We Are Not Makers Of History, We Are Made By History

It never fails to surprise - strike that - shock me how healthcare providers talk about patients.  For a long time I thought it was the result of intolerance -  religious, ethnic, cultural, economic - or doctors and nurses feeling superior to and wanting to control the behaviors and experiences of patients. However, the more I truly listen to what providers are saying to patients, and, perhaps more telling, to one another, the more I realize that it is fundamentally about a lack of historical understanding.  How are we situated in this particular cultural and historic moment and what has come before that has informed our current consciousness?  I have lamented here many times that I am struck by our very poor historical memory.   I have come to realize this is not the issue at all, for how can one remember something that was never learned?

Recently, I have begun to think about how both medical and nursing training are sorely lacking in any basic, general education.  Bizarre, I know.  How could we not be educating the professionals whose sole purpose it is to understand people, not only by way of the body, but through culture, day-to-day lived experience, family, work, etc?  How can an educational system train providers to diagnose without teaching them to situate absolutely every situation presented in history? Why do doctors and nurses speak with such confidence and attitude in regard to their own judgement of patients, but often lack any real understanding of the historical experience that has informed a patient's entire existence?  

Undergraduate study in the United States is, to my eye, a sad reflection of our general society in its total lack of basic education.  As for medical school, it teaches the minutiae of pharmacology, pathophysiology, microbiology, microorganisms, pathogenesis and much more precise practice and knowledge geared toward specialization. Medical students, as a whole, have some grounding through a four year university education in which, during the first two years, they fulfill the basic requirements which probably include things like reading The Yellow Wallpaper or sampling a bit of Aristotle.  Nursing school, on the other hand, is solely focused on systemic education and the making of healthcare providers. And while it may include some cursory ethics and "cultural competence" classes, it totally and completely lacks any rounded general education, even in the simplest form.  

Read Mark Twain? How about James Baldwin? Can you find Uganda on a map? How about Yemen? Can you name a logical fallacy? Can you tell me about Plato's cave?  Have you seen the work of Jacob Lawrence? Can you tell me about the Dawes Act or perhaps Japanese internment or what about American eugenics?  In my experience with both groups, for the most part, the answers are no.

So this lack of historical understanding and educational/ cultural paucity leads us to one place, the place where I end up stuck many times when interacting with healthcare providers.  On an almost daily basis I ask myself: What is it about poor people and procreation that healthcare providers find so intolerable?  I hear said that it has to do with  "dependence upon the system", "skyrocketing healthcare costs" and "inappropriate/ overuse of social services." (Direct quote "I'm all for discouraging the poor from having many children").  I also hear this animosity couched as concern, as in "risks of multiple pregnancies", "poor maternal and fetal outcomes" and "welfare of the children".  These concerns, however relevant, are never discussed in reference to middle class/upper middle class nor, specifically, white families having more than two children.  It is true that it is not the norm, generally speaking, for the upper middle and upper classes to have large families, but it is true of the rural poor and I suspect the same feedback would be found regionally.  That having been said, as you may have gathered or intuited, fertility trends by social status tend to show a decrease in reproductive rates as a group gains higher status.  The simple explanation is that this can, of course, be influenced by education about, and access to, contraception. But there are much more complex social patterns related to education, women in the workforce and the perceived social potential of a childfree lifestyle.  Additionally we would have to consider the historical trend toward more children in the lower classes as a form of familial support, historically high death rates and, of course, the growing gap between the rich and the poor. If you want to take the evolutionary biology perspective you could argue that this is simply the result of growing up in a "harsh, unpredictable environment... where you might die young [and therefore requires] a fast reproductive strategy - grow up quickly, and have offspring early and close together." Interestingly, the desire to attain a higher social status has a direct correlation to the decrease in fertility among individuals; research indicates, however, that maintaining one's social status does not necessarily have this same attributable effect on decreased procreation.

So what about being in healthcare has this influence upon perception of other people's fertility and personal life choices?  I heard recently a woman who had three children at 24 years-old referred to, with absolutely no irony, as a "repeat offender".  There will be audible "tsks" if a woman is a gravita in the double digits, regardless of the number of children she has borne and without consideration of the number of losses whether terminated pregnancies or spontaneous abortions, because we have no access to this information unless we are a clinician providing direct care.  Not that these numbers should matter in our treatment of the patient for her current pregnancy.  The most recent untoward discussion to which I was privy was in regard to mandatory hormonal contraception upon discharge from a hospital or birth center for women of lower SES after delivery of the third+ child.  I should say here that this discussion did not take place in the institution where I was educated nor where I work, nor was it presented as a recommendation (though one of the providers did claim that it was a standard practice in a medical center in which s/he had worked several years prior).  The idea was being tossed about more as an illustration of how one might control behavior via procreative limitation: specifically, controlling the behavior of people who just happen to be poor and largely from minority groups.  When I called the plan out as dangerous in terms of its ignorance of our history of eugenics, I was quickly rebuffed with the response that it was simply "making free birth control available to the poor."

So you can call it paternalistic or call it an effort to "save people from themselves" (more common hyperbole) but if you're going to call it anything, you'd better also include calling it a contemporary branch of the eugenics movement and way to control behaviors that we find repugnant.   Namely all of the behaviors associated with being poor. And if you want to do something about it, start with a history book and a bit of mercy.