Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930 (review)

Sandra Lee Barney. Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930. Chapel Hill: University of North Carolina Press, 2000. xiii + 222 pp. Ill. $39.95 (cloth, 0-8078-2522-0), $17.95 (paperbound, 0-8078-4834-4).

The persistent mythology surrounding rural life in America can be traced, in part, to representations of rural life in novels, film, music, and politics. In Authorized to Heal, Sandra Lee Barney does an admirable and much-overdue job of debunking some of the persistent myths about medicine in the hardscrabble communities that constitute rural Appalachia. Although her focus is on medical practice in the mountains, her research provides support for the view that Appalachia remains very much a part of general rural culture in America. That she manages this without ignoring the region's complex and diverse cultural heritage is a testimony to fine scholarship. Her careful review of regional medical journals and other archival materials convinces the reader that Appalachian physicians felt a kinship with their more formally educated brethren and were not isolated, at least in terms of their sense of professional identity.

Coincident with this evolving professional sense of cohesion and identity was a growing maternalist movement that had a significant impact on the evolution of medical practice in the region. The women involved in this movement were reform-minded middle-class women who either came from the more well-to-do native families or arrived as part of the new industrial class that transformed Appalachian communities after the Civil War. The alliance between allopathic physicians and these "committed maternalists" (a marvelous phrase) affected powerfully the practice of medicine in the mountains, especially in regard to maternal and child health issues. Women's clubs and medical societies worked together to establish and expand county public health units--a development that created new and economically beneficial professional roles for mountain doctors. Over time, the medical community's anxiety about nonphysicians' role in medicine and public health evolved into a rift between disease- and patient-focused doctors and public-health-oriented maternalists in alliance with nursing organizations, the latter eager to define an unambiguous professional role in Appalachian health care for themselves.

At times the gender issue is given greater weight than class and economic issues, although clearly all three were operative and interacting. This is illustrated best in Barney's examination of the central issue of twentieth-century American medicine: whether a government-sponsored and public-health-oriented system of health care was to be supported over a private and individually oriented system controlled by the medical profession. The conflict was not fundamentally between public-health-oriented women reformers and the primarily male medical community. Throughout the twentieth century, physicians were willing to support public health initiatives, at least insofar as they increased the public's expectations of the advantages of scientific medicine and advanced physicians' role at the center of scientific practice. When the next logical step was proposed--the reorganization of health care to promote a public health agenda--in Appalachia and elsewhere both men and women physicians alike largely balked, as did most of the members of the women's clubs. Barney does bring the economic and ideological issues into play, but with more brevity than is justifiable.

Authorized to Heal rests well within the extant literature on the subject of class and gender in medical care, but does so with a unique regional focus that is founded on substantive and cogent research. Barney's scholarship provides a nuanced perspective on the shifting and complex motivations of rural physicians and public health and women social reformers. The book's contemporary resonance will appeal to readers interested in the historical tension between traditional medical practice and public health. Barney's honest portrayal of rural medical practice during an unusually rapid period of regional...