Social Medicine – History and
Contemporary Relevance
Social Medicine, Human Rights,
and the Physician
Emory Medicine, 2nd year elective
Timothy H. Holtz, MD, MPH
Alyssa Finlay, MD
January 10, 2005
Summary




Components of social medicine
History
Contemporary examples
Advocacy and social justice
Components




Medical care
Preventive medicine
Public health
Social well-being
Consequence
 Ensure universal and equitable access
to and appropriate use of an
effective and efficient medical care
system
 Encourage preventive medicine
 Strengthen governmental health
authorities
 Increase resources for the promotion
of social well-being
Recognition
 Medical professionals should
recognize a patient as a social
creature, that many aspects of their
lives impact upon their health, their
exposure to illness and illnessproducing behaviors, and their
“agency” (capacity to mobilize
resources to improve well-being)
Consequence
 A socially-oriented physician would
take action to improve housing,
nutrition, educational opportunities,
and employment opportunities;
combat racism and discrimination;
eliminate poverty; and alter the
inequities and inadequacies of the
medical care delivery system…and in
society at large
 Change pathogenic situations in the
community to protect community at large
 May incur social and professional
opprobrium (ridicule/disgrace)
 May face resistance in using your
professional role to ameliorate pathogenic
social situations
 Ibsen’s Dr. Stockman = Enemy of the
People
Ethics and responsibility
 Modern medicine should encompass
expanded notions of the physician’s
responsibility to society
 Physicians should contemplate the global
forces that cause or contribute to disease
or prevent its amelioration
 Physicians can adopt an advocacy role in
pursuing change that will net result in
health improvements (grand scope)
Contemporary Social Medicine










Galdston – British theorist
Rosen – historian
Silver – medical historian
Terris – journal editor, Vermont
Navarro – public health at Hopkins
Roemer – public health at UCLA
Eisenberg – Harvard Dept of Social Medicine
Sidel – emeritus professor, Einstein Dept S
Waitzkin – anthropologist, Univ NM
Farmer – Harvard Dept of Social Medicine
“An Introduction to Social Medicine”
Tom McKeown and CR Lowe,
Welsh National Medical School

Social Medicine is concerned with a body of
knowledge and methods of obtaining knowledge
appropriate to a discipline. This discipline may
be said to compromise:
1.
2.
Epidemiology
The study of the medical needs of society
(medical care)
Important figures in Social Medicine
 France – Cabanis, Villerme, Guepin
[“Illness is determined by the errors of society” 1804]
 England – Thackrah, Chadwik, Engels
[Inquiry into the Sanitary Condition of the Labouring
Population of Great Britain, 1842]
 Germany – Virchow, Neumann,
Leubuscher
 Chile - Salvador Allende
Friedrich Engels (1820-1895)
Called attention to the health of the working class
Engels
 Family owned a factory in industrial
England, early 1800s
 Held strong views against Puritanism
 Active in journalism at a young age,
described worker’s illness and
suffering with a passion
 “Hung out” with Irish revolutionaries
Condition of the Working Class in
England, 1845
 First real account of the health problems
of working children and adults
 Roots of illness and early death lay in the
organization of production and the social
environment
 Industrialism forced working class people
to live and work in conditions that
inevitably caused sickness
 Clear analysis of the causal relationship
between social structure and physical
illness
Issues covered by Engels








Environmental toxins, lead poisoning
Infectious diseases such as TB, typhus
Nutrition and food supply
Alcoholism
Maldistribution of medical personnel
Mortality rates and social class
Industrial accidents
Occupational diseases of the
musculoskeletal system, eye, lung
Rudolf Ludwig Karl Virchow (1821-1902)
the “Father” of Social Medicine
Virchow’s career
 A pathologist and medical school lecturer in Berlin
 Pioneer in establishing cell doctrine in pathology
and effects of disease in the human body
 He coined the terms thrombus and embolus,
leukocytosis and leukemia, amyloid and heme
pigments, “Virchow’s node”
 Discovered the pathophysiology of trichinosis,
called for compulsory meat inspection in Germany
 Designed and supervised Berlin sewage system
 Never accepted the simple causal relationship
between bacterium and disease (Koch)
Die Medicinische Reform, 1848
 Founded/edited the medical weekly with
Rudolf Leubuscher, lasted only 48 issues
 Analyzed social structure of society and
now it related to the spread of disease
 Used journal as a platform to call for
improvements in housing and nutrition,
employment and income
Typhus epidemic in Upper Silesia
 Epidemic of relapsing fever among coal miners and
their families in Prussian province of Upper Silesia
in Feb/March 1848
 Tradition to send a junior lecturer to investigate
the problem, write a report, and shelve it
 Virchow spent 3 weeks in early 1848 investigating
the Polish families and their conditions in Silesia
 Virchow’s findings and report earned him notoriety
as a progressive leader in Germany, gave birth to
the social medicine movement, and altered the
trajectory of his career
“The physician is the natural attorney
(advocate) for the poor.”
Report on the Typhus Epidemic in
Upper Silesia, 1848
 Geographical, anthropologic, and social account of
Silesia
 Description of housing, education, diet, drinking,
medical beliefs
 Analysis of the role of the Catholic church, and
perpetuation of caste-like social stratification
 Detailed clinical account of typhus, nine case
descriptions, five autopsy reports
 Assesses validity and accuracy of available health
statistics of typhus
 Analyzes morbidity and mortality of typhus by
age, sex, occupation, social class
Conclusions of Report on the Typhus
Epidemic in Upper Silesia, 1848
 Virchow reported that the underlying
causes of the epidemic were more social
than medical
 Economic and political conditions in Upper
Silesia played a significant role
 The conditions in which the workers were
forced to live, particularly bad housing with
malnutrition, that made them vulnerable to
disease
“Revolutionary ideas”
 Public provision of medical care for the
indigent, including free choice of physician
 Prohibition of child labor
 Protection for pregnant women
 Reduction of work hours in dangerous
occupations
 Control of toxic substances at work
 Adequate ventilation at work sites
Quotes
“There cannot be any doubt that such a
typhus epidemic was only possible under
these conditions and that ultimately they
were the result of the poverty and underdevelopment of Upper Silesia. I am
convinced that if you changed these
conditions, the epidemic would not recur.
In theory, the answer to the question as to
how to prevent outbreaks in Upper Silesia
is quite simple: education, together with its
daughters, freedom and welfare.”
“With one and a half million you cannot begin with
palliatives, if you want to achieve anything you
have to be radical.”
“The task of any reasonable and democratic
government will always be to educate the people
and liberate them, not only materially but
spiritually.”
“The absolute separation of school and church is
more necessary in Upper Silesia than anywhere.”
“That is why I insist that free and unlimited
democracy is the single most important principle.
If we get free and well-educated people then we
shall undoubtedly have healthy ones as well.”
Section on long-term planning







Unlimited democracy
Devolution of decision-making
Universal education
Disestablishment of the church
Taxation reform
Agricultural reform
Industrial development
Virchow and the birth of Social
Medicine
He advocated that medicine be reformed on
the basis of four principles:
1.
That the health of the people is a matter of
direct social concern
2. That social and economic conditions have an
important effect on health and disease and that
these relations must be subjected to scientific
investigation
3. That the measures take to promote health and to
combat disease must be social as well as medical
(The Medical Reform, 1848)
Virchow’s political career
 Suspended from Berlin medical school
 Pathology chair in Wurzberg where he
wrote his classic pathology texts
 Returned as Chair of Pathology in Berlin in
1856
 Elected to Berlin City Council in 1861, and
German Reichstag in 1880
 Questioned increases in military budget
while education budget stagnated
 Accused of being “unpatriotic” (met with
the French)
 Refused to be knighted as “von” Virchow
Accomplishments
 City sewage systems in Berlin and
other cities
 Mandatory meat inspection
 Ventilation and heating of public
buildings
 School health services
 Improvement of working conditions of
health personnel, esp nurses
Virchow’s contemporaries
 Max von Pettenkoffer – dogged resistance
to the theories of Pasteur and Koch that
bacterium was necessary and sufficient
 Alfred Grotjahn – rescued insistence on
social factors other than hygiene from
developing into solely a movement for
sanitary reform, as it had in UK
 Social Medicine spread throughout
continental Europe in late 1880s, social
medicine incorporated into medical
education and practice in Czechoslovakia,
USSR, France, Belgium
Grotjahn’s Social Pathology, 1911
 The significance of a disease is determined by the
frequency in which it occurs. Medical statistics
are therefore the basis for any investigation of
social pathology.
 The etiology of disease is biological and social.
 Not only are the origins of disease determined by
social factors, but these diseases may in turn
exert an influence on social conditions.
 It must be established whether medical treatment
can exert an appreciable influence on its
prevalence, if this is negligible we must attempt to
prevent diseases or influence their course by
social measures. This requires attention to the
social and economic environment of the patient.
Medicine is a
social science,
and politics
nothing but
medicine on a
grand scale.
- R. Virchow, Die Medicinische Reform, 1848
Salvador Allende
 Professional family background,
grandfather an Army physician, father a
liberal lawyer
 Influenced by working class contacts as
young person
 Attended medical school in the 1920s
 Learned of health problems of the poor by
working as an autopsy assistant
 Taught night class to workers
 President of medical student association,
led a school strike against the
administration
Allende – early politics/medicine
 Organizer of Chilean Socialist Party
 Founded the Journal of Social
Medicine
 Wrote The Structure of National
Health which would serve as blueprint
for national health service in Chile
 Founded the Popular Front coalition
 Appointed Minister of Health in
Cerda government in 1940?
Chilean Medico-Social Reality
 Major treatise of social medicine in
20th century, linking illness and
socioeconomic status
 Conceptualized illness as a
disturbance in the individual fostered
by deprived social conditions
 Concluded that social change is only
effective approach to health
problems
Content
 Similar to Engels’ treatise on working class
health problems
 “It is impossible to give health and
knowledge to a people who are
malnourished, who wear rags, and who work
at a level of unmerciful exploitation.”
 Could not hope to cure the sick without
working towards a more egalitarian
economic system
Topics









Nutrition and earning power
Housing conditions
Sanitation and excess mortality
Population density and infectious disease
Wage differentials b/t men/women
Tuberculosis and class differentials
Typhus and pauperization
Dysentery, typhoid, diptheria, pertussis
Alcoholism and social misery
The individual in society is not an abstract
entity: one is born, develops, lives, works,
reproduces, falls ill, and dies in strict
subjection to the surrounding environment,
who different modalities create diverse
modes of reaction, in the face of the
etiologic agents of disease. This material
environment is determined by wages,
nutrition, housing, clothing, and culture…
- S. Allende
Chilean Medico-Social Reality
- 2nd half
 Occupational health and disability
 Analysis of national health care
resources available
 Critique of price gouging by North
American pharmaceutical firms
versus use of generics
 Proposed that health policy must
transcend the health sector
Policy suggestions






Wage restructuring
Improvement of milk supplies
Land reform
Rent control in private sector
Reorganization of Ministry of Health
Control of pharmaceutical production
Legislative career
 Wrote legislation that created the Chilean
National Health Service (SNS) in 1940s
 Reformed medical curriculum in Chile to
include social sciences
 Established the Chilean Medical
Association
 Helped develop national generic drug
formulary
 Proposed nationalizing the drug industry
Presidential career
 Failed to win presidency in 1958, 1964
 Won plurality in 1970 election, first
socialist president in W Hemisphere
 Generally “reformist” president, did not
radically alter Chilean Health System
 Attempted to limit control of Chilean
natural resources by transnational capital
 Put him at odds with western hemisphere
capitalist democracies
Destabilization
 US Presidential directive to destabilize
the Chilean economy [“Let Chile burn,”
Richard Nixon told Henry Kissinger]
 Allende attempted to wrest control of
copper industry back into national hands
 Strikes and boycotts fomented by USfunded (CIA) campaign among far left in
Chilean politics (Communist Party)
 CEO of ITT with major holdings in Chile
was former head of CIA
Final overthrow
 Elimination of allies in armed forces seen
as lynchpin
 General Schneider assassinated in 1973
 Internal revolt in military against Allende
 September 11th, 1973 – Presidential palace
bombed, Allende assassinated (?suicide)
 Augusto Pinochet installed as President,
ruled Chile for >20 years [later ordered to
stand trial in Spain for human rights
violations]
General Themes
 Major contributor of health and
illness in a population is determined
by the structure of society
 Social origins of illness demand social
solutions
 NOT a novel idea now
 Reformism vs structural change
General Themes 2
 Engels –
 organization and process of economic
production is primary determinant of illness;
 disease mainly due to occupational toxins and
physical demands of work;
 principal contradiction is between profit and
safety;
 analysis of poor health written partly as
propaganda
General Themes 3
 Virchow –
 focused on inequalities in the distribution and
consumption of social resources;
 disease due to poverty, unemployment,
malnutrition, under education,
disenfranchisement, and poor access to medical
services;
 did not criticize illness-generating conditions of
economic production;
 advocated for scientist’s passionate
participation in politics
General Themes 4
 Allende-
 focused on relationships between countries,
impact of class structure as determine by
underdevelopment of poor countries by rich
countries;
 attributed low wages, malnutrition, and poor
housing to the extraction of wealth from poor
countries by transnational capital;
 most crucial social determinant of health is
national development;
 analysis of health was meant to be used as a
planning document for restructuring of the
health system
Social Medicine Strategy
 Engels – Manifesto for revolutionary change,
reformism made little sense
 Virchow – ultimately opted for reform, rational
food distribution, modifying education, political
enfranchisement, building a public health service,
believed strongly in constitutional democracy,
turned down chance to be “knighted”
 Allende – altering the class structure of society by
changing both distribution of resources with
reform, and relationship with more powerful
countries, believed in peaceful radical
transformation through democracy
 INDICT but not FIGHT?
The “Disappeared”
 3 billion people live on less than
$2/day.
 2.6 billion without access to adequate
sanitation
 2 billion deprived of electricity
 1 billion without adequate shelter
 840 million malnourished
 880 million without access to medical
care
1998 Human Development Report, UN Development Program
Concentrated wealth
 The 200 richest people in the world more
than doubled their net worth in the four
years prior to 1998, to $1 trillion.
 The wealth of the richest 225 people in the
world is greater than the collective wealth
of 2.5 billion people (47% of the world’s
population).
 The 15 richest have assets that exceed the
total GDP of Sub-Saharan Africa.
1998/9 Human Development Report, UN Development Program
Economic rights - Gross
inequality
 The top quintile (20%) of the world’s
people living in the high income countries
control:
 86% of world gross domestic product (GDP)
 82% of the world’s export markets
 68% of foreign direct investment
 The bottom quintile (20%) of the world’s
poorest countries control less than 1% in
each category.
1999 Human Development Report, UN Development Program
Growing inequality
 The income gap between the richest
quintile (20%) of the world’s
population and the poorest quintile,
measured by per capita national
income, increased from 30:1 in 1960
to 74:1 in 1997.
1999 Human Development Report, UN Development Program
Worsening inequality in the US
Source: Left Business Observer
Does social medicine still matter?
 Contemporary social medicine in the face
of high tech medicine
 Antibiotics can cure typhus and
tuberculosis, vaccines can prevent
pertussis and measles
 What is the role of social determinants of
health, when we know that many diseases
have a genetic basis?
“All medicine is inescapably social
medicine” - Eisenberg
 Social forces as determinants of infectious
disease
 Infectious agents as necessary but not sufficient
cause of disease?
 Persistence of class-related inequalities in disease
prevalence
 “Human social organization creates the conditions
necessary for infectious diseases to exert
selective evolutionary pressure on human biology.”
 Social disorganization/chaos is a “culture” medium
in which IDs thrive, i.e. MDR TB and HIV
If disease is an expression of
individual life under favorable
conditions, then epidemics must
be indicative of mass
disturbances of mass life.
– R. Virchow, Report on the Typhus
Epidemic in Upper Silesia, 1848
Diabetes
 Social determinants of IDDM in
Sardinia and Sardinians in Italy
 NIDDM in Native Americans,
Aboriginals, Polynesians
Farmer – contemporary social
medicine
 Many disease make a preferential option for the
poor
 Structural analysis of the forces and mechanisms
that create a situation in which the poor get
poorer (structural violence)
 The poor have no access to vaccines, poor TB
treatment, no access to HIV/AIDS medicine,
shorter life expectancies
 Lives of the poor are not divorced from the
decisions by the powerful
 Inequalities in society as genesis of ill health are
often overlooked, or given only brief mention
Social justice
 “Preferential option for the poor” rooted in
Second Vatican Council, 1968, and Puebla
conference, 1978
 Created liberation theology movement in Latin
America in 1980s-1990s
 The way to work for the poor is to struggle for
their liberation
 “Are we free because we help keep the poor
oppressed?”
 Observe, judge (moments of moral clarity), act
(pragmatic solidarity)
Conclusions
 Inequalities in health still persist despite
decades of reform
 Differentials in access to care by social
class and race persist and plague the
disadvantaged in society
 Unregulated market forces in medicine
exacerbate inequalities
 Social medicine has a vital role to play even
in 21st century medical practice
Medical statistics will be our
standard of measurement: we will
weigh life for life and see where
the dead lie thicker, among the
workers or among the privileged.
R. Virchow, Die Medicinische Reform, 1848