The problem with consumers


This post was considerably delayed, first due to the urgent need to publicize “Struck by Orca” and then by successive authorial waves of random health events (specifically J00[1], 2 separate bouts of A09.9[2], and in the middle, a nasty encounter with W00[3]). Now I am more or less healthy and ready to post about consumers.

On November 13, I concluded my post about patients by saying:
“So if patient is historically and socioculturally loaded, what else can we call them? Pat Mastors lists some alternatives: consumer, partner, person. Dr Hem, in Norway, overlaps in saying user,consumer, customer.”

Consumer, as an alternative to patient, has been around for quite a long time. Its origins are fundamentally economic; a consumer is a person engaged in a transaction who is not a producer. The Oxford English Dictionary entry shows you how old this usage is:

“consumer, n.” [OED Online. September 2013. Oxford University Press. 14 October 2013.]
2. A person who uses up a commodity; a purchaser of goods or services, a customer. Freq. opposed to producer.

1692 J. Locke Some Considerations Lowering Interest 20 Money may be considered as in the hands of the Consumer, under which Name I here reckon the Merchant who buys the Commodity, when made, to export.
1725 D. Defoe Compl. Eng. Tradesman I. Introd. 5 By the retailer to the last consumer.
1757 J. Harris Ess. Money & Coins 37 All men are in some degree consumers of foreign commodities.
1860 R. W. Emerson Wealth in Conduct of Life (U.K. ed.) 75 Every man is a consumer, and ought to be a producer.
1897 Sears, Roebuck Catal. No. 104. 1 (heading) Consumers guide.
1923 H. Kyrk Theory of Consumption v. 112 Consumers are influenced by other forces than those set in motion by the merchants who have goods to sell.
1933 Planning 1 vii. 5 Retail outlets..where improvements can be tried out and consumer reactions tested.
1970 Which? June 163/1 Manufacturers and consumers do not have identical points of view.
2001 Amer. Jrnl. Philol. 122 270 One continues to wish that the Clarendon Press would put its clothbound books a bit more within the reach of the individual consumer.

So much for economics. How long has consumer been applied to a client of healthcare services? The health context is the tricky part. There are just too many ways to express it. Some historians attribute the term to the late 1930s, when the ancestor of today’s Kaiser Permanente network was formed by workers for the Kaiser shipyards in California. (For a pocket history of Kaiser, see here).
This was the first HMO (health maintenance organization) and the term consumer was used precisely because the organization enabled purchase of healthcare services prior to need, that is, prior to being a patient.

Thus from the beginning, consumers and patients were not synonymous. In fact, consumer had to be coined precisely because patient implied “a person in a relationship with a healthcare provider or system for the purpose of receiving care” and thus was not the appropriate word.

The phrase consumer health is easier to trace. Every so often I search digitized newspaper content for it. This can never be the whole story, because different commercial vendors provide access to different newspapers and different years. Newspaper Archive currently has the largest suite of possible newspapers, however. The oldest reference I find to consumer health comes from the Middletown (NY) Times Herald of September 12, 1937—contemporaneous with Kaiser. It was used in a story about promoting the dairy industry:

“Each particular phase of the program aims to high-light the various steps in milk production and handling, the sanitary precautions taken, and the benefit in consumer health resulting from increasing the milk content of the ordinary diet.”

Then there’s Google NGrams, which covers books that Google knows about, 1800 through 2000. The phrase Consumer health is comparatively modern (1933) next to the term consumer, which appears — context unknown — as early as 1800.

A number of studies have been published that investigate how patients feel about being called consumers or anything else. These are mostly British and mostly studies of pregnant women. (A finding that I believe is worth a small study of its own). And the results are:

100 UK pregnant women, 15-50 years old: “Mother-to-be” and “Pregnant women” preferred. Batra N, Lilford RJ. Not clients, not consumers and definitely not maternants.Eur J Obstet Gynecol Reprod Biol. 1996 Feb;64(2):197-9. PubMed PMID: 8820002.

446 Cornish mothers, median age 28. Most popular: “Patient”. Least popular: “Client”, “consumer”, and “customer.” Byrne DL, Asmussen T, Freeman JM. Descriptive terms for women attending antenatal clinics: mother knows best? BJOG. 2000 Oct;107(10):1233-6. PubMed PMID:11028573.

200 UK mothers, age not provided in abstract. Most popular: “Patient”. “Least popular: “Client”, “consumer”, “customer.” Baskett TF. What women want: don’t call us clients,and we prefer female doctors. J Obstet Gynaecol Can. 2002 Jul;24(7):572-4. PubMed PMID: 12196849.

Review of 80 published studies of mental health services published in the English language; no actual humans involved (except in the research and writing, presumably). Preferred terms in published studies: “Client”, “patient”. Dickens G, Picchioni M. A systematic review of the terms used to refer to people who use mental health services: user perspectives. Int J Soc Psychiatry. 2012 Mar;58(2):115-22. doi: 10.1177/0020764010392066. Epub 2011 Feb 21. Review. PubMed PMID: 21339236.

As a word, consumer is demonstrably problematic. For example, the animation at the top of this post features a Sneezing Person. I am not a healthcare professional, nor do I play one on TV, but I feel safe in stating that this gentleman has a cold, an allergy, or a photic sneeze reflex. Is he a patient? No. From the photographic evidence, we know nothing about his access to healthcare. We know more about his access to movies. For all we know, he subscribes to a religion that prohibits him from visiting a healthcare professional. So what the heck IS he? We have to call him something. Is consumer accurate if he is not buying anything? (Besides a movie ticket?) Consumer, as inadequate a term as it may be, may be all we have.

Personally and professionally, I believe that consumers are not necessarily patients and should not be equated with patients, particularly in the healthcare information-seeking and informatics worlds. Conflating consumer with patient obscures some important differences. A high-school student doing research on cancer for a term paper is a consumer; his grandmother undergoing chemotherapy is a patient; both individuals will be in need of accurate, authoritative, health information, but how that information is provided to them really ought to differ. Because virtually all consumers are future patients, or will be caring for/living with/supporting patients, enabling consumers to access health information is critically important. Let’s just call them what they want to be called: Sneezing People.

[1] “Acute nasopharyngitis.”
[2] “Gastroenteritis and colitis of infectious and unspecified origin”
[3] “Fall on same level involving ice and snow.”

Photo credit: “A series of animated GIFs excerpted by Okkult Motion Pictures from Coughs and Sneezes, a curious and amusing propaganda film from post war era on the dangers presented by… sneezing!” From the marvelous Public Domain Review.

Author: cat

Associate professor at the University of Wisconsin-Madison

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