Nancy Tomes: Remarks from the Bancroft Awards Dinner

UNC Press congratulates Nancy Tomes, winner of the prestigious 2017 Bancroft Prize in American History and Diplomacy from Columbia University for her book Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers. Tomes presented the following remarks at the awards dinner on April 29, 2017.

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I want to start by thanking the Bancroft Prize Committee for this incredible honor. My state of mind for the last few weeks is best summed up by the word, “wow,” which just keeps popping out of my mouth.

My sense of having wandered into an alternate reality is even more intense because of my very conflicted feelings about this book. It was very difficult for me to write. Although I’d had moments of struggle with my previous books, when they were done I liked them. I thought, hey, these are pretty good. With this one, as it went off to the printer I felt an emotion close to dread: I have not got it right yet, but I have to let it go. 

The idea for the book started out innocently enough: I’d been writing about germs, and how advertising about their dangers helped to reshape many aspects of everyday life. So, I thought to myself, wouldn’t it be interesting to think about how the dynamics of modern consumer culture, particularly advertising, have shaped our expectations of medicine. In that happy toddler phase, I had a lot of fun looking at old ads. But like a teenager, as the project matured it got more and more difficult. (I hasten to say here this child metaphor has nothing to do with my real child, who is sitting here tonight, who was and is a delightful daughter!) But this book child was a pain: at times sullen, at times maniacal, dragging me into all kinds of unpleasant places I didn’t want to go (like thinking about health insurance!). It was the one I felt I had to send to the corner to learn how to behave. What was supposed to be a quick little aside of a book turned into a monster that took almost eighteen years to complete, years when I made myself and those around me miserable with wails and moans: whatever possessed me to try to write this book? I would look gloomily at my graduate students and say, never ever try to do what I am attempting: a book that spans a century and attempts to reinterpret the history of American medicine from a patient/public perspective. This way madness lies.

For a lark, I recently went and typed in “American health care system” on Google Scholar: there were 3,590,000 results. As I wrote, I certainly felt the weight of all that has been written about that system, famous around the world for its complexity and its dysfunctionality. (Yes, we did know it was so complicated, Mr. President!) Whatever possessed me to think that there was something else that needed to be said? And yet I persisted.    

What kept me going was a determination to unravel what struck me as a contradiction of huge proportions: the U.S. claims to have a health care system shaped by a devotion to “evidence-based medicine,” patient empowerment, and consumer-driven policy and yet real patients seem to have a very limited role in shaping how it really works. They often end up with disorganized, ineffective, and whoppingly expensive care, only to be told it was their own fault: they made bad choices. They had unreasonable expectations of treatment. They were unwilling to pay what care “really” cost. I would often hear these arguments from economists when I was a Robert Wood Johnson investigator and I would wonder to myself, where did all these expectations come from? Who decides what care costs in the first place? Are the end users of health care really the ones who deserve the most blame? Those questions took on new significance when someone in my family—a child—became seriously ill and I experienced the reality that “so many Americans share a corrosive fear that the quality of their medical care depends too much on the size of their pocketbooks.”

Thinking about those issues was like entering a funhouse with distorted mirrors: people used the same words—patient, consumer, choice, value—and meant very different things by them. In search of the origins of this strange concept of the “patient as consumer,” I kept going back further and further, looking for where it came from. The roots turned out to be a lot earlier than I expected: the 1920s and 1930s, not the 1970s. It still surprises me to read advice given in Americans in the 1930s—that you need to check your doctor’s credentials and read up on treatments before you have them—that with barely adjusted phrasing could appear on the Internet today. I found that as early as 1954, somebody had the idea of forming an American Patients’ Association to create a voice for patients that would counter that of the AMA, the AHA, the pharmaceutical industry. While I discovered that these critics had had a lot more political impact than they’d gotten credit for in previous histories, their demands for change were deflected and co-opted all too easily, in part because of how bound they were by their own position of white middle-class privilege. That deflection also resulted from the endless creativity of entrepreneurs who skillfully adapted the language of consumer choice to their own advantage. 

One of the biggest challenges I faced was in being critical of consumerist thinking without dismissing what patient advocates and activists did accomplish. Likewise, I struggled with portraying the very complicated reactions that physicians had to the chorus of patient complaints. While the majority of doctors were outraged that patients dared to criticize them, a minority realized all too well that the patient-critics were getting their best ammunition from the pages of medical journals, where doctors themselves were worrying about an overly commercial spirit within the profession.

The difficulty of getting this complex story “just right” was the source of my chronic uncertainty, as well as the fact that every day something new was happening that could force me to revise my conclusions. One of the solaces I found was in collecting cartoons. When I’d had a bad day, I would refresh myself by looking at the spoofs that appeared in the Depression-era humor magazine Ballyhoo. Another of my prize finds was a Mad magazine spoof of the Parke Davis great moments in medicine series that showed a horrified patient getting his bill. And I was amazed at the cartoons I found in Medical Economics making fun of both doctors and patients.

In the end, my own stubbornness did a great deal to keep me going. Almost twenty years from start to finish, Remaking the American Patient is definitely a work of “slow history.” Like slow food, it required far more than my labors alone to finish. My name is the only one on the cover, but this work reflects a much more collective process. In its pages are the tracks of many invaluable conversations and helpful assists along the way. As writers, historians are usually solo artists. But we are social creatures too, and we benefit from the company of others. I was lucky to have support from three very different communities of fellow scholars: the National Humanities Center, where I spent a year in 1999-2000 and a summer in 2010; the Robert Wood Johnson investigator program, which put me in the company of the finest policy experts in the country from 2003 to 2005; and my department at Stony Brook, where I have happily taught since 1978, and which is the best history department in the universe.  

I was also very lucky in my choice of a press. In an era when university presses are fighting to stay solvent and relevant, which usually means getting their authors to write short books, they let me write a “slow history.” When I said in my initial proposal my aim was to write a book that was a cross between Paul Starr’s Social Transformation of American Medicine (514 pages long) and Lizabeth Cohen’s A Consumers’ Republic (539 pp.), they let me do it. (Mine is 539 pages, and every review by a non-historian says “Oh my God, this is so long!) They got me two fabulous readers to go over the text and save me from myself. Last but not least, they tapped a fund generously provided by Lillian Furst to help cover the costs.

I have saved the best to last: and that is the support of my husband and my daughter. My husband Christopher Sellers is an accomplished historian of health and the environment whose instincts for argument and evidence are superb. He also became very adept at Nancy management, which required hauling me out of my black moods. Our daughter Annie is herself a writer. She pitched in on numerous occasions to distract me as well as to help me with footnote checking, copying, and many other tedious aspects of finishing a book. Thank you both so much.

I wish I could stand here tonight and say I’m optimistic about what is going to happen to the American patient in the next few years. I’m not. I am painfully aware of the irony of my getting this award at the same time the Trump administration is trying to repeal the Affordable Care Act. After one defeat, they are back at it again this week. We remain mired in a toxic conversation about health care: too many politicians refuse to see health care as a right, not a privilege. Too many of them continue to push solutions that protect profits rather than patients. The wrecking ball now at work in Washington, D.C., is just going to make things worse. At a time like this, I wish I was better with the thirty-second quip. Slow history is not good in a crisis! Now we have 3,590,001 works on the American health care system that no one will read. But I am not going to give up. I take heart from other historians I know—like my husband—who are better at providing useful commentaries in real time.   

I also want to do whatever I can to ensure that future historians have the benefit of the collective strengths I have drawn on: institutions like the National Humanities Center, The Robert Wood Johnson Foundation, the University of North Carolina Press, and history departments at public universities. As I go forth to fight on, I deeply appreciate the honor the Bancroft Prize Committee has bestowed upon me.