PHA-Exchange> What is Social Medicine?

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Monthly Review January 2005 
<http://www.monthlyreview.org/0105anderson.htm>


What is Social Medicine?
Matthew R. Anderson, Lanny Smith, and Victor W. Sidel

The past two decades have seen a rapid expansion of the corporate agenda in 
the field of health and health care. Rather than moving toward a system of 
universal access to medical care in the United States, the access to and 
quality of clinical services is being turned over increasingly to the 
insurance industry. Patients are now "clients" and clinical services are 
"product lines." More clinical research is now funded by the pharmaceutical 
industry than the National Institutes of Health; pharmaceutical dollars pay 
the salaries of top academics and set the national research agenda. 
Clinicians and patients alike are wooed by sophisticated advertising 
campaigns (often disguised as education) that promote expensive drugs of 
dubious efficacy. The insertion of "market rationality" into health care has 
not brought the hoped for curbing of health care costs. The United States, 
despite spending more per capita on medical care than any other country in 
the world, continues to perform poorly on many health indicators, with a 
life expectancy at birth that ranks twenty-seventh in the world.

This corporate agenda, however, has not gone unchallenged. And rather than 
being pessimistic or defeatist, we think it might be useful to consider the 
long and rich history of progressive activism in medicine. This history 
dates back (at least) to the early nineteenth century when the systematic 
study of the relationships between society, disease, and medicine began in 
earnest. This study-and the forms of medical practice derived from it-became 
known as "social medicine." Over time the term "social medicine" took on 
varied meanings as it was adapted to differing societies and diverse social 
conditions. Nonetheless, certain common principles underlie the term:

1. Social and economic conditions profoundly impact health, disease, and the 
practice of medicine.

2. The health of the population is a matter of social concern.

3. Society should promote health through both individual and social means.

In this essay we explore the origins of these concepts in nineteenth-century 
Europe and their subsequent development in Latin America, South Africa, and 
the United States. While this brief essay cannot provide a comprehensive 
examination of social medicine, we hope it will suggest ways in which the 
historical experience of social medicine can shed light on some of the most 
vexing problems in modern health and health care.

How Social and Economic Conditions Impact Health and Disease

Although he was not the first to point out the links between society and 
health, the German physician, Rudolf Virchow, is considered by many to be 
the founder of social medicine.  Virchow was one of the great pathologists 
of the nineteenth century, most notably contributing to the understanding of 
disease at the cellular level. He was also keenly aware of the social 
origins of illness. In 1848, while working as a staff physician at the Royal 
Charité Hospital in Berlin, he investigated an outbreak of typhus in the 
Prussian province of Upper Silesia. Virchow identified social factors, such 
as poverty and the lack of education and democracy, as key elements in the 
development of the epidemic. The experience led him to the concept of 
"artificial epidemics" arising in periods of social disruption:

Artificial epidemics...are attributes of society, products of a false 
culture or of a culture that is not available to all classes. These are 
indicators of defects produced by political and social organization, and 
therefore affect predominately those classes that do not participate in the 
advantages of the culture.

These words seem prescient when we consider the AIDS pandemic. Social 
inequalities and disruptions have been central to the spread of the HIV 
virus.
 The links between the broader social context and individual stories of 
HIV-infected Haitians have been poignantly described by Paul Farmer.
 The struggle against AIDS is not only the fight against an infectious 
disease, but also a struggle for the rights of women, children, sex workers, 
and sexual minorities.

The struggle against AIDS is also a struggle to deliver clinical care to 
some of the world's poorest people. Here we can truly speak of living in the 
best of times and the worst of times. It is certainly one of the miracles of 
modern biomedicine that it was able rapidly to identify the causative agents 
of AIDS and to develop highly effective treatments for it. In the United 
States AIDS is now largely treatable, although not yet curable. But it is a 
great outrage-and also characteristic of modern medicine-that most people 
who need the medications are denied access to them.
 Of the estimated six million poor people who urgently need AIDS medications 
only an estimated 440,000 are actually getting them. Why are AIDS patients 
denied the treatments they so desperately need? The answer is not really the 
cost of the drugs. The "cocktail" of AIDS medications can be purchased for 
about $250 per year. But the U.S. government, working through the World 
Trade Organization, has fought long and hard to restrict the abilities of 
poorer countries to produce or purchase generic medications. The rights of 
pharmaceutical corporations to their "intellectual property" have trumped 
public health.

Nonetheless, organized medicine has traditionally been slow to accept the 
fact that social factors play an important role in disease. In the late 
nineteenth century the striking advances made in pathology and microbiology 
made social factors seem less germane in the etiology of disease. But humans 
are, in Aristotle's words, "social animals" in whom the biological and 
social are inextricably linked. The Russian philosopher, Georgi Plekhanov, 
used the "laws of digestion" to illustrate this in his characteristically 
sharp style:

Once the stomach has been supplied with a certain quantity of food, it sets 
about its work in accordance with the general laws of stomachic digestion. 
But can one, with the help of these laws, reply to the question of why 
savory and nourishing food descends every day into your stomach, while in 
mine it is a rare visitor? Do these laws explain why some eat so much, while 
others starve? It would seem that the explanation must be sought in some 
other sphere, in the working of some other kind of laws.
Much of the early inspiration for social medicine came from European health 
statistics demonstrating major mortality differences between classes. Health 
and disease were correlated with wealth and poverty. Unfortunately, this 
remains true today and health inequalities are an active area of research 
and activism.

The Health of the Population is a Matter of Social Concern

Various explanations are offered for the fact that the rich are healthier 
than the poor. Perhaps they have better genes. Or better lifestyles. Many 
saw these disparities as a call for social reform or revolution. Thomas 
Hodgkin, known for identifying Hodgkin's lymphoma,  and the Canadian 
surgeon, Norman Bethune, who worked to preserve the Republic during the 
Spanish Civil War and died helping the Chinese revolutionaries,  are just 
two examples of physician activists.

Virchow was another.
 If disease was socially derived, then ill health was to him an indictment 
of the political system. He stood on the barricades during the March 1848 
Berlin uprisings and later played an active political role, serving as 
Berlin city counselor, a founder of the German Progressive Radical Party, 
and a member of the Prussian and German parliaments. During the 
revolutionary days of 1848 his journal proclaimed that "Medicine is a social 
science, and politics nothing but medicine on a grand scale."

During the twentieth century Latin America developed one of the most active 
centers of social medicine. Two of its most prominent members-Salvador 
Allende and Che Guevara-are known primarily for their political engagement.

In the 1930s, Allende, a public health physician, served as Chilean minister 
of health. He produced an analysis of the social origins of disease and 
suffering in Chile: La Realidad Medico-Social Chilena.
 He argued that the solution to health problems lay not simply in improved 
medical care but also in better sanitation, housing, nutrition, and working 
conditions. Echoing Virchow, Allende wrote: "It is not possible to provide 
health and knowledge to a malnourished people, dressed in rags and working 
under merciless exploitation."
 These ideas were eventually embodied in the political program of the 
democratically-elected Popular Unity government in Chile. Allende served as 
president of the Popular Unity government from 1971 until 1973 when he was 
assassinated in the U.S. organized coup d'etat.

Che Guevara, an Argentinean physician, joined Fidel Castro's insurrection in 
Cuba, eventually becoming minister of the economy in the revolutionary 
government. Echoing Virchow, Che saw politics as medicine on a grand scale:
The revolution's task-the task of training and nourishing the children, the 
task of educating the army, the task of distributing the lands of the old 
absentee landlords among those who sweated every day on that same land 
without reaping its fruit-is the greatest work of social medicine that has 
been done in Cuba.

Like Salvador Allende, Che Guevara would die fighting for his beliefs.
Despite these deaths, Latin American social medicine flourished. Latin 
American social medicine developed a rich body of theoretical and practical 
work examining the relationship between health and society. It emphasizes 
praxis: developing a close relationship between theory and practice. 
Practitioners have been involved with community organizations, unions, and 
political movements; many others fell victim to political repression.
Latin American social medicine has also adopted a highly critical stance 
toward traditional thinking in medicine and epidemiology. Rather than seeing 
disease as an isolated state or event, it emphasizes the "health-illness 
dialectic," a concept that expresses the fluid, complex relationship between 
the normal and the pathological. This dialectic exists within a social 
structure that creates distinct patterns of diseases and distinct medical 
ideologies to explain and treat those diseases. Latin American social 
medicine influenced North Americans involved in the Central American antiwar 
movement in the 1980s, notably in the formation of "liberation medicine."

Unfortunately, the work of Latin American social medicine has been largely 
unavailable to English-speaking audiences, a situation partially remedied by 
the publication of several recent review articles and the creation of a 
website devoted to Latin American social medicine at the University of New 
Mexico.

Society Should Promote Health through Both Individual and Social Means

A desire for new-more democratic, less hierarchical-models of health care 
was not just felt in Latin America. Indeed, if politics is medicine writ 
large, it is also apparent that medicine is politics writ small.
 The way in which clinical care is provided has important political 
ramifications. Socially-minded physicians began to look for ways in which 
their clinical practice might reflect different social values.

Extremely important in this search was the development of community 
medicine, a movement in part associated with the South African doctors 
Sidney and Emily Kark. In 1940, at a particularly favorable time in South 
African politics, the Karks were charged with setting up a model health unit 
in Pholela in Natal (now in KwaZulu/Natal).
 The health center served as a testing ground for what the Karks initially 
described as "a practice of social medicine" but would later be dubbed 
"community oriented primary care."
 The project was expanded in 1946 into an Institute of Family and Community 
Health in Durban with eight health centers and a major teaching program. As 
political winds in South Africa changed the institute ceased operations in 
1959. The Karks eventually settled in Israel to work on a World Health 
Organization (WHO)-Israel Social Medicine Project.

The community-oriented primary care model incorporated innovations based on 
social medicine principles. Planning began with a "community diagnosis." 
Based on epidemiological work, Pholela's three most common conditions were 
identified as "malnutrition; communicable diseases; and psycho-social 
problems," the triad composing the "community syndrome." This diagnosis led 
to nontraditional health interventions, such as a milk distribution program 
for children and the planting of a community garden.

Clinical care was the responsibility of a team composed of a primary care 
doctor, a community nurse, and a health educator (typically someone drawn 
from the community). The team served a neighborhood of homes that they knew 
intimately, conceiving their "patient" as a family, not an individual:

Continuity of care by this team introduced personal relationships between 
the families and their doctors and nurses, of the same kind as those the old 
family doctor had in his village or neighborhood practice.

Unlike the traditional family doctor, the health team would systematically 
consider the implications of the broader social context for individual 
patients and the possible epidemiological implications of new diagnoses in 
their individual patients.

In the 1960s, the U.S. Office of Economic Opportunity funded the first two 
community health centers in the United States: one on Boston's Columbia 
Point peninsula and another in Mound Bayou, Mississippi.

The latter was founded by Jack Geiger, who had worked with the Karks in 
South Africa, and his colleagues. Congress eventually funded a national 
program of community health centers that continue to provide care today to 
the "third world" within the United States. Two of the authors of this paper 
(Matt Anderson and Lanny Smith) provide care at such centers.

Many of the ideals of the community health movement were embodied in the 
"Declaration of Alma-Ata" issued by the World Health Organization's 1978 
International Conference on Primary Care.
 The declaration reaffirmed the WHO's holistic definition of health as "a 
state of complete physical, mental and social wellbeing, and not merely the 
absence of disease or infirmity." It went on to signal that the "existing 
gross inequality in health" was unacceptable, that people have a right to 
participate in the organization and implementation of health care, and that 
primary care should be universally available. Finally, signaling the 
responsibility of governments for health, the declaration launched the 
ambitious goal of "health for all" by the year 2000. Alas, the neoliberal 
economic agenda has prevailed over this progressive and farsighted vision. 
Today "health for all" has been replaced by a variety of disease-specific 
initiatives such as the (seriously underfinanced) Global Fund to Fight AIDS, 
Tuberculosis and Malaria. But the ideals expressed in Alma-Ata continue to 
animate a broad-based international community health movement, now organized 
as the People's Health Movement.

The first hospital-based Department of Social Medicine in the United States 
was founded at Montefiore Medical Center in 1950.

Is Social Medicine Relevant to Medical Practice Today?

Sometimes it is useful to state the obvious. Two decades of "market reform" 
in U.S. health care have not given all Americans affordable, quality health 
care nor is it likely to do so. This emperor has no clothes. HIV treatment 
for all who need it could be supplied for a tiny fraction of what the U.S.. 
government has spent to pursue Saddam Hussein and his nonexistent weapons of 
mass destruction. The essence of the problem is a political one.

What, then, is to be done? Clinicians know the lives of their patients 
intimately and thus are uniquely suited to understand the political and 
social dimensions of their patients' problems. Virchow stated succinctly 
that the physician was the natural advocate for the poor. And, indeed, we 
have contemporary examples of physicians taking up this challenge. It is 
this mission that has been recognized by the Nobel Peace prize to Doctors 
without Borders in 1999 and to International Physicians for the Prevention 
of Nuclear War in 1985.

Those familiar with the history of social medicine understand that the 
United States' health problems will not be solved by more of the same-more 
doctors, more medicines, more quality control initiatives, more computers, 
more audits, and faster discharge times. A fundamental rethinking of the 
social role of medicine is required. Those progressive physicians who 
fashioned a medicine that was explicitly social can serve as a guide. 
Virchow's prescription for the Silesian typhus epidemic seems more germane 
than ever:

The logical answer to the question as to how conditions similar to those 
unfolded before our eyes in Upper Silesia can be prevented in the future is, 
therefore, very easy and simple: education, with its daughters liberty and 
prosperity.

Reference List has been omitted for brevity.