Harvard University Press Blog

Legally Poisoned by Chemical Compounds

In Legally Poisoned: How the Law Puts Us at Risk from Toxicants, Carl F. Cranor documents the health threats posed by toxic hazards in commercial products such as cosmetics and cookware. Cranor argues that these chemical compounds should be subject to pre-market testing, as is the case with pharmaceuticals and pesticides, rather than presumed safe until harm is done. Below, Cranor presents the case for legal reform and outlines some of the additional channels of toxic contamination that have been documented since the initial publication of Legally Poisoned, which is new in paperback this month.

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Recent scientific findings on the developmental origins of disease pose major problems for laws that currently seek to protect the public from toxic substances. Existing laws permit our children and us to be legally contaminated with untested substances that may be toxic. We are “legally poisoned.”

Since the hardcover publication of Legally Poisoned in 2011, a number of studies have reinforced its concerns. New York University researchers found that the chemical bisphenol-A (BPA)—previously known to cause hormone abnormalities, asthma, behavioral problems and obesity—is linked to heart disease in children. BPA is used to line food and beverage cans to prevent corrosion and because of its pervasiveness contaminates our food supply. More than ninety percent of the public is contaminated by BPA.

Brazilian scientists found that infants whose mothers were exposed to the commonly used pesticide permethrin during pregnancy were up to seven times more likely to have leukemia. Even children whose mothers were exposed three months before conception were twice as likely to develop infant leukemia as those whose mothers reported no exposure.

Scientists at UC Berkeley have found that children’s exposures to brominated flame-retardants (PBDEs) in the womb or early childhood can lead to cognitive declines: poorer attention and motor skills and lower IQ scores. Other researchers have found that brominated flame-retardants reduce the male hormone testosterone in men. Children have higher concentrations of these substances than adults, but virtually all citizens are contaminated. Brominated flame-retardants are in carpets, upholstery, curtains, plastics, furniture and house dust, but once released into the environment return to contaminate various foods.

These studies and others on the developmental origins of disease are revealing how diseases and dysfunctions can be predisposed or triggered by toxicants, diet, or even infections in utero or in early life. Children are especially susceptible to diseases and dysfunctions during development and much more sensitive to toxic exposures than adults at the same concentrations. Major catastrophes resulting from in utero exposures to Thalidomide, methylmercury, and diethylstilbestrol (DES) in the 1960s and 1970s shattered the view of the womb as a protective shelter in which children could develop safely before they began facing some of the risks and hazards of the external world into which they would soon be born. Subsequently, researchers have found that early life exposure to PCBs, lead, radiation, DDT, phthalates, brominated flame retardants, synthetic estrogens, some pesticides, some pharmaceuticals and other substances can cause less dramatic diseases or dysfunctions, many affecting a person for a lifetime.

“Ranges are for cattle. Give me a number.”

Much of the work of crafting and enacting public policy is dependent on predictions of the outcomes of the policy being considered. Such outcomes can’t actually be known with certainty—as any responsible researcher understands—yet there’s a drive to arrive at the concrete forecasts often demanded by legislators. A perhaps apocryphal story about Lyndon Johnson illustrates the pressure economists can feel to draw strong conclusions. The tale has an economist describing the uncertainty of his forecast to LBJ, and offering a range of values rather than unsupported precision. “Ranges are for cattle,” Johnson is said to have replied. “Give me a number.”

True or not, the anecdote as recounted by Charles F. Manski in Public Policy in an Uncertain World goes a long way towards explaining how the modest findings of cautious researchers become the bold assertions of self-sure politicians. In Manski’s experience, economic consultants understand policy makers to be “either psychologically unwilling or cognitively unable to cope with uncertainty.” And so researchers feel compelled to offer precise predictions that they understand may not be credible.

Following John Kenneth Galbraith’s popularization of the term “conventional wisdom,” Manski offers “conventional certitude” to describe predictions that are generally accepted as true but that may not warrant the certainty they’re afforded. He uses the Congressional Budget Office (CBO) as a case study of conventional certitude in action.

The CBO was established in the Congressional Budget Act of 1974, which includes language usually interpreted as mandating the CBO to provide precise predictions of the budgetary impact of pending legislation. These CBO “scores” are passed on to Congress without accompanying measures of uncertainty, as Manski explains, even though the legislation they assess is often far too complex to allow for the precise forecasting of budgetary implications. And so everyone involved takes for granted what they should surely understand to be fudged, and CBO scores are widely accepted. Even today they’re eagerly awaited by both sides of the aisle in our dysfunctionally contentious Congress.

Are Americans Better Off?

At this stage of the American presidential contest, we’ve become locked in debate over the fairly abstract question of whether or not Americans are “better off” now than they were when Barack Obama took office in early 2009. At his party’s convention, Republican nominee Mitt Romney made clear where he stands:

This president can ask us to be patient. This president can tell us it was someone else’s fault. This president can tell us that the next four years he’ll get it right. But this president cannot tell us that YOU are better off today than when he took office. America has been patient. Americans have supported this president in good faith. But today, the time has come to turn the page.

The following week many of the speakers at the Democratic National Convention offered direct rebuttals of Romney’s claim, which by then had become the central talking point for him and his surrogates. With no settled criteria for actually debating such a vaguely defined bit of sloganeering, this question is likely to remain front and center as we approach November 6th.

Leaving aside the disappointingly solipsistic suggestion that a citizen should judge their country’s course based only on his or her own well-being, though, we actually DO have a well-established and widely-embraced rubric by which to measure the fullness and quality of human lives. It’s just that we’re more accustomed to applying it in developing nations than in places like the United States. Indeed, having recognized the deficiencies of using Gross Domestic Product to gauge a developing country’s progress, Martha Nussbaum, Amartya Sen, and others pioneered an alternative, commonly known as the Capabilities Approach.

Nussbaum presented the basics of the Capabilities Approach in Creating Capabilities: The Human Development Approach, which we published last year. In the book she explains the need for a system to measure the degree to which a given government supports or impedes development across the various areas of human life in which people move and act. She outlines a threshold level of ten Central Capabilities required for a life worthy of human dignity. We offer them below, as presented by Nussbaum in the book, and encourage you to consider them in light of this roiling debate over whether or not Americans are now “better off” than they were four years ago.

Or, even more directly, take what you know of the country’s two major presidential candidates, and use this list to imagine the development of an American’s capabilities under the next administration. Even with what little specifics either candidate has actually offered, and regardless of whom you’re inclined to support, there are very clear ways in which this election will affect the ability of Americans to pursue dignified and at least minimally flourishing lives across nearly every one of these ten Central Capabilities:

1. Life. Being able to live to the end of a human life of normal length; not dying prematurely, or before one’s life is so reduced as to be not worth living.

2. Bodily health. Being able to have good health, including reproductive health; to be adequately nourished; to have adequate shelter.

3. Bodily integrity. Being able to move freely from place to place; to be secure against violent assault, including sexual assault and domestic violence; having opportunities for sexual satisfaction and for choice in matters of reproduction.

4. Senses, imagination, and thought. Being able to use the senses, to imagine, think, and reason—and to do these things in a “truly human” way, a way informed and cultivated by an adequate education, including, but by no means limited to, literacy and basic mathematical and scientific training. Being able to use imagination and thought in connection with experiencing and producing works and events of one’s own choice, religious, literary, musical, and so forth. Being able to use one’s mind in ways protected by guarantees of freedom of expression with respect to both political and artistic speech, and freedom of religious exercise. Being able to have pleasurable experiences and to avoid nonbeneficial pain.

5. Emotions. Being able to have attachments to things and people outside ourselves; to love those who love and care for us, to grieve at their absence; in general, to love, to grieve, to experience longing, gratitude, and justified anger. Not having one’s emotional development blighted by fear and anxiety. (Supporting this capability means supporting forms of human association that can be shown to be crucial in their development.)

6. Practical reason. Being able to form a conception of the good and to engage in critical reflection about the planning of one’s life. (This entails protection for the liberty of conscience and religious observance.)

7. Affiliation. (A) Being able to live with and toward others, to recognize and show concern for other human beings, to engage in various forms of social interaction; to be able to imagine the situation of another. (Protecting this capability means protecting institutions that constitute and nourish such forms of affiliation, and also protecting the freedom of assembly and political speech.) (B) Having the social bases of self-respect and nonhumiliation; being able to be treated as a dignified being whose worth is equal to that of others. This entails provisions of nondiscrimination on the basis of race, sex, sexual orientation, ethnicity, caste, religion, national origin.

8. Other species. Being able to live with concern for and in relation to animals, plants, and the world of nature.

9. Play. Being able to laugh, to play, to enjoy recreational activities.

10. Control over one’s environment. (A) Political. Being able to participate effectively in political choices that govern one’s life; having the right of political participation, protections of free speech and association. (B) Material. Being able to hold property (both land and movable goods), and having property rights on an equal basis with others; having the right to seek employment on an equal basis with others; having the freedom from unwarranted search and seizure. In work, being able to work as a human being, exercising practical reason and entering into meaningful relationships of mutual recognition with other workers.

Making Sex, From the Greeks to Akin

After Missouri Congressman and Senate candidate Todd Akin shared his view that the female body could mysteriously and miraculously prevent conception in cases of “legitimate rape,” his remarks were swiftly condemned by even his own Republican party. Much of the response, and Akin’s own apology, focused on his use of the word “legitimate” when in fact he’d meant “forcible,” a modifier whose political implications are, to many, no less offensive. Of course, the reaction to Akin’s politics has in some quarters overshadowed consideration of his complete lack of understanding of the female reproductive system. As explained last week in an op-ed by Jennifer Tucker, and further considered on Saturday’s episode of Up With Chris Hayes, the long-dismissed “logic” of Akin’s thoughts on conception stem from the ancient notion that female reproductive organs were merely inward-turned analogues of male. If the male needed to achieve orgasm for conception to occur, then so did the female; the victim of a “legitimate rape” would take no pleasure; hence no orgasm; hence the raped woman’s ability to “shut that whole thing down.”

For more on the trajectory of Akin’s medical fairytale, we turned to Thomas Laqueur’s indispensable Making Sex: Body and Gender from the Greeks to Freud, from which the following passage is excerpted.

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An interpretive chasm separates two interpretations, fifty years apart, of the same story of death and desire told by an eighteenth-century physician obsessed with the problem of distinguishing real from apparent death.

The story begins when a young aristocrat whose family circumstances forced him into religious orders came one day to a country inn. He found the innkeepers overwhelmed with grief at the death of their only daughter, a girl of great beauty. She was not to be buried until the next day, and the bereaved parents asked the young monk to keep watch over her body through the night. This he did, and more. Reports of her beauty had piqued his curiosity. He pulled back the shroud and, instead of finding the corpse “disfigured by the horrors of death,” found its features still gracefully animated. The young man lost all restraint, forgot his vows, and took “the same liberties with the dead that the sacraments of marriage would have permitted in life.” Ashamed of what he had done, the hapless necrophilic monk departed hastily in the morning without waiting for the scheduled interment.

When time for burial came, indeed just as the coffin bearing the dead girl was being lowered into the ground, someone felt movement coming from the inside. The lid was torn off; the girl began to stir and soon recovered from what proved not to have been real death at all but only a coma. Needless to say, the parents were overjoyed to have their daughter back, although their pleasure was severely diminished by the discovery that she was pregnant and, moreover, could give no satisfactory account of how she had come to be that way. In their embarrassment, the innkeepers consigned the daughter to a convent as soon as her baby was born.

Soon business brought the young aristocrat, oblivious of the consequences of his passion but far richer and no longer in holy orders because he had come into his inheritance, back to the scene of his crime. Once again he found the innkeepers in a state of consternation and quickly understood his part in causing their new misfortune. He hastened to the convent and found the object of his necrophilic desire more beautiful alive than dead. He asked for her hand and with the sacrament of marriage legitimized their child.

The moral that Jacques-Jean Bruhier asks his readers to draw from this story is that only scientific tests can make certain that a person is really dead and that even very intimate contact with a body leaves room for mistakes. But Bruhier’s contemporary, the noted surgeon Antoine Louis, came to a very different conclusion, one more germane to the subject of this book, when he analyzed the case in 1752. Based on the evidence that Bruhier himself offered, Louis argues, no one could have doubted that the girl was not dead: she did not, as the young monk testified, look dead and moreover who knows if she did not give some “demonstrative signs” in proof of her liveliness, signs that any eighteenth-century doctor or even layperson would have expected in the circumstances.

Contraception and the Catholic Church

As of August 1, most new and renewing health insurance plans must begin offering a spectrum of women’s preventive health services, including birth control, at no upfront cost. This provision of the Affordable Care Act has been among its most controversial, with many Catholic and other religious organizations suing the government to block a rule that they see as compelling them to act in opposition to their beliefs, which they represent as steadfast through time.

This improbable reemergence of contraception as a public issue in the public square turned our attention to John T. Noonan’s Contraception: A History of Its Treatment by the Catholic Theologians and Canonists. The book was originally published in 1965 and then enlarged back in 1986, but despite its age there seems to exist no comparable treatment of the entire history of the church and contraception, from the Roman Empire to Vatican II. One could argue that no such work could even be attempted today, as anyone with the access Noonan then enjoyed would today almost surely be censured for their effort.

On publication, Time called the book a “magisterially documented history of church teaching on birth control [which] suggests that there are good reasons why the traditional stand can change,” and Harper’s described it as a work of “inherent genius” that was as “truly exciting as a book can be.” In a post earlier this year, the U.S. Intellectual History blog detailed the roiling debate into which Noonan’s book entered in the mid-1960s.

What follows below is adapted from Noonan’s original Introduction to the book.

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“Contraception” is a term which could be applied to any behavior that prevents conception. Sexual continence is contraceptive in effect; sexual intercourse when an ovum will not be fertilized avoids procreation as much as intercourse where a physical barrier is used to prevent the meeting of spermatozoa and ovum. How has some behavior now generally approved by Catholic moralists been discriminated from other acts of contraception which have been condemned?

My focus is on the ideas and values clustered into a doctrine on contraception. Seen from one aspect, the doctrine is a reply to the question, “On what terms may the generation of human life be controlled?” Considered from another aspect, it is an answer to the question, “Under what conditions may human beings have sexual intercourse?” From another, it responds to the inquiry, “What revelation of God or what laws of nature are relevant to sexual conduct?”

There is an advantage to looking at a single set of concepts over two thousand years. As an attempt to set out what the purposes of sexual behavior should be, the tradition I explore uniquely combines appeals to divine instruction, natural laws, and psychological and social consequences. Is there any comparable effort, assiduously sustained within the same general framework for over nineteen hundred years, to express in rational terms a standard of sexual behavior?

The meaning of theory, however, is properly understood only when one determines what conditions it responds to. Consequently, I have described the contraceptive means known to different eras, and what can be inferred as to their diffusion and employment. The theory, then, will not be viewed as an abstract logic developed without reference to existing habits. I shall set out both the practice to which doctrine responded and the steps taken to alter the practice. The effort at enforcement tested the seriousness with which the theory was intended. Unlike a history of secular law, however, where the meaning of a rule may be measured by its effective sanctions, the history of a moral doctrine must be, chiefly, an account of what was taught. The application of a moral rule is effected primarily not by agencies of compulsion but by an individual's accepting it in his heart. If a moral teaching is violated, it may still have been “effective” if it played a part in the moral consciousness of the violator. The diffusion of a moral doctrine, and the external embodiment and enforcement of it, may be gauged; the principal effect of the doctrine, its effect on conscience, must largely be inferred from the terms in which it is proposed.

The believers to whom a moral doctrine is addressed will range from the devout to the conformists to the rebellious. Partly as a function of faith, partly as a function of other psychological attributes such as attitude to authority, partly as a function of social environment, the acceptance of the doctrine will vary. At no time, I suppose, has a specific moral teaching put forward by the theologians been received in an identical way by all the faithful. The seriousness with which a doctrine is taken by different persons and groups is a matter of estimate. The range of reaction in the audience may be presumed to have affected the enunciation of the doctrine itself. When the theologians speak to a community of various degrees of faith, various degrees of moral sensitivity, various degrees of education, they may use language unsuitable for more intimate dialogue, and, in the words of the Talmud, they may ''build a fence around the Law,” setting up outer ramparts to keep an inner treasure secure.

The assent of human beings, which gives effect to a doctrine, is not to a single set of propositions, but to the Christian faith. Within this faith there are beliefs on the Bible, grace, original sin, the sacraments, sexuality, marriage, the value of human lives, the purpose of human existence. These beliefs or doctrines structure the propositions on contraception. However tight the relation, however close the dependence on the Christian framework, the teaching on contraception has had its own set of problems, concepts, articulations: its own history.

Judge Richard Posner on the "Goofy" Republican Party

Richard A. Posner, judge on the United States Court of Appeals for the Seventh Circuit, University of Chicago Law School lecturer, and many-time HUP author, has long been an influential voice in American legal theory, particularly with respect to economics. Though known for being thoroughly Chicago School in ideology, his 2008 book A Failure of Capitalism was a surprise to many who’d considered Posner unlikely to deliver a book described as “a roundhouse punch to the proposition that markets are self-correcting.” But, then again, people are used to surprises from Posner. Writing in his Wall Street Journal Ideas Market blog just last month, Christopher Shea described how Posner “continues to amaze”:

I don’t know at what point he gave up on the idea of being nominated to the Supreme Court, but he opted instead to flout all of the conventional wisdom about what a federal appeals-court judge should do (and achieve near-total professional freedom in the process): He blogs, he opines, he dissects the reaction of banks, regulators and politicians to the financial crisis in books—and he takes part, as if he were just another pundit, in a Slate “Breakfast Table” on the latest Supreme Court opinions.

Indeed, in his June 27th “Breakfast Table” post, Posner offers fairly direct remarks on Supreme Court Justice Antonin Scalia’s dissenting opinion in Arizona v. United States, the high-profile dispute over the constitutionality of Arizona’s aggressive stance towards undocumented immigrants. Posner quotes several of Scalia’s jabs at the Obama administration before deeming them “fighting words.”

The nation is in the midst of a hard-fought presidential election campaign; the outcome is in doubt. Illegal immigration is a campaign issue. It wouldn't surprise me if Justice Scalia's opinion were quoted in campaign ads. The program that appalls Justice Scalia was announced almost two months after the oral argument in the Arizona case. It seems rather a belated development to figure in an opinion in the case.

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In his peroration, Justice Scalia says that “Arizona bears the brunt of the country’s illegal immigration problem. Its citizens feel themselves under siege by large numbers of illegal immigrant who invade their property, strain their social services, and even place their lives in jeopardy.” Arizona bears the brunt? Arizona is only one of the states that border Mexico, and if it succeeds in excluding illegal immigrants, these other states will bear the brunt, so it is unclear what the net gain to society would have been from Arizona's efforts, now partially invalidated by the Supreme Court. But the suggestion that illegal immigrants in Arizona are invading Americans’ property, straining their social services, and even placing their lives in jeopardy is sufficiently inflammatory to call for a citation to some reputable source of such hyperbole. Justice Scalia cites nothing to support it.

Then, this week, in a conversation with NPR legal correspondent Nina Totenberg, Posner acknowledged that he has become less conservative since the Republican Party “started becoming goofy.” Amid much speculation that the Supreme Court’s deliberations on health care reform were intentionally leaked so as to discredit Chief Justice John Roberts, who went against casting and expectations by siding with the Court’s liberal wing in upholding the individual mandate, Posner told Totenberg that “right-wingers who are blasting Roberts are making a very serious mistake.”

Because if you put [yourself] in his position ... what’s he supposed to think? That he finds his allies to be a bunch of crackpots? Does that help the conservative movement? I mean, what would you do if you were Roberts? All the sudden you find out that the people you thought were your friends have turned against you, they despise you, they mistreat you, they leak to the press. What do you do? Do you become more conservative? Or do you say, ‘What am I doing with this crowd of lunatics?’ Right? Maybe you have to re-examine your position.

It’s impossible to know how accurately this projects the evolution of the Chief Justice’s thinking, but one can’t help but wonder if perhaps it traces Posner’s own.

Body Clock Management

Tired? Probably. You can’t help but be yawny, especially during the workweek. That’s because the dictates of modern society rarely allow you to live in synchronicity with your individual body clock, which is just one of three that we’re constantly trying to balance. The others are the sun clock (daylight and darkness send us signals) and the social clock (that thing hanging on the wall or on your wrist).

For most of us, the social clock is boss. But when it requires us to live out of sync with our body clocks, we suffer from what chronobiologist Till Roenneberg calls “social jet lag.” Social jet lag can be just as powerful as the more familiar jet lag caused by traversing time zones, and because it’s a function of our daily lives it can be a chronic condition. And, as Roenneberg explains in the excellent video posted below, social jet lag has consequences:

Most people with social jet lag are more likely to be smokers. They are more likely to drink alcohol. And people with social jet lag drink a lot of caffeine during the day. And now we’ve discovered another consequence of living against the body clock, and that is if you are already a little chubby and not very thin, it is very likely that living against the body clock makes you even become obese. In view of all these consequences, it is really high time we do something against social jet lag.

 

 

Roenneberg and his colleagues have built an online body clock calculator to aid them in their research and to help you understand your own internal time, so head over to the Munich Chronotype Questionnaire to receive an evaluation of your chronotype. And then check out Roennenberg’s Internal Time for 24 short case stories meant to help you understand why you’re so tired.

Religious Freedom, Health Care, and Women in the Church

When then-candidate Rick Santorum declared in February that John F. Kennedy’s 1960 comments on the role of people of faith in the public square made him want to “throw up,” he merely presaged a showdown to come. After this week’s announcement of a lawsuit brought by Catholic groups upset with the Obama administration, HUP Publicity Assistant Bridget Martin turned to a few books for context, and offers the post below.

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This week, 43 Catholic organizations including schools and hospitals filed lawsuits against the Obama administration in response to the federal mandate that birth control coverage be included in health care plans. Though the Obama administration proposed a compromise by which the responsibility for payment could be shifted from employers to the insurance companies, those bringing suit characterize the mandate as an assault on religious liberty. The lawsuits have set off a maelstrom of responses, unveiling the political, ethical, and social complexities embedded in the issue.

In a Wall Street Journal opinion piece entitled “Why the Bishops Are Suing the U.S. Government,” Harvard Law School professor Mary Ann Glendon defends American bishops and their initiative to preserve the separation of Church and State. Glendon, whose HUP books include Abortion and Divorce in Western Law, argues that the health insurance mandate violates the Catholic Church’s constitutional liberty, ultimately demoting religion to a second-class right. She sees the debate not as an argument about contraception, but as a principle for preserving religious liberty, asserting, “The main goal of the mandate is not, as HHS claimed, to protect women’s health. It is rather a move to conscript religious organizations into a political agenda, forcing them to facilitate and fund services that violate their beliefs, within their own institutions.”

But what exactly did the founders intend when they included the separation of church and state clause in the US Constitution? In Religious Freedom and the Constitution, Christopher L. Eisgruber and Lawrence G. Sager caution us against imagining an impenetrable wall between church and state when we consider the ideal. Rather, they argue that while religious institutions and practitioners have the right to be free from governmental discrimination on account of religious beliefs, those religious beliefs do not on their own exempt institutions and practitioners from generally applicable laws. This interpretation sheds a different light on the relationship between church and state, especially as US bishops turn to the court in fear of being marginalized by the federal government.

Government influence is not the only social issue driving the contraception controversy. A day after Glendon’s piece was published, Maureen Dowd’s op-ed in the New York Times took an opposing stance. Dowd frankly rejects the position adopted by Glendon and others: “The church insists it’s an argument about religious freedom, not birth control. But, really it’s about birth control, and women’s lower caste in the church.”

Dowd’s argument is a window into the gender and power implications of this debate. As an institution dependent on male hierarchy, is the Church’s disapproval of contraception a tool to subordinate women? The struggles of women within the male power structure of the Church are chronicled in Jo Ann Kay McNamara’s Sisters in Arms, which traces the history of Catholic nuns in the Western world. McNamara shows that the earliest female converts were attracted to the Church by the proclamation of equality in the Kingdom of Heaven, a notion vastly different from the patriarchal societies of the Early Church. Yet since the establishment of female ministries, women have struggled to be recognized as equals in the church.

Garry Wills emphasized this subordination in an April post on the New York Review blog. Wills explains how the Vatican recently “stripped the Leadership Conference of Women Religious, representing most American nuns, of its powers of self-government, maintaining that its members have made statements that ‘disagree with or challenge the bishops, who are the church’s authentic teachers of faith and morals.’” Outraged by this blatant reduction of power for women in the Church, Wills calls attention to the nuns’ unwavering commitment to the social Gospel, aiding those suffering regardless of political implications involved, as in their response to the AIDS crisis, their facilitation of the spiritual needs of gay people, and their activism in the civil rights movement.

Debates over the politics of religious freedom and gender inequality seem certain to reach a fever pitch in this election year. The Catholic Church is planning a national campaign for their cause, “Fortnight for Freedom,” to run from June 21st through the symbolically chosen July 4th. The initiative, intended to encourage prayer, education, and public action about religious freedom, was created in direct response to the perceived threat posed by the Obama administration. With the Church seemingly demonstrating the primacy of a respect for life in its political motivations, it will be interesting to watch the extent to which American Catholics embrace Mitt Romney, even in light of his Mormonism, which some may still find unsettling.

Making Chefs and Surgeons

The latest dose of Lucky Peach, the newish quarterly journal of food and writing, is the Cooks and Chefs issue. With their characteristic blend of smart, irreverent writing and terrific illustration and design, the Lucky Peach team spends the issue riffing on celebrity chefs, cooking shows, old masters, lunch ladies, and the changing world of the culinary arts. A common thread running through the issue is a collective sense of loss over the ways in which the forty hour work week has changed both the education of cooks and the workings of restaurants.

In a piece titled “I See a Darkness,” Lucky Peach co-creator and chef/owner of Momofuku David Chang issues his own lament in pink type on black pages beneath a stark opening line: “I am convinced that cooking is dying.” From his piece:

(I)n the past, at almost all high-end restaurants, you just worked. One of the fundamental changes to the profession is the elimination of “shiftpay”—i.e. you make $80 for the period of time known as “Monday” regardless of how many hours you’re there. That’s been replaced by the forty-hour work week. You just can’t learn to cook in forty hours a week.

“There is a whole style of restaurant that has evolved from that restriction,” (Andrew) Carmellini explained. “You basically come in at four in the afternoon and just go shopping, because everything is ready for you. Get your fish, chives, shallots, or whatever, and then you’re just waiting for the cream and whatever to come down the conveyor belt. Unfortunately, it does affect the process. No one was paid to teach me how to make pasta, but the Italian guy downstairs would put in the extra hours to do that, and I’d put in the time to learn. It’s hard to do that now. Even if cooks wanted to stay late or work from start to finish, they are legally not allowed to.”

The response of the restaurant world—and I’m as guilty as anyone—has been to systematize and streamline the way food is prepared. You either have to do that or break the law. The best restaurants used to have minimal staff; they’d have a couple of prep cooks, but everyone was responsible for their own station and partner. Time was relative to the work that needed to be done. Now many restaurants operate with multiple crews—one team preps, and then, as Carmelini put it, the next shift “shops” for their mise en place.

Now, despite there being foodies among us, we’ve published too many books on labor history to sit here and worry much about what worker protections have done to the state of pasta-making. That said, the general concern for the ways that new restrictions can impede the training of current and future generations has put us in mind of a book on a different sort of knife skills, Dr. Nicolas Tilney’s Invasion of the Body: Revolutions in Surgery. Forgive the implications of the comparison, but, hey, chefs and surgeons DO both wear white coats, get their hands bloody, and surround themselves with stainless steel. And Tilney’s explanation of what’s lost when budding surgeons have their work weeks restricted has a number of parallels with Chang on cooks.

The Rise and Fall of American Madness

Richard Noll’s American Madness describes the electric rise and fall of the psychiatric diagnosis of the mysterious disorder known as “dementia praecox.” As the first specified disease of psychiatry, dementia praecox’s curious history has a great deal to teach us about the nature of the field. As the American Psychiatric Association engages in the vexed process of revising its Diagnostic and Statistical Manual of Mental Disorders, American Madness is a more timely study than many in the discipline would probably like to admit. We invited Noll to answer a few questions about what we can learn from the story.

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Q: Prior to your work, the last time “dementia praecox” appeared in the title of a book published in English was 1950. Clearly it has slipped into our cultural unconscious. Briefly, what is the narrative of the rise and fall of dementia praecox?

Ah, yes . . . dementia praecox is indeed a vanished kingdom of suffering and despair. Hundreds of thousands of Americans who received this diagnosis between 1896 and 1952 were stigmatized by both physicians and everyday people as incurably insane. One only has to remember how frequently it was invoked in the culture of that era (such as in the Tennessee Williams play Suddenly, Last Summer) to get a sense of how terrifying those two words once were.

As the influential psychiatrist Adolf Meyer once said, the history of dementia praecox is the history of psychiatry. American Madness is, at one level, the biography of a disease, but most importantly I regard it as the story of how, in the late 1890s, American alienists (as they called themselves) strove to rejoin an American medical profession that was moving toward a science-based, laboratory-driven moral economy founded on a new (circa 1860) European concept of diseases as separate, biologically-specifiable entities with specific biological mechanisms and typical courses and outcomes. For American psychiatry to survive as an accepted branch of medicine, and not remain as a queer survival of a nineteenth-century therapeutic sect, its legitimacy and authority depended upon adopting this doctrine. In an era where one was either sane, nervous, or insane, most alienists and neurologists assumed insanity was a hydra, a single monster with many faces, not separate creatures.

In 1896 German psychiatrist Emil Kraepelin proposed a classification of mental diseases based on this new fundamental medical principle, and described dementia praecox as a psychotic process that began in the decade after puberty with a distinctive course and outcome. Mental deterioration, weakness and defect worsened and became permanent. It was a hopeless diagnosis. But Kraepelin argued that dementia praecox, as well as other major mental diseases that he created, would one day be found to be rooted in natural, biological disease processes. This claim, in part, made Kraepelinian classification attractive to American alienists who desired to retain their status as physicians. There is a co-dependency of the psychiatric profession and a biological disease concept that persists today.

Beginning in 1896, as one American asylum after another slowly introduced dementia praecox as a diagnostic box, it became the most frequently diagnosed condition, labeling a quarter to a half of all patients in each institution. How American psychiatrists were making this diagnosis is anyone’s guess—they were probably just snap decisions based on whether someone was suffering from a “good prognosis madness” (such as manic depression) or a “bad prognosis madness” (dementia praecox). What we do know is that being young and male made it more likely someone would receive this diagnosis.

As dementia praecox and its successor (a uniquely American re-interpretation of the Swiss psychiatrist Eugen Bleuler’s concept of schizophrenia) became the natural focus of biological research for much of the twentieth century, American Madness also provides the heretofore untold story of the rise of biological psychiatry and laboratory research in the United States. By 1927 schizophrenia became the preferred term for inexplicable madness, but the Americans reframed Bleuler’s disease concept as a primarily functional or psychogenic condition that was caused by mothers or maladjustments to social reality. When Bleuler visited the United States in 1929 he was horrified to see what the Americans were calling schizophrenia. He insisted it was a physical disease with a chronic course characterized by exacerbations and remissions of hallucinations, delusions and bizarre behaviors.

Q: Is it possible to speak of a “typical” case of dementia praecox?

No. The label was so frequently used in an inchoate medical environment absent of consensual agreement on classification and nomenclature that we have little historical evidence as to how, on a daily basis, an individual physician applied these social constructions in his or her practice. Historian Gerald Grob termed this problem for historians of psychiatry as that of the “Invisible Patient.” Knowing the diagnosis of a person of the past tells us next to nothing about their history, signs or symptoms. Alienists and neurologists operated on a gut-feeling level. Diagnosis was not based on an explicit cognitive exercise, like running down a checklist of signs and symptoms, but was more like the experience of recognizing a melody or a scent. A “precox” patient evoked an uncanny feeling of remoteness or of the “bizarre” in a physician, and that was the most important basis of a diagnosis.

Q: How should American Madness help us to understand the sort of epistemic crisis currently confronting American psychiatry?

As everyone knows, the American Psychiatric Association is involved in a highly controversial effort to revise its diagnostic manual. DSM-5 (as it will be called when it appears in 2013) reflects the fact that scientific medicine has not yet solved the problem identified by American alienists a century ago: the linkage of clusters of signs, symptoms, and clinical history to biologically specified disease concepts. The proposed diagnostic criteria in DSM-5 requires a “bottom-up” differentiation of patients, which can be achieved only through an objective biological test (or tests). Until such a tool is developed for schizophrenia, a heuristic associated with an unimaginable assortment of confusing biological findings, we can neither validate nor invalidate our era’s schizophrenia concept. Genetic tests will almost certainly not be the answer, nor will the exclusive emphasis on the brain. As Sabine Bahn and her associates at the University of Cambridge are demonstrating with their new biomarker-based blood test for schizophrenia, severe psychotic disorders might be due to a life-long smoldering systemic or “whole body” disease process that involves glucose metabolism and immune system dysfunction. This is what Kraepelin proposed for dementia praecox, and it might be true for our era’s schizophrenia as well.