Open Moments and Surprise Endings: Historical Agency and the Workings of Narrative in The Social Transformation of American Medicine

The need for narrative derives from the essential messiness of the world, its lack of any pre-established harmony.

—Gary Saul Morson, "Narrativeness"

One of the most important aspects of Paul Starr's The Social Transformation of American Medicine is its synthetic quality. Published in 1982, the book brought together distinct approaches to the history of American medical care and health systems, stories that had long stood on their own as separate histories. Starr integrated several different strains of historiography: the intellectual history of medical knowledge about disease, science, and the body; histories of the politics of social insurance; the social history of municipal reform and public health; the literature of professionalization; and the American exceptionalism narratives of why there is no national health insurance. In an effective and compelling fashion, for example, Starr took the previous historiography of social insurance, typically case studies of a particular idea of risk pooling or a specific public insurance program, and another literature of the failure to pass national health insurance in the United States, usually a story of the failure of liberal politics, and embedded these rather insular political histories within the social history of a group of historical actors, physicians. In addition, he pulled in the urban public health story, the development of medical knowledge, the social history of the hospital, and the history of the professions, again linking separate historiographies. And most important, he connected the history of doctors' professionalization to a broader political economy. The book joins the changing nature of the physician's profession to the institutions through which medical care and health policy would be produced: municipal agencies, hospitals, clinics, corporations, unions, and state and national politics. Starr, then, does show, over a substantial swath of time, the "making of a vast industry."

In addition to the synthesis of academic literatures and interpretations, the book also achieves an engaging popular readability. Part of this general readability is due to fascinating details of the story, such as what it was like to obtain medical care in the 1760s or 1830s. These are then summed up in broad explanatory concepts—the dream of rationality, the resonance of science and democratic temper, authority and dependence, and a profession's creation of a sense of legitimate complexity—complex knowledge beyond common sense or popular capacity for comprehension. In part, the general accessibility of the book rests on the links Starr makes between medical history and big moments in American history: the Age of Revolution, the Age of Democracy and the Early Republic, the Jacksonian Era, the Progressive Era. Readers can readily grasp these periodizations. Moreover, Starr's engagements with academic debates are eased into the narrative usually late in the chapter—after the reader has been brought into the story and has learned some of the facts and ideas. Thus when Starr decides to take on Talcott Parsons and Renée Fox's hypothesis of care of the sick moving from the home to institutions, Simon Kuznets and Milton Friedman's study of physicians' incomes and monopolistic barriers to entering the profession, or Kenneth Arrow's functionalism and E. Richard Brown's Marxism, it doesn't alienate the reader as a rarified debate among experts unconcerned with nonexpert readers. It is part of a story the reader now knows. In fact, he often seems to reconcile easily two competing interpretations. Finally, book two is deeply concerned with one of the most persistent political issues of the twentieth century: access to health care. With its clearly presentist concerns and final stabs at prediction, The Social Transformation of American Medicine seems to link past, present, and future. Because of this, the book won a Pulitzer Prize.

Yet the book was also awarded a prize from within the academic historical profession, the prestigious Bancroft Prize in American History. I think there are several factors characteristic to its moment that made the book so appealing and respected. After a decade in which social history seemed to be crowding out political history, Starr's book appeared to reconcile...