Posts Tagged With: healthcare

Hysterical Men


Lerner, Paul.  Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890-1930.  Ithaca: Cornell University Press, 2003.

Lerner’s book centers on a German debate over how to interpret the “debilitating shakes, stutters, tics and tremors, and dramatic disorders of sight, hearing and gait” that were plaguing the nation’s veterans of the Great War (1).  Throughout his book, he traces the shift from describing such ailments as the result of “trauma” to being the outward symptoms of a deeper, inner “hysteria.”  This shift represented a growing power of psychiatrists in Germany, and Lerner shows that it also had ramifications on Germany’s laws, economy, and notions of masculinity.

The work of psychiatrist Hermann Oppenheim in the 1870s and 1880s demonstrated that the stutters, tics, and tremors that some men were experiencing were symptomatic of “trauma,” which was caused by external shocks and accidents.  Oppenheim’s work was successful enough that Bismarck included trauma as a legitimate reason for claiming insurance pensions in 1889 (pg 9).  The discourse was quickly replaced by a newer generation of psychiatrists and policy makers, though, who claimed that such a connection would “pension neurosis,” or a debilitating addiction to pensions (33).  In other words, a diagnosis of “trauma” would cast the men as victims and allow them to feel entitled to pension payment from the state.  Instead, a new diagnosis emerged:  men’s tics and tremors were manifestations of “hysteria”, a deeply rooted flaw of the person’s character.

When the Great War broke out in 1914, the nationalistic, conservative psychiatrists saw the conflict as a chance to harden up Germany’s weak and hysterical men.  But, by the time that hundreds of thousands of men were complaining of trauma during WWI, the situation became more serious, particularly as the state faced paying out insurance claims to all of its veterans.  The psychiatrists used their superior social stances to launch another “war on hysteria,” which included new therapies like “suggestive preparation” (103) and other “active treatments” like electro-shock therapy.  Lerner asserts that by claiming that these hysterical men were themselves flawed, psychiatrists absolving the state of any responsibility since these men’s ailments were not caused by any traumatic event of the war.  More importantly than saving the state any moral responsibility, a diagnosis of “hysteria” (versus “trauma”) would save the state money since it no longer had to pay out insurance pensions.  So, in imperial Germany, economic concerns overlapped with scientific changes, and economics always remained intertwined with the debate (85).  Once the men were deemed “cured” they were sent to support the war effort not on the front line, but in the labor force on the home front.

But Lerner reveals that much more was a stake here than money.  “Psychiatry was at once a product of modernity and a forum for critiquing modernity” (15).  In other words, while psychiatry was itself a modern science, psychiatrists saw themselves as trying to cure the weaknesses caused by modernity.  “Curing male hysterics meant medically manufacturing proper German subjects” (7).  They attempted to define a renewed German masculinity centered on patriotism, self-sacrifice, and economic productivity.  “The specter of the male hysteric, then, haunted the German imagination as the nation progressed along the path to modernity…To the conservative, stridently nationalistic psychiatric profession, male hysterics symbolized Germany’s social, political, and economic catastrophe” (250).  Psychiatrists then attempted to shape the national memory of the war and its conclusion in clinical terms.  The loss of 1918 was then portrayed as the result of Germany’s exhausted nerves, and the November revolutions were depicted as outbursts of mass insanity.

For more books on modern German history, see my list of book reviews here. 

Categories: Book Review, German History, History | Tags: , , , , , , , | Leave a comment

Five Obamacare Myths

Published: July 15, 2012 (original article here.)

ON the subject of the Affordable Care Act — Obamacare, to reclaim the name critics have made into a slur — a number of fallacies seem to be congealing into accepted wisdom. Much of this is the result of unrelenting Republican propaganda and right-wing punditry, but it has gone largely unchallenged by gun-shy Democrats. The result is that voters are confronted with slogans and side issues — “It’s a tax!” “No, it’s a penalty!” — rather than a reality-based discussion. Let’s unpack a few of the most persistent myths.

OBAMACARE IS A JOB-KILLER.The House Republican majority was at it again last week, staging the 33rd theatrical vote to roll back the Affordable Care Act. And once again the cliché of the day was “job-killer.” After years of trying out various alarmist falsehoods the Republicans have found one that seems, judging from the polls, to have connected with the fears of voters.

Some of the job-killer scare stories are based on a deliberate misreading of a Congressional Budget Office report that estimated the law would “reduce the amount of labor used in the economy” by about 800,000 jobs. Sounds like a job-killer, right? Not if you read what the C.B.O. actually wrote. While some low-wage jobs might be lost, the C.B.O. number mainly refers to workers who — being no longer so dependent on employers for their health-care safety net — may choose to retire earlier or work part time. Those jobs would then be open for others who need them.

The impartial truth squad has debunked the job-killer claim so many times that in its latest update you can hear a groan of weary frustration: words like “whopper” and “bogus” and “hooey.” The job-killer claim is also discredited by the experience under the Massachusetts law on which Obamacare was modeled.

Ultimately the Affordable Care Act could be a tonic for the economy. It aims to slow the raging growth of health care costs by, among other things, using the government’s Medicare leverage to move doctors away from exorbitant fee-for-service medicine, with its incentive to pile on unnecessary procedures. Two veteran health economists, David Cutler of Harvard and Karen Davis, president of the Commonwealth Fund, have calculated that over the first decade of Obamacare total spending on health care, in part by employers, will be half a trillion dollars lower than under the status quo.

OBAMACARE IS A FEDERAL TAKEOVER OF HEALTH INSURANCE. Let’s be blunt. The word for that is “lie.” The main thing the law does is deliver 30 million new customers to the private insurance industry. Indeed, a significant portion of the unhappiness with Obamacare comes from liberals who believe it is not nearly federal enough: that the menu of insurance choices should have included a robust public option, or that Medicare should have been expanded into a form of universal coverage.

Under the law, to be sure, insurance will be governed by new regulations, and supported by new subsidies. This is not the law Ayn Rand would have written. But the share of health care spending that comes from the federal government is expected to rise only modestly, to nearly 50 percent in 2021, and much of that is due not to Obamacare but to baby boomers joining Medicare.

This is a “federal takeover” only in the crazy world where Barack Obama is a “socialist.”

THE UNFETTERED MARKETPLACE IS A BETTER SOLUTION. To the extent there is a profound difference of principle anywhere in this debate, it lies here. Conservatives contend that if you give consumers a voucher or a tax credit and set them loose in the marketplace they will do a better job than government at finding the services — schools, retirement portfolios, or in this case health insurance policies — that fit their needs.

I’m a pretty devout capitalist, and I see that in some cases individual responsibility helps contain wasteful spending on health care. If you have to share the cost of that extra M.R.I. or elective surgery, you’ll think hard about whether you really need it. But I’m deeply suspicious of the claim that a health care system dominated by powerful vested interests and mystifying in its complexity can be tamed by consumers who are strapped for time, often poor, sometimes uneducated, confused and afraid.

“Ten percent of the population accounts for 60 percent of the health outlays,” said Davis. “They are the very sick, and they are not really in a position to make cost-conscious choices.”

LEAVE IT TO THE STATES. THEY’LL FIX IT. The Republican alternative to Obamacare consists in large part of letting each state do its own thing. Presumably the best ideas will go viral.

States do have a long history of pioneering new ideas, sometimes enlightened (Oregon’s vote-by-mail comes to mind) and sometimes less benign (see Florida’s loopy gun laws). Obamacare actually underwrites pilot programs to reduce costs, and gives states freedom — some would argue too much freedom — in designing insurance-buying exchanges. But the best ideas don’t spread spontaneously. Some states are too poor to adopt worthwhile reforms. Some are intransigent, or held captive by lobbies.

You’ve heard a lot about the Massachusetts law. You may not have heard about the seven other states that passed laws requiring insurers to offer coverage to all. They were dismal failures because they failed to mandate that everyone, including the young and healthy, buy in. Massachusetts — fairly progressive, relatively affluent, with an abundance of health providers — included a mandate and became the successful exception. To expand that program beyond Massachusetts required … Barack Obama.

OBAMACARE IS A LOSER. RUN AGAINST IT, RUN FROM IT, BUT FOR HEAVEN’S SAKE DON’T RUN ON IT. When Mitt Romney signed that Massachusetts law in 2006, the coverage kicked in almost immediately. Robert Blendon, a Harvard expert on health and public opinion, recalls the profusion of heartwarming stories about people who had depended on emergency rooms and charity but now, at last, had a regular relationship with a doctor. Romneycare was instantly popular in the state, and remains so, though it seems to have been disowned by its creator.

Unfortunately, the benefits of Obamacare do not go wide until 2014, so there are not yet testimonials from enthusiastic, family-next-door beneficiaries. This helps explain why the bill has not won more popular affection. (It also explains why the Republicans are so desperate to kill it now, before Americans feel the abundant rewards.)

Blendon believes that because of the delayed benefits and the general economic anxiety, “It will be very hard for the Democrats to move the needle” on the issue this election year.

He may be right, but shame on the Democrats if they don’t try. There’s no reason except cowardice for failing to mount a full-throated defense of the law. It is not perfect, but it is humane, it is (thanks to the Supreme Court) fiscally viable, and it comes with some reasonable hopes of reforming the cockeyed way we pay health care providers.

Even before the law takes full effect, it has a natural constituency, starting with every cancer victim, every H.I.V. sufferer, everyone with a condition that now would keep them from getting affordable coverage. Any family that has passed through the purgatory of cancer — as mine did this year, with decent insurance — can imagine the hell of doing it without insurance.

Against this, Mitt Romney offers some vague free-market principles and one unambiguous promise: to dash the hopes of 30 million uninsured, and add a few million to their ranks by slashing Medicaid.

If the Obama campaign needs a snappy one-liner, it could borrow this one from David Cutler: “Never before in history has a candidate run for president with the idea that too many people have insurance coverage.”

A version of this op-ed appeared in print on July 16, 2012, on page A17 of the New York edition with the headline: Five Obamacare Myths.
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