Sandra Lee Barney. Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930. Chapel Hill and London: University of North Carolina Press, 2000. xii + 222 pp. $39.95 (cloth), ISBN 978-0-8078-4834-0.
Reviewed by Michelle Haberland (Department of History, Tulane University)
Published on H-South (January, 2001)
In an era of almost daily breakthroughs in the technology of scientific medicine, it is easy to overlook the profound impact of medicine on less technologically sophisticated eras. When did healing become enveloped in a scientific robe? And how did ordinary people, especially rural people, respond to the emergence of professional physicians? Sandra Lee Barney examines this transition from folk medicine to scientific medicine in Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930. This is a cleverly conceived study, one that positions itself at the nexus of several distinct disciplines. Authorized to Heal offers insights into the history of gender and class relations, the history of medicine, southern history, and Appalachian history.
Perhaps most interesting, however, is Barney's examination of the Progressive era in a rural context. Barney explores the transition of medicine from the end of the nineteenth century through the early twentieth century, as scientifically-based medicine gained a foothold among the often widely scattered communities of southern Appalachia. Against a backdrop of class and gender conflict, Barney illustrates the professionalization of medicine and its many consequences for the mountaineers of Appalachia. In Authorized to Heal Barney takes the history of progressivism to the southern mountains, where she uncovers a complex network of gender- and class-based relationships behind the professionalization of medicine.
In the 1880s, there were few physicians in the rural mountain counties of Kentucky, Virginia, and West Virginia that Barney examines. And of this small number of physicians, very few had formal medical training. In Appalachia, rural people frequently relied on themselves and midwives for medical treatment. Labor historians will be interested to learn that coal-mining companies were often responsible for drawing the first formally trained physicians to many parts of Appalachia. Employed as company doctors, these physicians were often viewed with suspicion. The first chapters of Barney's study chronicle a growing tension between traditional healers and more expensive and scientifically-trained physicians.
Barney argues that the slow spread of scientific-based medicine through the southern mountains stemmed from "mountain poverty and isolation," for Appalachian residents quickly learned that formally trained physicians charged higher fees than traditional healers (p. 27). The tension between lay healers and younger physicians grew stronger near the turn of the century, as the physicians organized themselves into statewide professional associations. Barney describes how physicians created a professional discourse and carved a niche for themselves in the elite sectors of their Appalachian communities. These professional physicians associations often openly attacked lay healers, especially midwives, by pursuing state legislation requiring licensing and registration fees of informally trained lay practitioners.
Midwives, clubwomen, public health nurses and settlement workers are at the center of much of Barney's narrative. In the early years of this study, physicians utilized the maternalism of women volunteers and reformers in an effort to attract rural people, especially women and children, to their services. Soon after the emergence of class-based allegiances between male physicians and women volunteers, healing was transformed into a professional occupation. Middle-class women reformers went to work on behalf of the physicians, educating Appalachian residents about the benefits of scientific medicine and easing the transition from traditional healers to college-trained doctors.
The public health dimension of Progressive era reform was particularly useful to this crusade. Barney laments, however, the ways in which physicians later pushed midwives and women health assistants aside after the turn of the century. As public health advocates became more strident and their independent associations grew stronger during the Progressive era, Appalachian physicians began to see the women's activities as a threat to their professional monopoly over rural medicine.
Eventually some women public health nurses and clinic workers realized that working for benevolent associations and independent clinics distanced them from the financial support and scientific legitimacy physicians and hospitals could provide. Others remained long-time activists for widespread access to medical care and public health. And finally, in the latter stages of the Progressive era, middle-class reformers began to identify more with their own developing professional echelon and less with their working-class clients. In the end, Barney argues, it was female activists who brought scientific medicine to the southern mountains and eased the transition from traditional medicine to scientific medicine.
Barney's study is particularly noteworthy because of its applicability to a number of other fields of study. Historians interested in the study of the South, gender, class, Appalachia, medicine, progressivism or reform will find much to consider in Barney's concise work. Her careful research of local and state records of Appalachian women's clubs, medical associations and colleges, and charitable organizations reveals a history of the Progressive era that will have a wide influence and appeal. Appalachian medicine underwent important changes in the years between 1880 and 1930 and Barney's insightful analysis underscores the importance of class and gender to regional histories.
However, these same sources compel Barney to write primarily from the perspective of elite reformers, whether as male physicians or as female public health practitioners and advocates. The voices of the working class subjects of this transformation of medicine are rather quiet in Authorized to Heal. Those readers expecting to find accounts of an individual's or family's first experience with scientifically-based medicine will find only brief mentions. In this history, women nurses and public health advocates are the heroes and midwives and traditional healers are the victims of a modernizing society. Men physicians colluded and conspired to undermine the position of local healers and are cast in a negative light.
Despite the undeniable efforts of physicians to attain a lucrative monopoly over medical practice in Appalachia, it seems that scientifically trained medical practitioners must have been responsible for at least some moderate improvements in the overall health of their patients and have contributed significantly toward the containment of contagious diseases. Barney makes only a handful of references to the efficacy of scientific medicine in an era that witnessed important advances in the understanding of bacteria and viruses.
Nevertheless, these minor oversights do little to detract from the importance of Barney's book. The transformation of medical care in the South is an important subject and one that has received little attention from recent scholars. Paying close attention to the dynamics of class and gender, Barney contextualizes that history and, as a result, historians will find much to praise in Authorized to Heal.
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Michelle Haberland. Review of Barney, Sandra Lee, Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930.
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