d r a w a l o f t h e d r u g , b
e t a h i s -
tine hydrochloride, which supposedly offcrecl
symptomatic relief of Meniere's Syndrome (an af-
f l i c t i o n o f t h e i n n e r e a r ) . T h e r e i s c v e r y
r e a s o n t ( )
t h i n k t h a t t h i s c a s e i s r r o t a t y p i c a l . F o r
a d d i t i o n -
ally disquieting evidence of how the Cigarette l-a-
b e l i n g a n d A d v e r t i s i n g A c t o f 1 9 6 5 a c t u a
l l y c u r -
tailed the oower of the F.T.C. and other fedcral
agencies frbm regr,rlating cigarette advertising and
n u l l i f i e d a l l s u c h s t a t e a n d l o c a l r e g u l a t

o r y e f -
forts, see L. Fritschier, Smoking and Politics: Pol-
icymaking and the Federtrl Bureaucracy, New
York: Meredith, L969, and T. Whiteside, Selling
Death: Cigarette Aduertising and Puhlic Heahh,
N e w Y o r k : L i v e r i g h t , 1 9 7 0 . A l s o r e l c v a n
t a r c
C < r n g r e s s i o n a l Q u a r t e r l y , 2 7 ( 1 9 6 9 ) 6 6 6
, 1 0 2 6 ;
a n d U . S . D e p a r t m e n t o f A g r i c u l t u r c , E c o
n o m r c
R e s e a r c h S e r v i c e , T o b a c c o S i t u a t i o n , W a
s h i n g -
t o r l : G o v e r n n r e n t P r i n t i n g O f h c c , 1 9 6 9 .
1 2 . T h e t e r m " c u l t u r e " i s u s e d t o r e f e r t o :
r n u m b e r
o f o t h e r c h a r a c t e r i s t i c s a s w e l l . f J o w e v e
r , t h c s c
t w o a p p e a r t o b e c o m m o n l y a s s o c i i r t e c l w
i t h t h c
c o n c c p t . S e e . f . B . M c K i n l a y , " S o m e O b s
e r v a t i o n s
o n t h e C o n c e p t o f a S u b c u l t u r e . " ( 1 9 7 0 ) .
1 3 . T h i s h a s b e e n a r g u e d i n . f . B . M c K i n l
a y , " S o n r e
A p p r o a c h e s a n d P r o b l e r n s i n t h e S t u d y o f
t h c L l s e
o f S e r v i c e s , " J o u m a l o f H c a l t h a n d S o c i a
l B c h a t , -
i o r , Y o l . 1 3 ( | u l n 1 9 7 2 1 , p p . 1 l - 5 - l - 5 2 ; a
n d f . I 3 .
M c K i n l a y a n d D . f ) u t t o n , " S o c i a l P s v c h o
l o g i c a l
F a c t o r s A f f e c t i n g I l e a l t h S e r v i c c U t i l i z

r r t i o n , "
c l r a p t c r i t C o n s u n t e r I n c c n t i u c s f o r H a a l
t h ( . , a r c ,
N e w Y o r k : P r o d i s t P r e s s , 1 9 7 4 .
l 4 . R c l i a b l e s o u r c e s c o v e r i n g t h c s e a r e r s
a r c a v a i l -
a b l e i n m a n y g r r o f e s s i o n a l j o u r n a l s i n t h
e f i e l c l s o f
e p i d e r n i o l o g y , m e c l i c a l s o c i o l o g y , ; r r e v
e n t i v e m e d -
i c i n e , i n d u s t r i a l a n d o c c r - l p a t i ( ) n a l n r e
c l i c i n c a n d
public health. Usefr.ri refcrence s covering thcse
a n d r e l a t e d . r r e a s a p p e a r i n f . N . M o r r i s ,
L l s c s o f
Epidemiology, London: E. and S. I-ivingstonc'
I r t d . , 1 9 6 7 ; a n d M . ' W . S u s s e r a n d W . W a t
s o n , S o
ciology in Medicine, New Yolk: Oxford Univer-
s i t y P r e s s , 1 9 7 1 .
1 . 5 . D . Z w c r l i n g , " D e a t h f o r f ) i r . r n c q " T
h e N c t u Y o r k
R e u i e w o f B o o k s , V o l . 2 1 , N o . 2 ( F e b r u a r
y 2 1 ,
1 9 7 4 ) , p . 2 2 .
1 6 . D . Z w e r l i n g , " D e a t h f o r D i n n e r . " S c e
f o o t n o t c
1 5 a b o v e .
17. This figure was quoted by several witnesses at the
Hearings Before the Select Committee on Nutri-
tion and Human Needs, U.S. Government Print-
i n g O f f i c e , 1 9 7 3 .

1 8 . T h e m a g n i t u d e o f t h i s p r o b l e m i s d i s c
u s s e d i n P .
Wyden, The Ouerweight: Causes, Costs and
C o n t r c , t l , E n g l e w o o d C l i f f s : P r e n t i c e - H
a l l , 1 9 6 8 ;
National Center for Health Statistics, Weight by
Age and Height of Adults: 1960-62. Washington:
Vital dnd Health Statistics, Public Health Servrce
P u b l i c a t i o n # 1 0 0 0 , S e r i e s 1 1 , # 1 4 , G o v e r
n m e n t
P r i n t i n g O f f i c e , 1 9 6 6 ; U . S . P u b l i c H e a l t
h S e r v i c e ,
C c n t e r f o r C h r o n i c D i s c a s e C o n t r o l , O b e
s i t y a n d
L l e a l t b , ' W a s h i n g t o n : G o v e r n m e r t t P r i n t
i n g O f -
fice. 1966.
1 9 . - I ' h i s a b o r t e d s t u d y i s d i s c u s s e d i n M
. J a c o b s o n ,
Nutrition Scoreboard: Your Guide to Better Eat-
ing, Ccnter for Science in the Public Intcrest.
2 0 . M . S . H a t h a w a y a n c l E . D . F o a r d , H e i g
h t s a n d
Weights for Adults in the United Srares, Washing-
t o n : H o m e E c o n o m i c s R c s e a r c h R e p o r t 1 0
, A g r i -
c u l t u r a l R e s e a r c h S e r v i c e , U . S . D e p a r t r n
e n t o f
A g r i c u l t t r r c , G o v e r n m c n t P r i n t i n g O f f i c
e , 1 9 5 0 .
2 1 . l - l r i s i s c l i s c u s s e d b y D . Z w e r l i n g . S
e e f o o t n o t e

1 6 .
22. Sce Hcarinpls Before the Sclect Cotnmittee on Nu-
lrition ttnd Httntatt Needs, Parts 3 and 4, "T.V.
A d v c r t i s i n g o f F o o d t o C h i l d r e n , " M a r c h
5 ,
1 9 7 - l a n c i M a r c h 6 , 1 9 7 3 .
2 - i . I ) r . . f o h n U c l k i n , D e p a r t m e n t o f N u t
r i t i o n , Q u e e n
Eliz-ebcth Ci-rllcge, [.or.rdon LLriversity. See p. 225,
Senate Ht:arings, footncltc 22 above.
2 4 . D . Z w e r l i n g , , " D e a t h f o r I ) i r " r n c r . "
S e e f o o t n o t e
l 6 i r b o v c , ; > a g c 2 4 .
2 . 5 . ' f h i s i s w c l l a r e u e d i n F . P i v e n a n d R
. A .
(llowarcl, llegulaiing the Poor: The Functions of
Social X/elfalc, New York: Vintage, 1,971; L.
(ioodwin, Do the P<.s<tr 'Vlttnl to -W<trk?, Wash'
i r r g t < r r r : l l r o o k i n g s , 1 9 7 2 ; H . . | . G a n s , "
T h e P o s i -
tive Fr-rnctions of Povcrty," American Journal of
Sociltlog1,, Vrl. 78, No. 2 (September, 19721, pp.
275-28i; R. P. Roby (Fd.). Thc Pouerty Estab'
l i s b m u r t , N e w J c r s c y : P r e r " r t i c e - H a l l , 1
9 7 4 .
2 6 . S c ' c , f o r . * a m p i e , j u i e s H e n r y , " A m e r
i c a n S c h o o l -
r o ( ) n r s : t , c o r r r i , r g i h e N i g h t n i a r . ' , " C o l
u m b i a U n i '
t , c r s i t ) , F t n t n t z , - ( S p r i n g l 1 9 6 3 ) , p p . 2 4
- 3 0 ; - S e e

elso ihc paper by
'F.
Ht-twe and P. Lanter, "How
thc Sclrool
'system
is Riggcd for Fallure," New
ili; ii.' "'ili I
ti?.,- ll d1..'" "";i';;","
Ali:,€ti.
Y , , r P P r , ' 1 r * t , I B o o k s , ( J u n e 1 8 . 1 9 7 0 ) ' '
Wi t h rcg.r rrt t,,'p., r,., I o gy." f o r ex anr ple, :"9 thg t"-.1:
ic,rl *olik of R. Quiiney in Criminal l.a1ti.c1 !-
t ,,'';;,
A tt e r i t: "t, B o s to n : L-ittl e Bio w n,
1 9 7 4, and,Critique
of Legal Ordt:r, I)ostot't: Little Brown,797.4' . -:r ..: ],,;iil
S.e. i,, exarrtple, S. M. Sales, *Organizatjfi '',ir;,
2 7
2 8 .
s at the
'. Nutri-
t Print-

ed in P.
s B a n d
[ , 1 9 6 8 ;
eight by
Irngton:
r Service
e r n m e n t
S e r v i c e ,
tsity and
t i n g O f -
a c o b s o u ,
ttter Edt'
'est.
ghts and
Washing-
1 0 , A g r i -
t m e n t o f
: e , 1 9 6 0 .
footnote
e on Nu-
4, *T.V.
{ a r c h 5 ,
r , Q u e e n
e p . 2 2 5 ,
footnote
I R . A .
:tions of
9 7 7 ; L .
', Wash-

'he Posi-
urnal of
7 2 ) , p P .
t Estab'
S c h o o l -
bia Uni'
3 0 . S e e
, "How
," Neu
the crit'
stice in
)ritique
t .
:ational
er" Ad'
ministratiue Science Quarterly, Vol. 14, No. 3
( S e p t e r n b e r , 1 9 6 9 ) . p p . . 1 2 5 - 3 3 6 . T h e l i
r e r a t u r e i n
t h i s p a r t i c u l a r a r e a i s e n o r m o u s . F o r s e v
e r a l g o o d
r e v i e w s , s e e L . E . H i n k l e , " S o m e S o c i a l a
n d B i o -
l o g i c a l C o r r e l a t e s o f C o r o n a r y H e a r t D i s
e a s e , "
Social Science and Medi<:ine, Yol. 7 (19671, pp.
1 2 9 - 1 3 9 ; F . H . E p s t e i n , " T h e E p i d e m i o l o
g y o f
C o r o r r a r y H e a r t D i s e a s e : A R e v i e w , " l o u
r n a l o f
C h r o n i c D i s e a s e s , 1 8 ( A u g u s t , 1 9 6 5 ) , p p .
7 3 5 - 7 7 4 .
2 9 . S o n ' r e i n t e r e s t i n g i d e a s i n t h i s r e g a r

d a r e i n E .
N u e l . r r i r . r g a n d G . E . M a r k l e , " N i c o t i n e
a n d
N o r m s : T h e R e e m e r g e n c e o f a D e v i a n t l J e
h a v i o r "
S o c i a l P r o b l e m s , Y < t l . 2 1 , N o . 4 ( A p r i l ,
1 9 7 4 1 ,
p p . - 5 1 3 - 5 2 6 . A l s o , J . R . G u s f i e l d , S y m b
c ; l i c C r u -
sade: Status Politics and the Atncrican T'emoer-
a n c e M o u e m e n t , I J r b a n a , I l l i n o i s : U n i v e
r s i t j ' , t f
I l l i n o i s P r e s s , 1 9 6 3 .
3 0 . F o r a s t u d y o f t h e w a y s i n w h i c h p h y s i
c i a n s , c l e r -
g y m e n , t h c p o l i c e , w e l f : r r e o f f i c e r s , p s y
c h i a t r : i s t s
a n d s o c i a l w o r k e r s a c t z r s a g e n t s o f s o c i
a l c o r l t r o l ,
see E. Curnning, Systems of Social Regulatiorr,
N e w Y o r k : A t h c r t o n P r e s s , 1 9 6 8 .
3 1 . R . H . R o s e n m a n a n d M . F r i c d n r a n , " T
h e R o l e o f
a S p e c i f i c C ) v e r t B c h a v i o r P a t t e r n i n t l -
r e C ) c c u r -
r e n c e o f I s c h e r - n i c H c r t r t l ) i s e a s e , " C a r
d i o l < t g i a
P r a c t i c a , 1 3 ( 1 9 6 2 ) , p 1 t . 4 2 - 5 3 ; M . F r i e d
m a n : r n r l
R. H. Itosenntan, l'ype A Bchauior ttnd Your
H e a r t , K n < t y t f , 1 9 7 . 1 . A l s o , S . . f . Z y z a n
s k i a n c l
C . D . J e n k i r r s , " l l i r s i c D i m e n s i o u s V i t h
i n r n e

C o r o r r a r y - P r o n e B e h a v i o r P : l t t c n t , " . l r x
t m a l o f
O h r L t n i c [ ) i s e t t s e s , 2 2 ( 1 9 7 0 1 , p p . 7 8 1 - 7
9 - 5 . T h e r e
a r e , o f c o r l r s e , m a n y o t h e r i l l n e s s e s w l - r
i c h h a v c
a l s o b e e r - r r c l a t e d i n o n e w a y ( ) r a n ( ) t h e
r f o c c r t i r l r
p e r s o n a l i t y c h a r r r c t e r i s t i c s . H a v i n g f o u
n d t h i s
n e w t u r f , b c h : r v i o r r i l s c i c n t i s t s r v i l l m o
s t l i k e l y
c o n t i n u e t o p l a y i t f o r e v c r y t h i n g i t i s w o
r t l r a r r c l
t l - r c n , i n r h c i n t e r c s t s o f t h e i r o w n s t r r v
i v r r l . r v i l l
" d i s c o v e r " t l - r a t s o r n e t h i l r g c l s c i r r c l c
c t l a c e o u n r s
f o r w h a t t l r c y w c r e t r v i r r g t . , e x P l 3 i 1 1 . r
n c l w i l l
e v e u t u a l l y n r o v e o f f t h c r e r o f i n d r e n c w c
d f : r n r e
a n d f o r t u n e . F u r t h e r n r o r e , s e r i o u s r n e t h
o c l o l o g i -
c a l d o u b t s h a v e b e e n r : r i s e c l c o n c e r n i n q
t h c s r i l c l -
i e s o f t h e r e l a t i o n s h i p b e r w e c u p . . r s o n r r
l i t y r r n c l
a t - r i s k b c l . r a v i o r . S e e , i n t h i s r e g a r d , ( ;
. M .
H o c h b a u n r , " A C r i t i q u c o f P s y c l . r o l o g i c
a l R e -
s e a r c h o n S n r o k i u g , " p a p e r p r c s e n t e d t o t
h e
A r n e r i c a n P s y c h o l o g i c a l A s s o c i a r i o n , I -
o s A n g e -

l e s , 1 9 5 4 . A l s o B . l . e b o v i t s a n d A . O s t f e
l d ,
" S m o k i n g a n d P e r s o n : r l i t y : A M e t h o d o l o
g i c
A n a l y s i s , " . l t t u n n l o f ' C h r o n i c / ) l s c a s e s
( 1 9 7 1 ) .
3 2 . M . F r i e d m a n a n d R . H . I l r s e n n r a n . S e e
f o o t n o t c
J l . .
3 3 . I n t h e N e w Y o r k T i n t e s < ' t [ S L r n d a y ,
M a y 2 6 , 1 9 7 4 ,
lcussmg Upstreatn: I he l'olltrcal L,conomy of Illness 529
t h e r e w e r e j o b a d v e r t i s e m e n t s s e e k i n g " a
g g r e s s r v e
s e l f - s t a r t e r s , " " p e o p l e w h o s t a n d r e a l c h
a l l e n g e s , "
" t h o s e w h o l i k e t o c o r n p e f e , " " c a r e e r o r i
e n t e d s p e -
c i a l i s t s , " " t h o s e w i t h a s p a r k o f d e t e r m i
n a t i o n t o
s o m e d a y r u n t h e i r o w n s h o w , " " p e o p l e w i
t h t h e
s u c c e s s d r i v e , " a n d " t a k e c h a r g e i n d i v i d
u a l s . "
3 4 . A s p e c t s o f t h i s p r o c e s s a r e d i s c u s s e d
i n J . B . M c K i n -
l a y , " O n t h e P r o f e s s i o n a l R e g u l a t i o n o f
C h a n g e , "
in Thc Professions and Sociol Changc, P. Halrnos
( E d . ) , K e e l e : S o c i o l o g i c a l R e v i e w M o n o
g r a p h , N o .

2 0 , 1 9 7 3 , a r . r d i n " C l i e n t s a n d O r g a n i z a t
i o n s , "
c h a p t e r i n | . R . M c K i n l a y ( F i d . ) , P r < l t : e s
s i n g P e o -
ple-Studies in Organizationa| B ehduior, London:
H o l t , R i n e h a r t , a n d W i r r s t o : n , 1 9 7 4 .
. 1 . 5 . T l r e r c l r a v e b e e n a n u r n b e r o f r e p o r
t s r e c e n t l y
c o n c e r n i n g t h i s a c t i v i t y . Q u e s t i o n s h a v e
a n s e n
a b o u t t h c c o n d u c t o f r l r a j o r o i l c o r p o r a t
i o n s d u r -
i n g t h e s o - c a l l e d " e n e r g y c r i s i s . " S e e f o
o t n o t e 1 0 .
E q u a l l y q u e s t i o n a b l e n r a y b e t h e p u b l i c s
p i r i t e d
a c l v e r t i s e m e n t s s p o r ] s o r e c l b y v a r i ( ) u s
p r o f e s s i o n a l
o r g z r n i z i r t i o n s w h i c h , w h i l e c l a i n r i n g t
o b e s o l e l y
i r - r t h e i n t e r e s t s o f t h e p u b l i c , a c t u a l l y
s e r v e t o e u -
I t r r n c e b u s i n e s s i n v n r i o u s r . l . a 1 , s . F u r t
h e r r n o r e , b y
g r a n t i n g s p e c i a l s t a t u s t o l c t i v i t i e s o f p r
o f e s s i o n a l
g r o l r p s , g o v e n r n r c n t l g c r r c i c s l n t l l a r g e
c o r p o r r t -
t i o n s m a y e f f e c t i v e l y g a g t h e m t h r o u g h s
o l - n c e x -
y r e c f a t i o n o f r c c i p r o c i t y . F o r e x a t n p l e ,
l r o s t
l r c a l t h g r o u l - r s , n o t r r b l v t h e A r n e r i c a n
C e n c e r S o -
c i c t y , d i c l ! r o t s u p p o r t t h e F . C l . ( 1 . ' s r c t

i o n l l g r l i n s t
s n r o k i r r g c o n r n r e r c i i r l s b c c a u s c t h e y w c
r e f e r r r f u l
o f a l i e n a t i n g f h e n e t w o r k s f r o u r w h o r l r t
h e y r c -
c c i v e f r e e a n n o l . l u c c l n c - n t s f o r t h c i r f r .
r n d d r i v e s .
l J o t h t h c A r " n e r i c : r n ( l a n c c r S o c i e t y e n c
l t l r c " A m e r -
i c : r n F l e a r t A s s o c i a t i o n l r r r v c b c e n c r i t i
c i z e d f o r
t l t c i r r c l u c t a n c e t o e n l l r r l a c i r r d i r c c t o
r g , a n i z i r t i o n a l
c o n f l i c t w i t h p r o - c i g r r r e t t c f o r c ( ' s , p i l r
t i c r r l a r l y b c -
f o r e t h e : r l l i a n c e b e t w c c n t h e t e l e v i s i < ' r
n b r o a c l -
c i l s t c r s a n c l t h c t o b l c c o i n d r r s t r y [ r r o k e
d o w n .
R r r t h r - r i t h c y h n v c d i r c c t e c l t l r e i r e f f o r
t s t o t h e
c l o w n s t r c - l r n r r c ' f o r n r < l f t [ r e s u r o k e r .
S e c E .
N u e h r i n g r r r c j ( i . F l . M a r l c l e , c i t e r l i n f
o o t n ( ) t e 2 9 .
3 6 . l - .
. N u c h r i n g
a n c i ( 1 . F l . M a r k l c , c i t e d i n f ( x ) t n o t e
3 7 . T h c r v a 1 , s i r . r w h i c h l r , r r g e - s c : r l c o
r g : r n i z i t t i < l n s e n g i -
n e e r a n c l d i s s e n r i n r r t e t h c s e n r y t h s c o n c
e n r i n g
t h e i r n r : r n i f e s t a c t i v i t i c s , w h i l e a v o i d i

n g a n y r n e n -
t i o n o f t h e i r r - r n r i c r l y i n g l a t c n t t c t i v i t i
e s , a r e d i s -
c t r s s e c l i n m o r e d e t a i l i n t h e t w o r e f e r e n
c e s c i t e d
i n f o o f n o t e 3 4 a b o v c .
. 1 8 . F o r a p o p t r l a r l y r v r i t t e n a n c l e f f e c t
i v e t r e a t m e n t o f
t h e r e l a t i o n s h i p b e t w e c n g i r n t c o r p o r e t i
o n s a n d
f o < t c l p r o d u c t i o n a n d c o r r s u m p t i o n , s e c
W . R o b -
birrs, T/re American Food Scttndal New York:
W i l l i a r n M o r r o w a n d ( ' . < t . - 1 9 7 4 .
A C a s e f o r R e f o c u s s i n g U p s t r e a r n : T h e P
o l i t i c a l E c o n o m y o f I l l n e s s

5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h .docx

Recommended

Recommended

More Related Content

Similar to 5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h .docx

Similar to 5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h .docx (20)

More from alinainglis

More from alinainglis (20)

Recently uploaded

Recently uploaded (20)

5 1 6 T o w a r d A l t e r n a t i v e s i n H e a l t h .docx