Pubdate: Thu, 08 Feb 2001
Source: New England Journal of Medicine (MA)
Copyright: 2001 Massachusetts Medical Society
Contact:  10 Shattuck Street, Boston, MA 02115-6094
Fax: (617) 739-9864
Author: Daniel M. Fox, M.D.
Note: Here are three items by Sally Satel from the MAP archives:
The Swiss Heroin Trials: Scientifically Sound?
WSJ book review: Battle Plan for the Drug War
OPED: The Hard Line


By Sally Satel. 285 pp. New York, Basic Books, 2000. $27. ISBN

In PC, M.D., Satel deplores the "political correctness" (the PC of her
title) advocated by some physicians, academics in the fields of
nursing and public health, psychologists, social workers, and health

She defines political correctness as the assumption that the health
problems of the poor, members of minority groups, women, and persons
with mental illness are mainly a result of their oppression by
dominant groups in society. "Indoctrinologists" for political
correctness in the health professions have what the author calls a
"social empowerment agenda" that "will divert resources from
strategies that really work" and is already "making some people sick,
or sicker than they need to be."

Satel devotes a chapter to each of seven examples of the effects of
this social empowerment agenda.

These examples are urging by an "academic elite" that the theory and
practice of public health "encompass the quest for social justice";
the participation of former psychiatric patients ("consumer-survivors"
of a "medical model" of care) in the delivery of mental health
services; the preoccupation of some academic nurses with "fad
therapies" and its contribution to the "dumbing down of nursing
education"; false claims by leaders of the "modern women's health
movement" that women are "not getting sufficient attention from
medical research"; a misguided "lawyer-mounted campaign" for the
"freedom" of "crack" cocaine- addicted women in South Carolina to use
cocaine during pregnancy; simplistic analysis by officials of federal
agencies and professional associations of the causes of disparities in
access to care and health status between members of minority groups
and whites of European descent; and the "strange new world" of
"psychotherapy for victims," especially victims of actual or imagined
abuse and discrimination.

This book will be controversial. Satel's arguments and rhetoric blend
analysis and anger.

She can report engagingly on what she has witnessed and read. But she
also dispenses harsh and inadequately documented opinions about issues
and individual persons.

Satel is sympathetic to many of the issues that she accuses
"indoctrinologists" of taking to extremes.

Thus, she acknowledges that health status has multiple determinants,
that members of minority groups have historically had less access to
health care and worse health status than other Americans, and that
many persons with mental illness and addiction to narcotic drugs have
not retained their civil rights. Her complaint is that
political-correctness extremists support policies on the basis of
ideology rather than evidence.

Their strident advocacy increases the difficulty of gaining support
for interventions that are both more moderate and more effective.

Satel exaggerates the influence of these advocates.

She elevates the status of "PC medicine" by calling it the "fourth
era" of American public health, following the "sanitation, biological
and lifestyle eras." PC medicine is, however, an insurgency rather
than the defining theme of an era. For example, the academics in the
field of public health who embrace the extreme version of the "social
production of health" that dismays Satel have had little discernible
influence on public health practitioners. Similarly, nurses who
embrace New Age rhetoric and alternative therapies embarrass many
nursing leaders.

Satel overstates her criticism of politically correct professionals in
her own field of mental health.

Health care providers, managed-care organizations, and public
officials in each state make most policy for the care of patients with
mental illness; "consumer-survivors" and their sympathizers have a
limited role. The courts and the media are increasingly skeptical of
persons who, during therapy, recover memories of sexual and physical

Moreover, Satel is too often an unreliable guide to the issues she
discusses. Sometimes she oversimplifies complicated matters.

For instance, she claims that public health is a "clinical enterprise"
and ignores its other core functions.

Similarly, her discussions of harm reduction as an approach to
treating substance abusers and of community mental health fail to take
into account the history and complexity of these concepts.

She also makes dubious accusations. For example, Satel associates
Harvey V. Fineberg and William H. Foege with the extremists among
public health advocates because they have expressed opinions that she
supports elsewhere in the book. Similarly, she assigns the National
Institute of Drug Abuse sole responsibility for defining addiction as
a "chronic and relapsing brain disease" and reduces the distinguished
history of the Bazelon Center for Mental Health Law to the inaccurate
epithet "consumer-survivor advocacy group."

In addition, Satel omits pertinent information that would weaken her
case. Describing the success of politically correct nursing in the
United Kingdom, for example, she claims that "by 1995 all the
traditional nursing schools had closed," that the new schools diverted
students' attention to social science and "race and gender awareness,"
and that "patient care suffered" as a result.

She neglects to add, however, that nursing education in Britain, which
had been vocational since the 19th century, has recently been
integrated into higher education, and that the effect on care of
offering degrees in nursing is a controversial issue.

Finally, Satel invents data. For instance, "California has approved
legislation requiring their public medical schools to increase the
number of training slots for primary care physicians and decrease
slots for specialists." Not so: in 1993 and 1994, the California
legislature twice passed and Governor Pete Wilson twice vetoed bills
to achieve this purpose.

Participants in the health sector have been debating for years the
issues that Satel addresses.

This book, like Satel's newspaper op-ed articles on similar themes,
could make more people aware of these debates.

If that happens, it will be regrettable that her publisher did not
conduct a rigorous review of the manuscript.

Daniel M. Fox, M.D., Milbank Memorial Fund, New York, NY 10022
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MAP posted-by: Richard Lake